Doug Brunk

SAN DIEGO — Silent cerebral infarction occurs in midlife more than five times as often as clinical stroke, according to an analysis of data from the Framingham Heart Study.

“Silent cerebral infarcts have been referred to as 'silent' because patients and/or clinicians may not recognize them when they occur, but silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke,” Dr. Jose Rafael Romero said in an interview at the International Stroke Conference. “Given that hypertension is the main risk factor associated with higher risk of silent cerebral infarcts [SCIs], and is a modifiable risk factor, early surveillance and treatment should be emphasized. Our study supports the recommendation by several guidelines for early treatment of hypertension and surveillance.”

Dr. Romero, of the department of neurology at Boston University, and his colleagues studied 1,485 participants in the original Framingham cohort and their offspring. They were free of stroke or transient ischemic attacks and had undergone two brain MRI scans at least 1 year apart, in 1999–2003 and 2004–2006. SCI was defined as a lesion greater than 3 mm with hyperintense signal on T2-weighted images and cerebrospinal fluid signal intensity on subtraction images, separate from the circle of Willis vessels and perivascular spaces. Clinical stroke was determined by prospective ongoing surveillance using standard protocols. The mean age of the patients at baseline was 63 years, 46% were women, and 40% had hypertension.

Over a mean follow-up of 5 years, SCI was observed in 8.7% of study participants while clinical stroke occurred in 1.7% of study participants. The majority of SCIs (83%) were single incident in nature.

An age-stratified analysis revealed that the incidence of SCI was more than five times that of clinical stroke among those younger than 65 years of age (4.8% vs. 0.9%, respectively). The incidence of both SCI and stroke increased among those aged 65–74 years (13% vs. 2.8%, respectively) and those aged 75 years and older (16.9% vs. 3.2%).

“Our study adds to what is known about incident SCI by including younger persons,” Dr. Romero said, because the Framingham Heart Study participants are nearly a decade younger than those of prior studies of silent infarcts. “Hypertension appears to be the main stroke risk factor associated with a higher risk of incident SCI.” A significant link between hypertension and higher risk of incident SCI was observed in those older than 65 years (odds ratio 1.75).

A key limitation of the study is that the participants were primarily of European descent, Dr. Romero said at the conference, which was sponsored by the American Heart Association.

The study was supported by grants from the National Institutes of Health.

'Silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke.' DR. ROMERO

SAN DIEGO — Silent cerebral infarction occurs in midlife more than five times as often as clinical stroke, according to an analysis of data from the Framingham Heart Study.

“Silent cerebral infarcts have been referred to as 'silent' because patients and/or clinicians may not recognize them when they occur, but silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke,” Dr. Jose Rafael Romero said in an interview at the International Stroke Conference. “Given that hypertension is the main risk factor associated with higher risk of silent cerebral infarcts [SCIs], and is a modifiable risk factor, early surveillance and treatment should be emphasized. Our study supports the recommendation by several guidelines for early treatment of hypertension and surveillance.”

Dr. Romero, of the department of neurology at Boston University, and his colleagues studied 1,485 participants in the original Framingham cohort and their offspring. They were free of stroke or transient ischemic attacks and had undergone two brain MRI scans at least 1 year apart, in 1999–2003 and 2004–2006. SCI was defined as a lesion greater than 3 mm with hyperintense signal on T2-weighted images and cerebrospinal fluid signal intensity on subtraction images, separate from the circle of Willis vessels and perivascular spaces. Clinical stroke was determined by prospective ongoing surveillance using standard protocols. The mean age of the patients at baseline was 63 years, 46% were women, and 40% had hypertension.

Over a mean follow-up of 5 years, SCI was observed in 8.7% of study participants while clinical stroke occurred in 1.7% of study participants. The majority of SCIs (83%) were single incident in nature.

An age-stratified analysis revealed that the incidence of SCI was more than five times that of clinical stroke among those younger than 65 years of age (4.8% vs. 0.9%, respectively). The incidence of both SCI and stroke increased among those aged 65–74 years (13% vs. 2.8%, respectively) and those aged 75 years and older (16.9% vs. 3.2%).

“Our study adds to what is known about incident SCI by including younger persons,” Dr. Romero said, because the Framingham Heart Study participants are nearly a decade younger than those of prior studies of silent infarcts. “Hypertension appears to be the main stroke risk factor associated with a higher risk of incident SCI.” A significant link between hypertension and higher risk of incident SCI was observed in those older than 65 years (odds ratio 1.75).

A key limitation of the study is that the participants were primarily of European descent, Dr. Romero said at the conference, which was sponsored by the American Heart Association.

The study was supported by grants from the National Institutes of Health.

'Silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke.' DR. ROMERO

SAN DIEGO — Silent cerebral infarction occurs in midlife more than five times as often as clinical stroke, according to an analysis of data from the Framingham Heart Study.

“Silent cerebral infarcts have been referred to as 'silent' because patients and/or clinicians may not recognize them when they occur, but silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke,” Dr. Jose Rafael Romero said in an interview at the International Stroke Conference. “Given that hypertension is the main risk factor associated with higher risk of silent cerebral infarcts [SCIs], and is a modifiable risk factor, early surveillance and treatment should be emphasized. Our study supports the recommendation by several guidelines for early treatment of hypertension and surveillance.”

Dr. Romero, of the department of neurology at Boston University, and his colleagues studied 1,485 participants in the original Framingham cohort and their offspring. They were free of stroke or transient ischemic attacks and had undergone two brain MRI scans at least 1 year apart, in 1999–2003 and 2004–2006. SCI was defined as a lesion greater than 3 mm with hyperintense signal on T2-weighted images and cerebrospinal fluid signal intensity on subtraction images, separate from the circle of Willis vessels and perivascular spaces. Clinical stroke was determined by prospective ongoing surveillance using standard protocols. The mean age of the patients at baseline was 63 years, 46% were women, and 40% had hypertension.

Over a mean follow-up of 5 years, SCI was observed in 8.7% of study participants while clinical stroke occurred in 1.7% of study participants. The majority of SCIs (83%) were single incident in nature.

An age-stratified analysis revealed that the incidence of SCI was more than five times that of clinical stroke among those younger than 65 years of age (4.8% vs. 0.9%, respectively). The incidence of both SCI and stroke increased among those aged 65–74 years (13% vs. 2.8%, respectively) and those aged 75 years and older (16.9% vs. 3.2%).

“Our study adds to what is known about incident SCI by including younger persons,” Dr. Romero said, because the Framingham Heart Study participants are nearly a decade younger than those of prior studies of silent infarcts. “Hypertension appears to be the main stroke risk factor associated with a higher risk of incident SCI.” A significant link between hypertension and higher risk of incident SCI was observed in those older than 65 years (odds ratio 1.75).

A key limitation of the study is that the participants were primarily of European descent, Dr. Romero said at the conference, which was sponsored by the American Heart Association.

The study was supported by grants from the National Institutes of Health.

'Silent infarcts are associated with a higher risk of cognitive impairment and clinical stroke.' DR. ROMERO

SAN DIEGO — The development of cerebral palsy is associated with adverse intrapartum events in about 27% of term infants and 38% of preterm infants with the condition, according to findings from a large, retrospective population-based cohort analysis.

Previous studies have indicated that intrapartum events were a factor in only 10% of infants with cerebral palsy. “Our data would suggest that 10% estimate is a little bit low,” Dr. William M. Gilbert said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

For the study, which is the largest of its kind, Dr. Gilbert and his associates analyzed maternal/infant discharge and birth records in California for 1991–2001.

Of the more than 6,000,000 births that occurred over the 10-year period, 8,946 children with cerebral palsy were identified. Of these, 5,478 were delivered at term and 3,468 were delivered preterm. All cases of cerebral palsy were then compared with the population without cerebral palsy, said Dr. Gilbert, codirector of the Center for Perinatal Medicine and Law at the University of California, Davis.

Adverse obstetrical outcomes included asphyxia, placental abruption, fetal distress, and uterine rupture. Adverse neonatal outcomes included mild to severe birth asphyxia, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and meningitis.

The investigators reported that 38% of preterm infants and 27% of term infants with cerebral palsy had one or more of the adverse obstetrical outcomes, compared with 17% and 13% of controls, respectively. These differences are statistically significant.

Maternal or neonatal infections only modestly affected the risk of cerebral palsy in term infants (9% with cerebral palsy vs. 6% among controls), while the impact was significantly greater in preterm infants (29% with cerebral palsy vs. 11% among controls).

Adverse neonatal outcomes occurred significantly more often in infants with cerebral palsy, compared with controls—5% among term infants vs. 0.5% among controls and 59% among preterm infants vs. 6% among controls.

“Birth asphyxia increased the risk of cerebral palsy development in term infants (eightfold) more than in the preterm infants (twofold), possibly suggesting that term infants cannot handle asphyxiating insults as well as preterm infants,” Dr. Gilbert and his associates said.

Dr. Gilbert had no conflicts of interest to disclose.

SAN DIEGO — The development of cerebral palsy is associated with adverse intrapartum events in about 27% of term infants and 38% of preterm infants with the condition, according to findings from a large, retrospective population-based cohort analysis.

Previous studies have indicated that intrapartum events were a factor in only 10% of infants with cerebral palsy. “Our data would suggest that 10% estimate is a little bit low,” Dr. William M. Gilbert said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

For the study, which is the largest of its kind, Dr. Gilbert and his associates analyzed maternal/infant discharge and birth records in California for 1991–2001.

Of the more than 6,000,000 births that occurred over the 10-year period, 8,946 children with cerebral palsy were identified. Of these, 5,478 were delivered at term and 3,468 were delivered preterm. All cases of cerebral palsy were then compared with the population without cerebral palsy, said Dr. Gilbert, codirector of the Center for Perinatal Medicine and Law at the University of California, Davis.

Adverse obstetrical outcomes included asphyxia, placental abruption, fetal distress, and uterine rupture. Adverse neonatal outcomes included mild to severe birth asphyxia, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and meningitis.

The investigators reported that 38% of preterm infants and 27% of term infants with cerebral palsy had one or more of the adverse obstetrical outcomes, compared with 17% and 13% of controls, respectively. These differences are statistically significant.

Maternal or neonatal infections only modestly affected the risk of cerebral palsy in term infants (9% with cerebral palsy vs. 6% among controls), while the impact was significantly greater in preterm infants (29% with cerebral palsy vs. 11% among controls).

Adverse neonatal outcomes occurred significantly more often in infants with cerebral palsy, compared with controls—5% among term infants vs. 0.5% among controls and 59% among preterm infants vs. 6% among controls.

“Birth asphyxia increased the risk of cerebral palsy development in term infants (eightfold) more than in the preterm infants (twofold), possibly suggesting that term infants cannot handle asphyxiating insults as well as preterm infants,” Dr. Gilbert and his associates said.

Dr. Gilbert had no conflicts of interest to disclose.

SAN DIEGO — The development of cerebral palsy is associated with adverse intrapartum events in about 27% of term infants and 38% of preterm infants with the condition, according to findings from a large, retrospective population-based cohort analysis.

Previous studies have indicated that intrapartum events were a factor in only 10% of infants with cerebral palsy. “Our data would suggest that 10% estimate is a little bit low,” Dr. William M. Gilbert said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

For the study, which is the largest of its kind, Dr. Gilbert and his associates analyzed maternal/infant discharge and birth records in California for 1991–2001.

Of the more than 6,000,000 births that occurred over the 10-year period, 8,946 children with cerebral palsy were identified. Of these, 5,478 were delivered at term and 3,468 were delivered preterm. All cases of cerebral palsy were then compared with the population without cerebral palsy, said Dr. Gilbert, codirector of the Center for Perinatal Medicine and Law at the University of California, Davis.

Adverse obstetrical outcomes included asphyxia, placental abruption, fetal distress, and uterine rupture. Adverse neonatal outcomes included mild to severe birth asphyxia, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and meningitis.

The investigators reported that 38% of preterm infants and 27% of term infants with cerebral palsy had one or more of the adverse obstetrical outcomes, compared with 17% and 13% of controls, respectively. These differences are statistically significant.

Maternal or neonatal infections only modestly affected the risk of cerebral palsy in term infants (9% with cerebral palsy vs. 6% among controls), while the impact was significantly greater in preterm infants (29% with cerebral palsy vs. 11% among controls).

Adverse neonatal outcomes occurred significantly more often in infants with cerebral palsy, compared with controls—5% among term infants vs. 0.5% among controls and 59% among preterm infants vs. 6% among controls.

“Birth asphyxia increased the risk of cerebral palsy development in term infants (eightfold) more than in the preterm infants (twofold), possibly suggesting that term infants cannot handle asphyxiating insults as well as preterm infants,” Dr. Gilbert and his associates said.

Dr. Gilbert had no conflicts of interest to disclose.

SAN DIEGO — Planned primary cesarean delivery was associated with increased morbidity, compared with vaginal delivery, among low-risk primiparous women at term, results from a large population-based study showed.

Clinicians have debated the role of planned primary cesarean delivery over the last decade in particular, yet “there is little evidence to help guide us in how to counsel patients on the risks and benefits” of the procedure, Dr. Lisa May Olson reported at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Olson, a recent graduate of the MD/MPH program at Oregon Health and Science University, Portland, noted that the rate of planned primary cesarean delivery in the United States has been increasing in the last decade, with a high of 20% in 2006, up from 17% in 2002.

Using administrative discharge data for low-risk primiparous women who gave birth to a term singleton infant in California, Dr. Olson and her associates compared maternal and neonatal outcomes of planned primary cesarean, with and without labor, to maternal and neonatal outcomes of vaginal delivery.

The average age of the 122,578 women studied was 25 years. Of these, 111,486 (90.9%) had a vaginal delivery, 5,603 (4.6%) had a planned primary cesarean delivery with labor, and 5,489 (4.4%) had a planned primary cesarean delivery without labor.

Dr. Olson reported that the planned primary cesarean delivery with and without labor groups were associated with higher maternal morbidities, compared with the vaginal delivery group, including a 10- to 20-fold increased risk of cardiac complications, a 4- to 8-fold increased risk of major infection, and a 3-fold increased risk of anesthetic complications. On the other hand, planned primary cesarean delivery with and without labor had a protective effect on hemorrhage and the need for transfusion, reducing the risk of those outcomes by 1.5- to 3-fold.

Compared with neonates in the planned primary cesarean delivery without labor group, their counterparts delivered by planned primary cesarean in the presence of labor were 5 times more likely to have CNS complications, 2.3 times more likely to require NICU admission, 1.9 times more likely to have respiratory distress syndrome, and 1.6 times more likely to develop sepsis, Dr. Olson said.

The study was supported in part by a Tartar Fellowship and Greenlick Grant at the university.

SAN DIEGO — Planned primary cesarean delivery was associated with increased morbidity, compared with vaginal delivery, among low-risk primiparous women at term, results from a large population-based study showed.

Clinicians have debated the role of planned primary cesarean delivery over the last decade in particular, yet “there is little evidence to help guide us in how to counsel patients on the risks and benefits” of the procedure, Dr. Lisa May Olson reported at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Olson, a recent graduate of the MD/MPH program at Oregon Health and Science University, Portland, noted that the rate of planned primary cesarean delivery in the United States has been increasing in the last decade, with a high of 20% in 2006, up from 17% in 2002.

Using administrative discharge data for low-risk primiparous women who gave birth to a term singleton infant in California, Dr. Olson and her associates compared maternal and neonatal outcomes of planned primary cesarean, with and without labor, to maternal and neonatal outcomes of vaginal delivery.

The average age of the 122,578 women studied was 25 years. Of these, 111,486 (90.9%) had a vaginal delivery, 5,603 (4.6%) had a planned primary cesarean delivery with labor, and 5,489 (4.4%) had a planned primary cesarean delivery without labor.

Dr. Olson reported that the planned primary cesarean delivery with and without labor groups were associated with higher maternal morbidities, compared with the vaginal delivery group, including a 10- to 20-fold increased risk of cardiac complications, a 4- to 8-fold increased risk of major infection, and a 3-fold increased risk of anesthetic complications. On the other hand, planned primary cesarean delivery with and without labor had a protective effect on hemorrhage and the need for transfusion, reducing the risk of those outcomes by 1.5- to 3-fold.

Compared with neonates in the planned primary cesarean delivery without labor group, their counterparts delivered by planned primary cesarean in the presence of labor were 5 times more likely to have CNS complications, 2.3 times more likely to require NICU admission, 1.9 times more likely to have respiratory distress syndrome, and 1.6 times more likely to develop sepsis, Dr. Olson said.

The study was supported in part by a Tartar Fellowship and Greenlick Grant at the university.

SAN DIEGO — Planned primary cesarean delivery was associated with increased morbidity, compared with vaginal delivery, among low-risk primiparous women at term, results from a large population-based study showed.

Clinicians have debated the role of planned primary cesarean delivery over the last decade in particular, yet “there is little evidence to help guide us in how to counsel patients on the risks and benefits” of the procedure, Dr. Lisa May Olson reported at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Olson, a recent graduate of the MD/MPH program at Oregon Health and Science University, Portland, noted that the rate of planned primary cesarean delivery in the United States has been increasing in the last decade, with a high of 20% in 2006, up from 17% in 2002.

Using administrative discharge data for low-risk primiparous women who gave birth to a term singleton infant in California, Dr. Olson and her associates compared maternal and neonatal outcomes of planned primary cesarean, with and without labor, to maternal and neonatal outcomes of vaginal delivery.

The average age of the 122,578 women studied was 25 years. Of these, 111,486 (90.9%) had a vaginal delivery, 5,603 (4.6%) had a planned primary cesarean delivery with labor, and 5,489 (4.4%) had a planned primary cesarean delivery without labor.

Dr. Olson reported that the planned primary cesarean delivery with and without labor groups were associated with higher maternal morbidities, compared with the vaginal delivery group, including a 10- to 20-fold increased risk of cardiac complications, a 4- to 8-fold increased risk of major infection, and a 3-fold increased risk of anesthetic complications. On the other hand, planned primary cesarean delivery with and without labor had a protective effect on hemorrhage and the need for transfusion, reducing the risk of those outcomes by 1.5- to 3-fold.

Compared with neonates in the planned primary cesarean delivery without labor group, their counterparts delivered by planned primary cesarean in the presence of labor were 5 times more likely to have CNS complications, 2.3 times more likely to require NICU admission, 1.9 times more likely to have respiratory distress syndrome, and 1.6 times more likely to develop sepsis, Dr. Olson said.

The study was supported in part by a Tartar Fellowship and Greenlick Grant at the university.

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, family physician Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants, has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm), and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good quality water (0.5 oz/lb of body weight per day); using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours; using a steam inhaler for 15–20 minutes two to three times per day; inhaling medicinal eucalyptus oil frequently; and swabbing peppermint oil outside of both nostrils following use of the saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize fresh, organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, who also was in the department of family medicine and is now in the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, in addition to stretching and strengthening exercises. If patients currently have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises” that strengthen immune function. These include practicing “safe” anger release technique such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. “Repressed anger is the primary emotional factor contributing to chronic sinusitis,” he said.

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis and the most challenging to treat—often have food allergies and sensitivities and should avoid sugar, milk, and dairy products; fruits; vinegar; mushrooms; alcohol; and bread and other foods that contain yeast or wheat. After 3 weeks, “then you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues demonstrated the effectiveness of an integrative holistic approach for treating chronic fungal sinusitis with fluconazole and a restrictive diet (Altern. Ther. Health Med. 2009;15[1]:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet. That seems to correlate quite well with successful antifungal outcomes,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd.

▸ Address the mental, emotional, spiritual, and social causes. Staying positive and fostering social connections play a role in good respiratory health, Dr. Ivker said. In a study of medical students who were tested at final exam time, those who scored high on the Holmes-Rahe Social Readjustment Rating Scale and the UCLA Loneliness Scale had significantly lower levels of natural killer cell activity, 90% lower interferon gamma levels, and lower T-cell responsiveness, compared with those with low-scale scores (Psychosom. Med. 1984;46:7–14).

Findings from another study demonstrated that among caregivers of dementia patients, social connectedness correlated directly with immune function. Those reporting the fewest social connections had more upper respiratory infections and decreased immune responsiveness, compared with those who had the greatest number of social connections (Psychosom. Med. 1991;53:345–62).

Dr. Ivker also pointed out that the recent emergence of laughter yoga (www.laughteryoga.org

Dr. Ivker had no relevant conflicts to disclose.

Getting at least 7 hours of sleep per night 'is possibly the most overlooked keyto … a strong immune system.' DR. IVKER

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, family physician Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants, has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm), and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good quality water (0.5 oz/lb of body weight per day); using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours; using a steam inhaler for 15–20 minutes two to three times per day; inhaling medicinal eucalyptus oil frequently; and swabbing peppermint oil outside of both nostrils following use of the saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize fresh, organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, who also was in the department of family medicine and is now in the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, in addition to stretching and strengthening exercises. If patients currently have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises” that strengthen immune function. These include practicing “safe” anger release technique such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. “Repressed anger is the primary emotional factor contributing to chronic sinusitis,” he said.

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis and the most challenging to treat—often have food allergies and sensitivities and should avoid sugar, milk, and dairy products; fruits; vinegar; mushrooms; alcohol; and bread and other foods that contain yeast or wheat. After 3 weeks, “then you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues demonstrated the effectiveness of an integrative holistic approach for treating chronic fungal sinusitis with fluconazole and a restrictive diet (Altern. Ther. Health Med. 2009;15[1]:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet. That seems to correlate quite well with successful antifungal outcomes,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd.

▸ Address the mental, emotional, spiritual, and social causes. Staying positive and fostering social connections play a role in good respiratory health, Dr. Ivker said. In a study of medical students who were tested at final exam time, those who scored high on the Holmes-Rahe Social Readjustment Rating Scale and the UCLA Loneliness Scale had significantly lower levels of natural killer cell activity, 90% lower interferon gamma levels, and lower T-cell responsiveness, compared with those with low-scale scores (Psychosom. Med. 1984;46:7–14).

Findings from another study demonstrated that among caregivers of dementia patients, social connectedness correlated directly with immune function. Those reporting the fewest social connections had more upper respiratory infections and decreased immune responsiveness, compared with those who had the greatest number of social connections (Psychosom. Med. 1991;53:345–62).

Dr. Ivker also pointed out that the recent emergence of laughter yoga (www.laughteryoga.org

Dr. Ivker had no relevant conflicts to disclose.

Getting at least 7 hours of sleep per night 'is possibly the most overlooked keyto … a strong immune system.' DR. IVKER

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, family physician Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants, has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm), and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good quality water (0.5 oz/lb of body weight per day); using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours; using a steam inhaler for 15–20 minutes two to three times per day; inhaling medicinal eucalyptus oil frequently; and swabbing peppermint oil outside of both nostrils following use of the saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize fresh, organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, who also was in the department of family medicine and is now in the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, in addition to stretching and strengthening exercises. If patients currently have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises” that strengthen immune function. These include practicing “safe” anger release technique such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. “Repressed anger is the primary emotional factor contributing to chronic sinusitis,” he said.

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis and the most challenging to treat—often have food allergies and sensitivities and should avoid sugar, milk, and dairy products; fruits; vinegar; mushrooms; alcohol; and bread and other foods that contain yeast or wheat. After 3 weeks, “then you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues demonstrated the effectiveness of an integrative holistic approach for treating chronic fungal sinusitis with fluconazole and a restrictive diet (Altern. Ther. Health Med. 2009;15[1]:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet. That seems to correlate quite well with successful antifungal outcomes,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd.

▸ Address the mental, emotional, spiritual, and social causes. Staying positive and fostering social connections play a role in good respiratory health, Dr. Ivker said. In a study of medical students who were tested at final exam time, those who scored high on the Holmes-Rahe Social Readjustment Rating Scale and the UCLA Loneliness Scale had significantly lower levels of natural killer cell activity, 90% lower interferon gamma levels, and lower T-cell responsiveness, compared with those with low-scale scores (Psychosom. Med. 1984;46:7–14).

Findings from another study demonstrated that among caregivers of dementia patients, social connectedness correlated directly with immune function. Those reporting the fewest social connections had more upper respiratory infections and decreased immune responsiveness, compared with those who had the greatest number of social connections (Psychosom. Med. 1991;53:345–62).

Dr. Ivker also pointed out that the recent emergence of laughter yoga (www.laughteryoga.org

Dr. Ivker had no relevant conflicts to disclose.

Getting at least 7 hours of sleep per night 'is possibly the most overlooked keyto … a strong immune system.' DR. IVKER

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, and family history.

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, subjects completed the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

He reported that the rate of postpartum depression was directly related to the extremes of BMI. For example, the rates of postpartum depression in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class 2 women and 3.94 for obese class 3 women.

Dr. LaCoursiere reported that she had no conflicts to disclose.

A woman with a prepregnancy BMI of 35 kg/m

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, and family history.

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, subjects completed the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

He reported that the rate of postpartum depression was directly related to the extremes of BMI. For example, the rates of postpartum depression in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class 2 women and 3.94 for obese class 3 women.

Dr. LaCoursiere reported that she had no conflicts to disclose.

A woman with a prepregnancy BMI of 35 kg/m

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, and family history.

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, subjects completed the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

He reported that the rate of postpartum depression was directly related to the extremes of BMI. For example, the rates of postpartum depression in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class 2 women and 3.94 for obese class 3 women.

Dr. LaCoursiere reported that she had no conflicts to disclose.

A woman with a prepregnancy BMI of 35 kg/m

SAN DIEGO — Over the past year, Bridget A. Stewart and her associates at Children's Hospital Boston had a hunch that duplicate testing was going on among adults with congenital heart disease who were evaluated at Children's Hospital and subsequently admitted to nearby Brigham and Women's Hospital.

“If a patient is seen at Children's Hospital and then goes immediately over to the Brigham for admission, does that admitting resident realize that you just drew a full set of labs or that you just did an EKG, or does that resident reorder everything?” Ms. Stewart, administrative director of the hospital's cardiology department, said in an interview.

She and her associates conducted a retrospective study of 86 adult congenital heart patients admitted to Brigham and Women's Hospital after postcatheterization, a postclinic visit, or a post-emergency department visit at Children's Hospital Boston between Jan. 1, 2006, and Dec. 31, 2007. Each hospital has a separate electronic medical record system.

The researchers found that 28 (32%) of the 86 patients underwent some form of duplicate testing. Of these 28 cases, 18 (64%) were deemed non-clinically relevant by two independent reviewers.

The duplicate testing, the largest source of which derived from patients who originated in the clinic at Children's Hospital Boston, resulted in $1,800 in reimbursements, based on the Medicare fee schedule.

Cardiology clinicians at Children's Hospital Boston were surprised, because “they try to mitigate duplication through communication. … The dollar value was relatively small, but they were surprised to see that 18 patients had duplication testing that was not clinically indicated,” Ms. Stewart said during a poster session at the annual conference of the Medical Group Management Association.

If the researchers followed adult congenital heart disease patients who live in Florida or Arizona for the winter months after being followed in Boston, “we'd find a lot of duplicate testing,” she added.

One solution is to develop a national integrated EMR system such as that of the Department of Veterans Affairs. “All of their computer health records are integrated,” she said. “I think that's what we need to do across America.”

One study limitation was the fact that physicians' intentions in ordering the duplicate tests were unknown. “I do not know if he looked for results in the EMR prior to ordering testing, if he ordered it to have testing results in the institution's EMR, if there was some undocumented change in patient status that we did not pick up, or if he did not trust the data from the referring facility,” said Ms. Stewart, who had no conflicts to disclose.

Clinicians were surprised to see that some of the duplicate testing 'was not clinically indicated.' MS. STEWART

SAN DIEGO — Over the past year, Bridget A. Stewart and her associates at Children's Hospital Boston had a hunch that duplicate testing was going on among adults with congenital heart disease who were evaluated at Children's Hospital and subsequently admitted to nearby Brigham and Women's Hospital.

“If a patient is seen at Children's Hospital and then goes immediately over to the Brigham for admission, does that admitting resident realize that you just drew a full set of labs or that you just did an EKG, or does that resident reorder everything?” Ms. Stewart, administrative director of the hospital's cardiology department, said in an interview.

She and her associates conducted a retrospective study of 86 adult congenital heart patients admitted to Brigham and Women's Hospital after postcatheterization, a postclinic visit, or a post-emergency department visit at Children's Hospital Boston between Jan. 1, 2006, and Dec. 31, 2007. Each hospital has a separate electronic medical record system.

The researchers found that 28 (32%) of the 86 patients underwent some form of duplicate testing. Of these 28 cases, 18 (64%) were deemed non-clinically relevant by two independent reviewers.

The duplicate testing, the largest source of which derived from patients who originated in the clinic at Children's Hospital Boston, resulted in $1,800 in reimbursements, based on the Medicare fee schedule.

Cardiology clinicians at Children's Hospital Boston were surprised, because “they try to mitigate duplication through communication. … The dollar value was relatively small, but they were surprised to see that 18 patients had duplication testing that was not clinically indicated,” Ms. Stewart said during a poster session at the annual conference of the Medical Group Management Association.

If the researchers followed adult congenital heart disease patients who live in Florida or Arizona for the winter months after being followed in Boston, “we'd find a lot of duplicate testing,” she added.

One solution is to develop a national integrated EMR system such as that of the Department of Veterans Affairs. “All of their computer health records are integrated,” she said. “I think that's what we need to do across America.”

One study limitation was the fact that physicians' intentions in ordering the duplicate tests were unknown. “I do not know if he looked for results in the EMR prior to ordering testing, if he ordered it to have testing results in the institution's EMR, if there was some undocumented change in patient status that we did not pick up, or if he did not trust the data from the referring facility,” said Ms. Stewart, who had no conflicts to disclose.

Clinicians were surprised to see that some of the duplicate testing 'was not clinically indicated.' MS. STEWART

SAN DIEGO — Over the past year, Bridget A. Stewart and her associates at Children's Hospital Boston had a hunch that duplicate testing was going on among adults with congenital heart disease who were evaluated at Children's Hospital and subsequently admitted to nearby Brigham and Women's Hospital.

“If a patient is seen at Children's Hospital and then goes immediately over to the Brigham for admission, does that admitting resident realize that you just drew a full set of labs or that you just did an EKG, or does that resident reorder everything?” Ms. Stewart, administrative director of the hospital's cardiology department, said in an interview.

She and her associates conducted a retrospective study of 86 adult congenital heart patients admitted to Brigham and Women's Hospital after postcatheterization, a postclinic visit, or a post-emergency department visit at Children's Hospital Boston between Jan. 1, 2006, and Dec. 31, 2007. Each hospital has a separate electronic medical record system.

The researchers found that 28 (32%) of the 86 patients underwent some form of duplicate testing. Of these 28 cases, 18 (64%) were deemed non-clinically relevant by two independent reviewers.

The duplicate testing, the largest source of which derived from patients who originated in the clinic at Children's Hospital Boston, resulted in $1,800 in reimbursements, based on the Medicare fee schedule.

Cardiology clinicians at Children's Hospital Boston were surprised, because “they try to mitigate duplication through communication. … The dollar value was relatively small, but they were surprised to see that 18 patients had duplication testing that was not clinically indicated,” Ms. Stewart said during a poster session at the annual conference of the Medical Group Management Association.

If the researchers followed adult congenital heart disease patients who live in Florida or Arizona for the winter months after being followed in Boston, “we'd find a lot of duplicate testing,” she added.

One solution is to develop a national integrated EMR system such as that of the Department of Veterans Affairs. “All of their computer health records are integrated,” she said. “I think that's what we need to do across America.”

One study limitation was the fact that physicians' intentions in ordering the duplicate tests were unknown. “I do not know if he looked for results in the EMR prior to ordering testing, if he ordered it to have testing results in the institution's EMR, if there was some undocumented change in patient status that we did not pick up, or if he did not trust the data from the referring facility,” said Ms. Stewart, who had no conflicts to disclose.

Clinicians were surprised to see that some of the duplicate testing 'was not clinically indicated.' MS. STEWART

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, Dr. Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Striving for optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants and has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm) and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good-quality water (0.5 ounces per pound of body weight per day), using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours, using a steam inhaler for 15–20 minutes 2–3 times per day, inhaling medicinal eucalyptus oil frequently, and swabbing peppermint oil outside of both nostrils following use of saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said. Other methods include using a neti pot or SinuCleanse, or squeeze bottle sinus rinses such as that available from NeilMed Pharmaceuticals.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, of the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, plus stretching and strengthening exercises. If patients have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises,” including “safe” anger-release techniques such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. In a randomized study of asthma patients, writing about stressful experiences had a favorable effect on symptoms (JAMA 1999;281:1304–9).

The growth of laughter yoga (www.laughteryoga.org

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system. A lack of sleep is one of the most common causes of colds and sinus infections.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis—often have food allergies and sensitivities and should avoid sugar, milk and other dairy products, fruits, vinegar, mushrooms, alcohol, and bread and other foods that contain yeast or wheat. After 3 weeks, “you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues showed the effectiveness of a holistic combination of fluconazole and a restrictive diet for chronic fungal sinusitis (Altern. Ther. Health Med. 2009;15:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd. He begins with 720–900 mg t.i.d. and gradually decreases the dose to 180–450 mg every day over the course of 3–4 months.

Dr. Ivker had no conflicts of interest to disclose.

'A lack of sleep is one of the most common causes of colds and sinus infections.' DR. IVKER

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, Dr. Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Striving for optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants and has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm) and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good-quality water (0.5 ounces per pound of body weight per day), using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours, using a steam inhaler for 15–20 minutes 2–3 times per day, inhaling medicinal eucalyptus oil frequently, and swabbing peppermint oil outside of both nostrils following use of saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said. Other methods include using a neti pot or SinuCleanse, or squeeze bottle sinus rinses such as that available from NeilMed Pharmaceuticals.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, of the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, plus stretching and strengthening exercises. If patients have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises,” including “safe” anger-release techniques such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. In a randomized study of asthma patients, writing about stressful experiences had a favorable effect on symptoms (JAMA 1999;281:1304–9).

The growth of laughter yoga (www.laughteryoga.org

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system. A lack of sleep is one of the most common causes of colds and sinus infections.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis—often have food allergies and sensitivities and should avoid sugar, milk and other dairy products, fruits, vinegar, mushrooms, alcohol, and bread and other foods that contain yeast or wheat. After 3 weeks, “you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues showed the effectiveness of a holistic combination of fluconazole and a restrictive diet for chronic fungal sinusitis (Altern. Ther. Health Med. 2009;15:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd. He begins with 720–900 mg t.i.d. and gradually decreases the dose to 180–450 mg every day over the course of 3–4 months.

Dr. Ivker had no conflicts of interest to disclose.

'A lack of sleep is one of the most common causes of colds and sinus infections.' DR. IVKER

SAN DIEGO — Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health.

At a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine, Dr. Robert S. Ivker described four steps to achieve this goal:

▸ Heal the mucous membrane by reducing and/or eliminating inflammation. Striving for optimal air quality is key, said Dr. Ivker, cofounder and past president of the American Board of Holistic Medicine. He defined this as air that is free from pollutants and has a humidity level between 35% and 55%, a temperature between 65° and 85° F, 100% oxygen saturation, and a negative ion content between 3,000 and 6,000 0.001-mcm ions/cm

Home-based methods for achieving optimal air quality include using a negative-ion generator that does not emit ozone, an electrostatic or pleated furnace filter, and keeping the furnace, air ducts, and carpets clean, without the use of harsh chemical-based cleaning agents.

Dr. Ivker recommends the use of a warm-mist room humidifier in bedrooms and offices, especially during the winter months. Certain plants can also assist in cleaning the air, including those that remove formaldehyde (Boston fern, chrysanthemums, striped Dracaena, and the dwarf date palm) and carbon monoxide (spider plant).

Other strategies for healing mucous membranes include getting proper hydration with good-quality water (0.5 ounces per pound of body weight per day), using a saline nasal spray with aloe vera or other anti-inflammatory herbs every 2–3 hours, using a steam inhaler for 15–20 minutes 2–3 times per day, inhaling medicinal eucalyptus oil frequently, and swabbing peppermint oil outside of both nostrils following use of saline nose spray.

Nasal irrigation has also been found to alleviate sinonasal symptoms (Otolaryngol. Head Neck Surg. 2001;125:44–8). Options include the SinuPulse, a pulsatile irrigation device that removes biofilm covering the mucous membrane. This is “the most effective and most expensive option at around $100,” Dr. Ivker said. Other methods include using a neti pot or SinuCleanse, or squeeze bottle sinus rinses such as that available from NeilMed Pharmaceuticals.

▸ Strengthen and/or restore balance to the immune system. Inflammation increases free radicals, so emphasize organic fruits and vegetables, whole grains, fiber, and protein, said Dr. Ivker, of the department of otolaryngology at the University of Colorado, Denver.

Exercise helps. He recommends 20–30 minutes of aerobic exercise at least three times a week, plus stretching and strengthening exercises. If patients have no exercise regimen, “start very gradually,” he said. “Patients with chronic and fungal sinusitis have a weakened immune function, so you don't want to recommend strenuous exercise right off the bat.”

Dr. Ivker also recommends “emotional exercises,” including “safe” anger-release techniques such as pounding one's fists on a pillow or punching bag, screaming, laughing, crying, and writing in a journal. In a randomized study of asthma patients, writing about stressful experiences had a favorable effect on symptoms (JAMA 1999;281:1304–9).

The growth of laughter yoga (www.laughteryoga.org

He emphasized that getting at least 7 hours of sleep per night “is possibly the most overlooked key to overall well-being and a strong immune system. A lack of sleep is one of the most common causes of colds and sinus infections.”

▸ Mitigate fungus/candida, if applicable. Patients with suspected fungal sinusitis or candida/yeast overgrowth—typically the most severe cases of chronic sinusitis—often have food allergies and sensitivities and should avoid sugar, milk and other dairy products, fruits, vinegar, mushrooms, alcohol, and bread and other foods that contain yeast or wheat. After 3 weeks, “you can start to introduce nongluten grains such as brown rice, quinoa, millet, and so on,” he said.

In a study, Dr. Ivker and his colleagues showed the effectiveness of a holistic combination of fluconazole and a restrictive diet for chronic fungal sinusitis (Altern. Ther. Health Med. 2009;15:36–43).

“We still don't have a consistently reliable diagnostic test for fungal sinusitis. Genova [Diagnostics'] Comprehensive Digestive Stool Analysis is currently the best test we have, but it's not consistent. There are still too many false negatives. I use the patient's history, clinical picture, and Dr. William Crook's Candida Questionnaire and Score Sheet,” he said.

One antifungal supplement he routinely recommends is 100% pure allicin as found in the products Allimax and Allimed from AlliMax International Ltd. He begins with 720–900 mg t.i.d. and gradually decreases the dose to 180–450 mg every day over the course of 3–4 months.

Dr. Ivker had no conflicts of interest to disclose.

'A lack of sleep is one of the most common causes of colds and sinus infections.' DR. IVKER

When Dr. Donna Chester steps onto the dog agility obstacle course with Penny, her 3-year-old papillon, she brings a team approach to the task ahead.

It's them against the course timer.

That sense of alliance isn't lost on Penny, either, said Dr. Chester, an ob.gyn. who practices in Anchorage, Alaska. "We're a team out there, and she knows it. It's giving her a job and it's giving me something to release my energy and have fun with."

To date, Penny has earned three "double Qs," meaning that she has run three agility courses perfectly and under the time allotted. She's also earned 350 points toward her first Master Agility Champion (MACH), which is the ultimate American Kennel Club agility title. (A MACH designation is earned when a dog runs 20 courses perfectly and runs them under the time allotted.)

Seven years ago, after watching her husband, Michael, guide dogs through agility tunnels, over teeter totters, and between weave poles in competitions as a hobby, Dr. Chester decided to follow suit. Her first experience came with Mysti, the family's wheaten terrier, who is now 9 years old and is the retired house dog. Dr. Chester worked with the terrier for 3 years on agility, and during the time she also learned a little about herself. During one competition a fellow trainer approached her and said, "You're too tense when you're out there. Mysti feels your tenseness. So if you don't relax, she's not going to."

Dr. Chester took the advice to heart and incorporated relaxation exercises into her precompetition regimen, a fix that led to positive results. "After that, I had 2 really good years of agility with her," Dr. Chester recalled. "When you connect like that with your dog, it's awesome. There is not a better feeling; there really isn't."

These days, she spends 1 hour 2 days per week and 10–15 minutes per day the rest of the week in training sessions with Penny "to keep things going." She and Michael and their daughter, Krystin, who is currently a high school senior, devote 10 weekends between May and September to attending dog agility competitions in Eugene and Portland, Ore., and in other Northwest locales.

"We're one of the few families that are doing this," Dr. Chester observed. "You might see a husband and a wife out there, but usually it's the husband or the wife, and there are very few kids out there, which is a shame because you can get college scholarships from this."

A family highlight came in 2006, when Teller, a papillon trained by Krystin, earned a MACH title. Teller "was an abused dog that we rescued; we'd had a lot of anger issues with him and tried to get him past those," Dr. Chester said. "Krystin became the first teenager in Alaska to get a MACH title, which is the highest title you can get with a dog. It was awesome to watch her do that and to also watch her bloom doing it, because she was always a reserved child. This helped bring her out."

The Alaska climate poses certain challenges to a consistent agility training routine. During the winter months, the family trains its dogs in an 80-by-60-foot building owned by friends. "You need a 100-by-100-foot space to have a really good training center, but this is good to keep them remembering what they are supposed to be doing," Dr. Chester said.

In the near future, she and her husband intend to build a training center on their own property that would serve as a competition site during the harsh winter months. For now, "all of our competitions are compacted into 3 months during the summer," she said. "It's frustrating because we spend almost every weekend during the summer doing dog agility. We'd like to fish, camp, hike, and do other things, but the dogs are taking so much of our time. We're hoping that if we put up this facility, we'll be able to spread out the competitions more."

But Dr. Chester isn't complaining too much. After all, she said, the magic that comes in the connection between dog and trainer is beyond measure. "It's a wonderful feeling to be out there training your dog, seeing that your dog 'gets it,' and to learn how smart dogs are," she said. "It's amazing how a little flick of the finger will send them one direction or another and that they understand these subtle commands."

A Whole Different Ball Game

Dr. Karen Reed has practiced dog obedience training since she was a child, but 7 years ago, she added dog agility training to her list of hobbies, which she considers a whole different ball game.

"Obedience training is so strict," said Dr. Reed, a pediatrician who practices in Wichita Falls, Tex., and is membership chair of the Obedience Training Club of Wichita Falls. "In agility, you can't touch the dogs when you're competing, but you can talk to them and cheer them on. It's so much fun."

In 2002, she was "looking for something new" to do with Allye, her then 4-year-old bearded collie, so the duo enrolled in weekly dog agility classes at a training facility in Rhome, Tex., which is a 1.5-hour drive from Wichita Falls.

"Many people in our obedience club also got interested, so we carpooled down there with our dogs and went through the beginning foundation class and up to training level 5," she recalled.

She did the same with Madeleine, a 6-year-old bearded collie she rescued from a shelter, but she and Allye, who is now 11, differ in their skill set on the agility course. She described Allye as "very focused" and Madeleine as a "wild child."

Allye "watches me all the time and is eager to do everything just right; when she finishes, she has the biggest smile on her face," Dr. Reed said. Madeleine, on the other hand, "is very social. During a competition if one of the club members she knows is in the ring as a steward, she's liable to go over and visit that person before completing the course. She also tends to work ahead of me, and sometimes she would rather take the A frame than go over a triple jump."

She and her dogs have competed in shows around Texas such as in McKinney, Las Colinas, Longview, Fort Worth, Dallas, and Houston, and they've also traveled to events in North Carolina and Colorado.

"We're competing, but I don't pressure them to compete rigorously," she said. "I'm on call almost every other weekend so I don't get to a whole lot of shows, but my goal is to get out there and have fun. I like to go to the shows and talk with the other dog lovers and watch the dogs run. I've learned a lot from how other people run their dogs."

She recently added another bearded collie, Sterling, to her family. Not yet a year old, Sterling is progressing with obedience training but Dr. Reed will wait until his joints and muscles mature (around age 2) before starting formal agility training.

For Dr. Reed, dog agility is a form of therapy. "Dogs are so forgiving; they just want to be with you, please you, and have fun," she explained. "My work as a pediatrician is pretty serious most of the time. I tend to worry about patients and take those worries home with me. But when I can just go out there and forget about my worries and concentrate on the dogs and how much fun they're having, it's a good bonding time with them. It's a good stress relief, as long as you're not too terribly serious about competing."

These days Dr. Reed doesn't have to cart Allye and Madeleine too far for competitions. The Obedience Training Club of Wichita Falls launched a club that stages twice yearly local agility events sanctioned by the American Kennel Club. The club also offers agility training for people who live in or near Wichita Falls and are unable or unwilling to travel further for training. "Many of these students are now competing in shows with their dogs and doing very well," she said. "It's opened up a whole new area of training possibilities in our area of Texas."

Dr. Reed would like to "get Sterling up to [the age when] he can train and get out there and have some fun, too. Mostly, it's to enjoy and be around the people who are also crazy about their dogs. There's a wide variety of people who train and compete in the sport. I've really enjoyed them, being part of their lives as well as spending time bonding and playing with my own dogs."

Dr. Donna Chester gives a command to Mysti, her wheaten terrier, during a run. COURTESY DR. DONNA CHESTER

Allye makes a jump as part of the obstacle course at a competition. BERT HENRY

Dr. Karen Reed trains three bearded collies: Allye, Madeleine, and Sterling. BERT HENRY

When Dr. Donna Chester steps onto the dog agility obstacle course with Penny, her 3-year-old papillon, she brings a team approach to the task ahead.

It's them against the course timer.

That sense of alliance isn't lost on Penny, either, said Dr. Chester, an ob.gyn. who practices in Anchorage, Alaska. "We're a team out there, and she knows it. It's giving her a job and it's giving me something to release my energy and have fun with."

To date, Penny has earned three "double Qs," meaning that she has run three agility courses perfectly and under the time allotted. She's also earned 350 points toward her first Master Agility Champion (MACH), which is the ultimate American Kennel Club agility title. (A MACH designation is earned when a dog runs 20 courses perfectly and runs them under the time allotted.)

Seven years ago, after watching her husband, Michael, guide dogs through agility tunnels, over teeter totters, and between weave poles in competitions as a hobby, Dr. Chester decided to follow suit. Her first experience came with Mysti, the family's wheaten terrier, who is now 9 years old and is the retired house dog. Dr. Chester worked with the terrier for 3 years on agility, and during the time she also learned a little about herself. During one competition a fellow trainer approached her and said, "You're too tense when you're out there. Mysti feels your tenseness. So if you don't relax, she's not going to."

Dr. Chester took the advice to heart and incorporated relaxation exercises into her precompetition regimen, a fix that led to positive results. "After that, I had 2 really good years of agility with her," Dr. Chester recalled. "When you connect like that with your dog, it's awesome. There is not a better feeling; there really isn't."

These days, she spends 1 hour 2 days per week and 10–15 minutes per day the rest of the week in training sessions with Penny "to keep things going." She and Michael and their daughter, Krystin, who is currently a high school senior, devote 10 weekends between May and September to attending dog agility competitions in Eugene and Portland, Ore., and in other Northwest locales.

"We're one of the few families that are doing this," Dr. Chester observed. "You might see a husband and a wife out there, but usually it's the husband or the wife, and there are very few kids out there, which is a shame because you can get college scholarships from this."

A family highlight came in 2006, when Teller, a papillon trained by Krystin, earned a MACH title. Teller "was an abused dog that we rescued; we'd had a lot of anger issues with him and tried to get him past those," Dr. Chester said. "Krystin became the first teenager in Alaska to get a MACH title, which is the highest title you can get with a dog. It was awesome to watch her do that and to also watch her bloom doing it, because she was always a reserved child. This helped bring her out."

The Alaska climate poses certain challenges to a consistent agility training routine. During the winter months, the family trains its dogs in an 80-by-60-foot building owned by friends. "You need a 100-by-100-foot space to have a really good training center, but this is good to keep them remembering what they are supposed to be doing," Dr. Chester said.

In the near future, she and her husband intend to build a training center on their own property that would serve as a competition site during the harsh winter months. For now, "all of our competitions are compacted into 3 months during the summer," she said. "It's frustrating because we spend almost every weekend during the summer doing dog agility. We'd like to fish, camp, hike, and do other things, but the dogs are taking so much of our time. We're hoping that if we put up this facility, we'll be able to spread out the competitions more."

But Dr. Chester isn't complaining too much. After all, she said, the magic that comes in the connection between dog and trainer is beyond measure. "It's a wonderful feeling to be out there training your dog, seeing that your dog 'gets it,' and to learn how smart dogs are," she said. "It's amazing how a little flick of the finger will send them one direction or another and that they understand these subtle commands."

A Whole Different Ball Game

Dr. Karen Reed has practiced dog obedience training since she was a child, but 7 years ago, she added dog agility training to her list of hobbies, which she considers a whole different ball game.

"Obedience training is so strict," said Dr. Reed, a pediatrician who practices in Wichita Falls, Tex., and is membership chair of the Obedience Training Club of Wichita Falls. "In agility, you can't touch the dogs when you're competing, but you can talk to them and cheer them on. It's so much fun."

In 2002, she was "looking for something new" to do with Allye, her then 4-year-old bearded collie, so the duo enrolled in weekly dog agility classes at a training facility in Rhome, Tex., which is a 1.5-hour drive from Wichita Falls.

"Many people in our obedience club also got interested, so we carpooled down there with our dogs and went through the beginning foundation class and up to training level 5," she recalled.

She did the same with Madeleine, a 6-year-old bearded collie she rescued from a shelter, but she and Allye, who is now 11, differ in their skill set on the agility course. She described Allye as "very focused" and Madeleine as a "wild child."

Allye "watches me all the time and is eager to do everything just right; when she finishes, she has the biggest smile on her face," Dr. Reed said. Madeleine, on the other hand, "is very social. During a competition if one of the club members she knows is in the ring as a steward, she's liable to go over and visit that person before completing the course. She also tends to work ahead of me, and sometimes she would rather take the A frame than go over a triple jump."

She and her dogs have competed in shows around Texas such as in McKinney, Las Colinas, Longview, Fort Worth, Dallas, and Houston, and they've also traveled to events in North Carolina and Colorado.

"We're competing, but I don't pressure them to compete rigorously," she said. "I'm on call almost every other weekend so I don't get to a whole lot of shows, but my goal is to get out there and have fun. I like to go to the shows and talk with the other dog lovers and watch the dogs run. I've learned a lot from how other people run their dogs."

She recently added another bearded collie, Sterling, to her family. Not yet a year old, Sterling is progressing with obedience training but Dr. Reed will wait until his joints and muscles mature (around age 2) before starting formal agility training.

For Dr. Reed, dog agility is a form of therapy. "Dogs are so forgiving; they just want to be with you, please you, and have fun," she explained. "My work as a pediatrician is pretty serious most of the time. I tend to worry about patients and take those worries home with me. But when I can just go out there and forget about my worries and concentrate on the dogs and how much fun they're having, it's a good bonding time with them. It's a good stress relief, as long as you're not too terribly serious about competing."

These days Dr. Reed doesn't have to cart Allye and Madeleine too far for competitions. The Obedience Training Club of Wichita Falls launched a club that stages twice yearly local agility events sanctioned by the American Kennel Club. The club also offers agility training for people who live in or near Wichita Falls and are unable or unwilling to travel further for training. "Many of these students are now competing in shows with their dogs and doing very well," she said. "It's opened up a whole new area of training possibilities in our area of Texas."

Dr. Reed would like to "get Sterling up to [the age when] he can train and get out there and have some fun, too. Mostly, it's to enjoy and be around the people who are also crazy about their dogs. There's a wide variety of people who train and compete in the sport. I've really enjoyed them, being part of their lives as well as spending time bonding and playing with my own dogs."

Dr. Donna Chester gives a command to Mysti, her wheaten terrier, during a run. COURTESY DR. DONNA CHESTER

Allye makes a jump as part of the obstacle course at a competition. BERT HENRY

Dr. Karen Reed trains three bearded collies: Allye, Madeleine, and Sterling. BERT HENRY

When Dr. Donna Chester steps onto the dog agility obstacle course with Penny, her 3-year-old papillon, she brings a team approach to the task ahead.

It's them against the course timer.

That sense of alliance isn't lost on Penny, either, said Dr. Chester, an ob.gyn. who practices in Anchorage, Alaska. "We're a team out there, and she knows it. It's giving her a job and it's giving me something to release my energy and have fun with."

To date, Penny has earned three "double Qs," meaning that she has run three agility courses perfectly and under the time allotted. She's also earned 350 points toward her first Master Agility Champion (MACH), which is the ultimate American Kennel Club agility title. (A MACH designation is earned when a dog runs 20 courses perfectly and runs them under the time allotted.)

Seven years ago, after watching her husband, Michael, guide dogs through agility tunnels, over teeter totters, and between weave poles in competitions as a hobby, Dr. Chester decided to follow suit. Her first experience came with Mysti, the family's wheaten terrier, who is now 9 years old and is the retired house dog. Dr. Chester worked with the terrier for 3 years on agility, and during the time she also learned a little about herself. During one competition a fellow trainer approached her and said, "You're too tense when you're out there. Mysti feels your tenseness. So if you don't relax, she's not going to."

Dr. Chester took the advice to heart and incorporated relaxation exercises into her precompetition regimen, a fix that led to positive results. "After that, I had 2 really good years of agility with her," Dr. Chester recalled. "When you connect like that with your dog, it's awesome. There is not a better feeling; there really isn't."

These days, she spends 1 hour 2 days per week and 10–15 minutes per day the rest of the week in training sessions with Penny "to keep things going." She and Michael and their daughter, Krystin, who is currently a high school senior, devote 10 weekends between May and September to attending dog agility competitions in Eugene and Portland, Ore., and in other Northwest locales.

"We're one of the few families that are doing this," Dr. Chester observed. "You might see a husband and a wife out there, but usually it's the husband or the wife, and there are very few kids out there, which is a shame because you can get college scholarships from this."

A family highlight came in 2006, when Teller, a papillon trained by Krystin, earned a MACH title. Teller "was an abused dog that we rescued; we'd had a lot of anger issues with him and tried to get him past those," Dr. Chester said. "Krystin became the first teenager in Alaska to get a MACH title, which is the highest title you can get with a dog. It was awesome to watch her do that and to also watch her bloom doing it, because she was always a reserved child. This helped bring her out."

The Alaska climate poses certain challenges to a consistent agility training routine. During the winter months, the family trains its dogs in an 80-by-60-foot building owned by friends. "You need a 100-by-100-foot space to have a really good training center, but this is good to keep them remembering what they are supposed to be doing," Dr. Chester said.

In the near future, she and her husband intend to build a training center on their own property that would serve as a competition site during the harsh winter months. For now, "all of our competitions are compacted into 3 months during the summer," she said. "It's frustrating because we spend almost every weekend during the summer doing dog agility. We'd like to fish, camp, hike, and do other things, but the dogs are taking so much of our time. We're hoping that if we put up this facility, we'll be able to spread out the competitions more."

But Dr. Chester isn't complaining too much. After all, she said, the magic that comes in the connection between dog and trainer is beyond measure. "It's a wonderful feeling to be out there training your dog, seeing that your dog 'gets it,' and to learn how smart dogs are," she said. "It's amazing how a little flick of the finger will send them one direction or another and that they understand these subtle commands."

A Whole Different Ball Game

Dr. Karen Reed has practiced dog obedience training since she was a child, but 7 years ago, she added dog agility training to her list of hobbies, which she considers a whole different ball game.

"Obedience training is so strict," said Dr. Reed, a pediatrician who practices in Wichita Falls, Tex., and is membership chair of the Obedience Training Club of Wichita Falls. "In agility, you can't touch the dogs when you're competing, but you can talk to them and cheer them on. It's so much fun."

In 2002, she was "looking for something new" to do with Allye, her then 4-year-old bearded collie, so the duo enrolled in weekly dog agility classes at a training facility in Rhome, Tex., which is a 1.5-hour drive from Wichita Falls.

"Many people in our obedience club also got interested, so we carpooled down there with our dogs and went through the beginning foundation class and up to training level 5," she recalled.

She did the same with Madeleine, a 6-year-old bearded collie she rescued from a shelter, but she and Allye, who is now 11, differ in their skill set on the agility course. She described Allye as "very focused" and Madeleine as a "wild child."

Allye "watches me all the time and is eager to do everything just right; when she finishes, she has the biggest smile on her face," Dr. Reed said. Madeleine, on the other hand, "is very social. During a competition if one of the club members she knows is in the ring as a steward, she's liable to go over and visit that person before completing the course. She also tends to work ahead of me, and sometimes she would rather take the A frame than go over a triple jump."

She and her dogs have competed in shows around Texas such as in McKinney, Las Colinas, Longview, Fort Worth, Dallas, and Houston, and they've also traveled to events in North Carolina and Colorado.

"We're competing, but I don't pressure them to compete rigorously," she said. "I'm on call almost every other weekend so I don't get to a whole lot of shows, but my goal is to get out there and have fun. I like to go to the shows and talk with the other dog lovers and watch the dogs run. I've learned a lot from how other people run their dogs."

She recently added another bearded collie, Sterling, to her family. Not yet a year old, Sterling is progressing with obedience training but Dr. Reed will wait until his joints and muscles mature (around age 2) before starting formal agility training.

For Dr. Reed, dog agility is a form of therapy. "Dogs are so forgiving; they just want to be with you, please you, and have fun," she explained. "My work as a pediatrician is pretty serious most of the time. I tend to worry about patients and take those worries home with me. But when I can just go out there and forget about my worries and concentrate on the dogs and how much fun they're having, it's a good bonding time with them. It's a good stress relief, as long as you're not too terribly serious about competing."

These days Dr. Reed doesn't have to cart Allye and Madeleine too far for competitions. The Obedience Training Club of Wichita Falls launched a club that stages twice yearly local agility events sanctioned by the American Kennel Club. The club also offers agility training for people who live in or near Wichita Falls and are unable or unwilling to travel further for training. "Many of these students are now competing in shows with their dogs and doing very well," she said. "It's opened up a whole new area of training possibilities in our area of Texas."

Dr. Reed would like to "get Sterling up to [the age when] he can train and get out there and have some fun, too. Mostly, it's to enjoy and be around the people who are also crazy about their dogs. There's a wide variety of people who train and compete in the sport. I've really enjoyed them, being part of their lives as well as spending time bonding and playing with my own dogs."

Dr. Donna Chester gives a command to Mysti, her wheaten terrier, during a run. COURTESY DR. DONNA CHESTER

Allye makes a jump as part of the obstacle course at a competition. BERT HENRY

Dr. Karen Reed trains three bearded collies: Allye, Madeleine, and Sterling. BERT HENRY

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS