1 APPROACH TO THE PATIENT & HEALTH MAINTENANCE APPROACH TO THE PATIENT & HEALTH MAINTENANCE CHAPTER...

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APPROACH TO THEAPPROACH TO THE PATIENT PATIENT

& & HEALTH MAINTENANCEHEALTH MAINTENANCE

CHAPTER 1CHAPTER 1

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PATIENT COMPLIANCEPATIENT COMPLIANCEWHAT’S THE PROBLEM?WHAT’S THE PROBLEM?

Compliance is difficult, and is a problem.Compliance is difficult, and is a problem. 50% fail50% fail 1/3 never take their meds.1/3 never take their meds. drop out prematurely.drop out prematurely. Short-term compliance betterShort-term compliance better Long-term difficultLong-term difficult Compliance better with-Compliance better with- Medication takingMedication taking Not good with non medication Not good with non medication adviseadvise

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PATIENT COMPLIANCEPATIENT COMPLIANCEHOW CAN WE HELP?HOW CAN WE HELP?

1) Define / agree on treatment goals.1) Define / agree on treatment goals.

2) Spell out the treatment plan.2) Spell out the treatment plan.

3) Emphasize the importance of compliance, and the 3) Emphasize the importance of compliance, and the consequences of non-compliance.consequences of non-compliance.

4) During follow-up, ask detailed questions about how 4) During follow-up, ask detailed questions about how they are complying. they are complying.

5) Educate, educate, educate!5) Educate, educate, educate!

6) Enlist Family help6) Enlist Family help

7) Set up mutually understood goals for compliance7) Set up mutually understood goals for compliance ““To cure sometimes, to relieve often, to To cure sometimes, to relieve often, to comfort alwayscomfort always.. ““The secret of the care of the patient is in caring for The secret of the care of the patient is in caring for

the patient.”the patient.”

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National Commission Prevention PrioritiesNational Commission Prevention Priorities 2004 data: (<50% utilization)2004 data: (<50% utilization) Aspirin usage for preventionAspirin usage for prevention Tobacco use screening and interventionsTobacco use screening and interventions Immunizing children, older adultsImmunizing children, older adults Young women screens for chlaymydiaYoung women screens for chlaymydia

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HEALTH MAINTENANCE & DISEASE HEALTH MAINTENANCE & DISEASE PREVENTIONPREVENTIONGENERAL.GENERAL.PREVENTION OF INFECTIOUS DISEASE.PREVENTION OF INFECTIOUS DISEASE.PREVENTION OF CARDIOVASCULAR DISEASE.PREVENTION OF CARDIOVASCULAR DISEASE.PREVENTION OF PHYSICAL INACTIVITY.PREVENTION OF PHYSICAL INACTIVITY.PREVENTION OF OBESITY / OVERWEIGHT.PREVENTION OF OBESITY / OVERWEIGHT.CANCER PREVENTION.CANCER PREVENTION.PREVENTION OF INJURIES & VIOLENCE.PREVENTION OF INJURIES & VIOLENCE.SUBSTANCE ABUSE.SUBSTANCE ABUSE.

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HEALTH MAINTENANCE & DISEASE HEALTH MAINTENANCE & DISEASE PREVENTION: 2009PREVENTION: 2009

GENERALGENERAL ESTIMATED DEATHS FROM PREVENTABLE CAUSES:ESTIMATED DEATHS FROM PREVENTABLE CAUSES: TOBACCOTOBACCO- 467,000 - 467,000 HGH BLOOD PRESSURE – 395,000HGH BLOOD PRESSURE – 395,000 POOR DIET- 216,000 POOR DIET- 216,000 PHYSICAL INACTIVITY- 191,000PHYSICAL INACTIVITY- 191,000 HIGH BLOOD GLUCOSE- 190,000 HIGH BLOOD GLUCOSE- 190,000 HIGH CHOLESTEROL - 113,000HIGH CHOLESTEROL - 113,000 HIGH SALT DIET- 102,000HIGH SALT DIET- 102,000 HIGH TRANS FATS- 82,000HIGH TRANS FATS- 82,000 LOW SEAFOOD- 84,000LOW SEAFOOD- 84,000 LOW FRUITS/VEGS- 58,000LOW FRUITS/VEGS- 58,000 LOW PUFA- 15,000LOW PUFA- 15,000 ACLOCHOL ABUSE- 64,000ACLOCHOL ABUSE- 64,000

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CARDIOVASCULAR PREVENTIONCARDIOVASCULAR PREVENTION

Abdominal Aortic Aneurysm (AAA)-65-75 Abdominal Aortic Aneurysm (AAA)-65-75 smoking malessmoking males

Aspirin Use- Aspirin Use- BP ScreeningBP Screening Serum lipid screeningSerum lipid screening Counseling healthy dietCounseling healthy diet Counseling to promote physical activityCounseling to promote physical activity Diabetes screeningDiabetes screening Smoking cessation and quitSmoking cessation and quit

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HEALTH MAINTENANCE & DISEASE HEALTH MAINTENANCE & DISEASE PREVENTIONPREVENTION

GENERALGENERAL The #1 cause of preventable death in the U.S. is from The #1 cause of preventable death in the U.S. is from

tobacco-related diseases.tobacco-related diseases. Therefore, if you had to tell patients one thing they could Therefore, if you had to tell patients one thing they could

do to improve their health and alter the age at which they do to improve their health and alter the age at which they die, and from what they die, it would be smoking cessation.die, and from what they die, it would be smoking cessation.

Of the 70% of smokers who see a physician each year, only Of the 70% of smokers who see a physician each year, only 20% receive information on quitting.20% receive information on quitting.

Smokers whose physicians advise them to quit are 1.6 Smokers whose physicians advise them to quit are 1.6 times more likely to attempt to quit.times more likely to attempt to quit.

See text pages for smoking cessation strategies, tricks, etc.See text pages for smoking cessation strategies, tricks, etc.

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PREVENTION OF INFECTIOUS DISEASESPREVENTION OF INFECTIOUS DISEASES IMMUNIZATIONSIMMUNIZATIONS- “Best means of preventing many - “Best means of preventing many

infectious diseases.”infectious diseases.” In the U.S., have nearly eradicated: measles, mumps, In the U.S., have nearly eradicated: measles, mumps,

rubella, polio, diphtheria, pertussis, tetanus.rubella, polio, diphtheria, pertussis, tetanus. Still have work to do on: hepatitis A & B, influenza, Still have work to do on: hepatitis A & B, influenza,

pneumococcal infectious (50,000-70,000 deaths per pneumococcal infectious (50,000-70,000 deaths per year in the U.S.).year in the U.S.).

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Last update:Last update:

10/28/200710/28/2007

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PREVENTION OF CARDIOVASCULAR DISEASEPREVENTION OF CARDIOVASCULAR DISEASE CIGARETTE SMOKING.CIGARETTE SMOKING. LIPID DISORDERS.LIPID DISORDERS. HYPERTENSION.HYPERTENSION. CHEMOPREVENTION.CHEMOPREVENTION.

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PREVENTION OF CARDIOVASCULAR DISEASEPREVENTION OF CARDIOVASCULAR DISEASE

MODIFIABLE RISK FACTORS:MODIFIABLE RISK FACTORS: 1) Smoking.1) Smoking. 2) Lipid disorders.2) Lipid disorders. 3) Hypertension.3) Hypertension. 4) Lifestyle / behavioral factors- activity level, diet, weight 4) Lifestyle / behavioral factors- activity level, diet, weight

control, alcohol, etc.control, alcohol, etc. 5) Diabetes.5) Diabetes. 6) Type “A” personality, stre6) Type “A” personality, stresss.s.

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PREVENTION OF CARDIOVASCULAR DISEASEPREVENTION OF CARDIOVASCULAR DISEASE

NON-MODIFIABLE RISK FACTORS:NON-MODIFIABLE RISK FACTORS: 1) Gender.1) Gender. 2) Age.2) Age. 3) Family history.3) Family history. The good news is that many of the modifiable risk The good news is that many of the modifiable risk

factors can be addresses by the same modifications: factors can be addresses by the same modifications: diet, exercise, weight control, etc., which happen to diet, exercise, weight control, etc., which happen to be the same things one would do to prevent be the same things one would do to prevent physical physical inactivity and obesity.inactivity and obesity.

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PREVENTION OF PHYSICAL INACTIVITYPREVENTION OF PHYSICAL INACTIVITYAn “older” non-smoking male who walks at least 2 miles An “older” non-smoking male who walks at least 2 miles

per day has a 50% reduction in cardiovascular per day has a 50% reduction in cardiovascular mortality.mortality.Relative risk of stroke is less than 1/6Relative risk of stroke is less than 1/6thth that of those who that of those who

are inactive.are inactive.Benefits are dose-dependent – there is a major Benefits are dose-dependent – there is a major difference difference

between no exercise and mild-between no exercise and mild- moderate exercise, but moderate exercise, but less less difference between moderate and vigorous exercise.difference between moderate and vigorous exercise.Any activity is better than no activity.Any activity is better than no activity.Gym membership, fancy-schmancy equipment, Gym membership, fancy-schmancy equipment, organized organized sports not required; activity can be sports not required; activity can be incorporated incorporated into into anyone’s daily routine: stairs instead anyone’s daily routine: stairs instead of elevator, park of elevator, park farther away from the office / H.E.B, etc.farther away from the office / H.E.B, etc.Baby steps.Baby steps.

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LIFESTYLE MODIFICATIONLIFESTYLE MODIFICATION

DIET –OBESITYDIET –OBESITYAA risk factor for cancers of the: risk factor for cancers of the: Breast, colon & rectum, and Breast, colon & rectum, and

lung, even in non-smokers.lung, even in non-smokers. Increased BMI* and Increased BMI* and

hypertension associated w/ hypertension associated w/ increased risk of renal cell increased risk of renal cell carcinoma in men.carcinoma in men.

*BMI= body mass index *BMI= body mass index kg/m2 kg/m2

http://apps.usa.gov/bmi-app/http://apps.usa.gov/bmi-app/ 2007 Survey: 63% of 2007 Survey: 63% of

Americans are Americans are overweight, with 26% now overweight, with 26% now in the obese category (a in the obese category (a BMI of 30 or more)BMI of 30 or more)

CategoryBMI range –

kg/m2

EmaciationEmaciation less than 16.0 less than 16.0

UnderweightUnderweight from 16.0 to from 16.0 to 18.5 18.5

NormalNormal from 18.5 to 25 from 18.5 to 25

OverweightOverweight from 25 to 30 from 25 to 30

Obese Class IObese Class I from 30 to 35from 30 to 35

Obese Class Obese Class IIII

from 35 to 40from 35 to 40

Obese Class Obese Class IIIIII Over 40Over 40

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PREVENTION OF OBESITY & OVERWEIGHTPREVENTION OF OBESITY & OVERWEIGHT

These data show an increase in the prevalence These data show an increase in the prevalence of of obesity of obesity of 74%74% compared to 1991. compared to 1991.Obesity is associated with an increase in: type Obesity is associated with an increase in: type II II diabetes, hypertension, cancer (lots of diabetes, hypertension, cancer (lots of ‘em), ‘em), osteoarthritis, cardiovascular disease, osteoarthritis, cardiovascular disease, obstructive sleep apnea, and asthma.obstructive sleep apnea, and asthma.With the rise in obesity since 1991, the With the rise in obesity since 1991, the prevalence prevalence of type II diabetes has increased of type II diabetes has increased 30-40%.30-40%.BMI > 40 associated with a death rate from BMI > 40 associated with a death rate from cancer 52% higher for men and 62% higher for cancer 52% higher for men and 62% higher for women compared to the non-obese.women compared to the non-obese.

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PREVENTION OF OBESITY & OVERWEIGHTPREVENTION OF OBESITY & OVERWEIGHT Nine million are obese and also smoke Nine million are obese and also smoke Obesity and smoking are primary risk Obesity and smoking are primary risk

factors for from early death from several factors for from early death from several chronic conditions chronic conditions

5.3% of men and 4.2% of women are in the 5.3% of men and 4.2% of women are in the dual-risk subgroup (African Americans (7%) dual-risk subgroup (African Americans (7%) than among other racial or ethnic groups, than among other racial or ethnic groups, and also among people in lower-income and also among people in lower-income (6.5%) and low-education brackets (6.1%).)(6.5%) and low-education brackets (6.1%).)

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http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid/index.htmlhttp://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid/index.html

Start with exercise. Start with exercise. Focus on food, not gramsFocus on food, not gramsGo with plants.Go with plants.Cut way back on American staples.Cut way back on American staples.Take a multivitamin, and maybe have Take a multivitamin, and maybe have drink. drink.

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CANCER PREVENTIONCANCER PREVENTION Primary prevention.Primary prevention. Screening and early detection.Screening and early detection.

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CANCER PREVENTION: CANCER PREVENTION: PRIMARY PREVENTIONPRIMARY PREVENTION..

Smoking.Smoking.UV exposure.UV exposure.Obesity- esp. of breast and colon.Obesity- esp. of breast and colon.Occupational- asbestos etc.Occupational- asbestos etc.Not mentioned in your text is dietary, such as diets rich Not mentioned in your text is dietary, such as diets rich in in fiber, Vitamins A, C, fiber, Vitamins A, C, & E, and lower in sugars and & E, and lower in sugars and fats are fats are associated w/ a decreased risk of colon cancer. associated w/ a decreased risk of colon cancer. (ONLY (ONLY Calcium and Aspirin!)Calcium and Aspirin!)

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SCREENING & EARLY DETECTIONSCREENING & EARLY DETECTION See text, table 1-2, 1-9 for specifics.See text, table 1-2, 1-9 for specifics. High yield w/ screening for breast, colon, and uterine High yield w/ screening for breast, colon, and uterine

cervix.cervix. Controversial for prostate.Controversial for prostate.

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PREVENTION OF OBESITY & OVERWEIGHTPREVENTION OF OBESITY & OVERWEIGHT ““Weight management is simple, but it isn’t easy.”Weight management is simple, but it isn’t easy.” It’s about the balance of calories consumed and calories It’s about the balance of calories consumed and calories

burned. That’s the simple part.burned. That’s the simple part. It’s about It’s about permanentpermanent life-style, dietary, behavioral, and life-style, dietary, behavioral, and

psychological changes. It’s not about “dieting”, magic bullets, psychological changes. It’s not about “dieting”, magic bullets, supplements or any of that “burn fat while you sleep” stuff, supplements or any of that “burn fat while you sleep” stuff, which I can’t believe we let them get away with. That’s the part which I can’t believe we let them get away with. That’s the part that isn’t easy.that isn’t easy.

Did I mention that these changes need to be permanent? As in Did I mention that these changes need to be permanent? As in for life, forever, and always.for life, forever, and always.

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PREVENTION OF INJURIES & VIOLENCEPREVENTION OF INJURIES & VIOLENCE MVA’s- seat belts, helmets, etc.MVA’s- seat belts, helmets, etc. Domestic violence- Domestic violence- Alcohol (again)- as it relates to MVA’s, domestic Alcohol (again)- as it relates to MVA’s, domestic

violence, suicide.violence, suicide. Prevention of falls in the elderly.Prevention of falls in the elderly.

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SUBSTANCE ABUSESUBSTANCE ABUSE Alcohol, prescription drugs, illegal drugs including Alcohol, prescription drugs, illegal drugs including

inhalants.inhalants. ““Clinician identification and counseling may improve Clinician identification and counseling may improve

the chances of recovery.”the chances of recovery.”

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COMPLEMENTARY & COMPLEMENTARY & ALTERNATIVE MEDICINEALTERNATIVE MEDICINE

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CAMCAM AN OVERVIEW.AN OVERVIEW. HERBAL MEDICINES.HERBAL MEDICINES. DIETARY SUPPLEMENTS.DIETARY SUPPLEMENTS. ACUPUNCTURE. ACUPUNCTURE.

(see reading resource supplement f-MRI (see reading resource supplement f-MRI datasets)datasets)

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WHAT IS CAM?WHAT IS CAM?ACCORDING TO THE NIH, IT IS:ACCORDING TO THE NIH, IT IS:

““A group of diverse health care systems, A group of diverse health care systems, practices, and products that are not practices, and products that are not PRESENTLY considered to be part of PRESENTLY considered to be part of conventional medicine.”conventional medicine.”

Maybe what is considered to be conventional Maybe what is considered to be conventional is in the eye of the beholder.is in the eye of the beholder.

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WHAT IS CAM?WHAT IS CAM?5 MAJOR CATEGORIES5 MAJOR CATEGORIES

1) BIOLOGICALLY BASED-1) BIOLOGICALLY BASED- substances found substances found in nature- herbs, special diets, vitamins.in nature- herbs, special diets, vitamins.

2) ENERGY MEDICINE- 2) ENERGY MEDICINE- Reiki, external Reiki, external Qigong, therapeutic touch.Qigong, therapeutic touch.

3) MANIPULATIVE / BODY-BASED-3) MANIPULATIVE / BODY-BASED- massage, massage, chiropractic, etc.chiropractic, etc.

4) MIND-BODY-4) MIND-BODY- meditation, prayer, imagery, meditation, prayer, imagery, etc.etc.

5) WHOLE MEDICAL SYSTEMS-5) WHOLE MEDICAL SYSTEMS- acupuncture, acupuncture, ayurveda, homeopathy, naturopathy, ayurveda, homeopathy, naturopathy, shaman, (Tibetan) traditional Oriental shaman, (Tibetan) traditional Oriental medicine, medicine,

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FACTS AND FIGURESFACTS AND FIGURESCDC NHIS SURVEY 2003CDC NHIS SURVEY 2003

38% of American Adults used some form of CAM in 38% of American Adults used some form of CAM in the previous 12 months.the previous 12 months.

When prayer and megavitamins included → 68%.When prayer and megavitamins included → 68%. Most popular therapy was prayer, 2Most popular therapy was prayer, 2ndnd were the were the

“biologically-based therapies”: herbs, dietary “biologically-based therapies”: herbs, dietary supplements.supplements.

1997- $36 billion, mostly out of pocket.1997- $36 billion, mostly out of pocket.

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CAM UsageCAM UsagePrayer-Self, 43%Prayer-Self, 43%Prayer by others, 24% Prayer by others, 24% Natural products 19 % Natural products 19 % Deep breathing exercises,12% Deep breathing exercises,12% Prayer group for own health, Prayer group for own health, 10 % 10 % Meditation, 8% Meditation, 8% Chiropractic care, 8%Chiropractic care, 8% Yoga, 5 % Yoga, 5 % Massage, 5 % Massage, 5 % Diet-based therapies (such as Diet-based therapies (such as Atkins, Pritikin, Ornish, and Atkins, Pritikin, Ornish, and Zone Zone diets), 4 %.diets), 4 %.

55 percent: use CAM 55 percent: use CAM combined with conventional combined with conventional medical treatments; medical treatments;

50 percent: CAM “interesting 50 percent: CAM “interesting to try” to try”

26 percent used CAM as 26 percent used CAM as prescribed by MD and prescribed by MD and

13 percent used CAM because 13 percent used CAM because conventional medicine was conventional medicine was too expensive.too expensive.

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?CAM Users?CAM Userswomenwomenpeople with higher educationpeople with higher educationthose who had been hospitalized within the those who had been hospitalized within the past year past year former smokers, compared to current former smokers, compared to current smokers or those who had never smokedsmokers or those who had never smoked

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FACTS AND FIGURESFACTS AND FIGURESCDC NHIS SURVEY 2003CDC NHIS SURVEY 2003

These patients used CAM therapies for:These patients used CAM therapies for: Musculoskeletal complaints.Musculoskeletal complaints. Colds.Colds. Anxiety, depression.Anxiety, depression. GI problems.GI problems. Sleep disorders.Sleep disorders.

Same as for most primary care practices.Same as for most primary care practices.

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FACTS AND FIGURESFACTS AND FIGURESTHE BAD NEWSTHE BAD NEWS

Only 12% sought CAM treatment advice from a Only 12% sought CAM treatment advice from a licensed CAM practitioner.licensed CAM practitioner.

The rest used CAM on their own.The rest used CAM on their own.THE GOOD NEWSTHE GOOD NEWS

The other 88% is your potential patient base.The other 88% is your potential patient base. CAM spending by public $47billion (1997)CAM spending by public $47billion (1997) Includes $20billion out of pocket spending Includes $20billion out of pocket spending

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HERBAL MEDICINESHERBAL MEDICINESFACTS & FIGURESFACTS & FIGURES

Used by 1 in 3 Americans.Used by 1 in 3 Americans. $40 billion annually.$40 billion annually. Fewer than half discuss the matter with a Fewer than half discuss the matter with a

conventional health care provider.conventional health care provider. Why is this?Why is this? What does it matter?What does it matter?

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HERBAL MEDICINESHERBAL MEDICINES

REGULATORY ISSUESREGULATORY ISSUES DSHEA - 1994 – Dietary Supplement & DSHEA - 1994 – Dietary Supplement &

Health Education Act.Health Education Act. Classified vitamins, minerals, herbs, and Classified vitamins, minerals, herbs, and

amino acids as dietary supplements, and amino acids as dietary supplements, and allows for their marketing (and sale) as long allows for their marketing (and sale) as long as no claims are made for their use in the as no claims are made for their use in the diagnosis, treatment, cure, or prevention of diagnosis, treatment, cure, or prevention of disease.disease.

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HERBAL MEDICINESHERBAL MEDICINES

REGULATORY ISSUESREGULATORY ISSUES DSHEA - 1994 – Dietary Supplement & DSHEA - 1994 – Dietary Supplement &

Health Education Act.Health Education Act. Can make “structure and function” claims – Can make “structure and function” claims –

supports urinary health, for example.supports urinary health, for example. No need to show it is safe and effective, No need to show it is safe and effective,

which is the standard required by the FDA of which is the standard required by the FDA of drugs.drugs.

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ACUPUNCTUREACUPUNCTURE

The NIH Consensus Conference on Acupuncture, The NIH Consensus Conference on Acupuncture, 1993.1993.

JAMA. 1998 Nov 4: 280(17): 1518-24.JAMA. 1998 Nov 4: 280(17): 1518-24. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin Berman BM, Lao L, Langenberg P, Lee WL, Gilpin

AMK, Hochberg MC. Effectiveness of Acupuncture as AMK, Hochberg MC. Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Randomized, Controlled Trial. Annals of Internal Annals of Internal MedicineMedicine. 2004; 141(12):901-910. . 2004; 141(12):901-910.

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NIH CONSENSUSNIH CONSENSUSPromising results have emerged showing efficacy of Promising results have emerged showing efficacy of acupuncture in:acupuncture in: √√nausea and vomiting: adult postoperative and nausea and vomiting: adult postoperative and chemotherapy related chemotherapy related √√ in postoperative dental pain in postoperative dental pain √√ addictionaddiction√√ stroke rehabilitationstroke rehabilitation√√ headacheheadache√√ menstrual crampsmenstrual cramps√√ tennis elbowtennis elbow√√ fibromyalgia, myofascial pain, fibromyalgia, myofascial pain, √√ osteoarthritis, low back pain, carpal tunnel syndromeosteoarthritis, low back pain, carpal tunnel syndrome√√ asthmaasthma““Further research is likely to uncover additional areas Further research is likely to uncover additional areas where acupuncture interventions will be useful.”where acupuncture interventions will be useful.”

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COMPLICATIONSCOMPLICATIONS““adverse events.”adverse events.”Frequency estimated at between 1:10,000 - Frequency estimated at between 1:10,000 - 1:100,000.1:100,000.14 year review of the world literature identified 193 14 year review of the world literature identified 193 complications (I suppose they meant “adverse complications (I suppose they meant “adverse events” also), another 30 year review identified 300.events” also), another 30 year review identified 300.

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Potential adverse events associated with acupuncturePotential adverse events associated with acupunctureCOMMON ADVERSE EVENTS RARE COMPLICATIONS Fainting during treatment Pneumothorax Nausea and vomiting Spinal cord injury Increased pain Hepatitis B Diarrhea Septicemia Local skin irritation Punctured organs • Bruising Convulsions • Needle site bleeding Argyria

Psychiatric disturbance Headaches Sweating Dizziness Aggravation of symptoms Needle breakage

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Precautions for needling certain areas of the bodyPrecautions for needling certain areas of the body

Pregnant women, avoid needling points on the abdomen and lumbar region, and certain points known to cause strong sensations (large intestine 4, spleen 6, bladder 60, bladder 67)

Avoid points on the scalps of infants with open fontanelles

Needling points close to the eyeball requires definite angle, depth, and skill (stomach 1, gallbladder 1, bladder 1). Avoid using these points and avoid manual manipulation, such as lifting or thrusting

Avoid deep perpendicular penetration of points on thoracic and lumbar regions due to risk of puncturing internal organs

Deep penetration of gallbladder 21 puts patients at risk of pneumothorax

Deep penetration of ren/governing vessel 17 puts patients at risk of heart injury

Avoid deep penetration of points at base of skull inferior to occiput (gallbladder 20, ren/governing vessel 16, and bladder 10) due to risk of injuring the medulla oblongata

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Risk factors for complications of acupunctureRisk factors for complications of acupuncture

• BLEEDINGBLEEDING

Hemophilia can affect clotting factors

Advanced liver disease could compromise production of clotting factors

Patients taking blood thinners could bleed for longer periods

• INFECTIONINFECTIONPatients with HIV infection or immunocompromised patients are at increased risk of

opportunistic infections

Patients with diabetes are subject to poor wound healing; neuropathy can reduce sensory ability, leaving them at increased risk of undetected infection

Patients who have had transplants often take immune suppressants that make them prone to infections

High-dose steroids suppress the immune system

Open wounds increase risk of infection

• FAINTINGFAINTING

Hypoglycemic, nervous, or very fatigued patients might faint

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COMPLICATIONSCOMPLICATIONS

Most frequent are vasovagal Most frequent are vasovagal syncope and sedating syncope and sedating reactions, drowsiness.reactions, drowsiness.Cardiac Tamponade (Cardiac Tamponade (Chest. 2000;117:1510-1511.)Chest. 2000;117:1510-1511.)

If ya do it right, there shouldn’t be any cases of If ya do it right, there shouldn’t be any cases of transmission of blood-borne infections.transmission of blood-borne infections.

HOWEVER……HOWEVER……According to Memorial Sloan Kettering….According to Memorial Sloan Kettering….

▲ ▲ Pregnant womenPregnant women ▲▲ Patients with lymphedemaPatients with lymphedema ▲▲ Those wearing pacemakers, or Those wearing pacemakers, or ▲▲ Those with low platelet count Those with low platelet count

should inform should inform their practitioners before receiving treatment.their practitioners before receiving treatment.

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COMPLICATIONSCOMPLICATIONS

Can be reduce by Excellent Training!Can be reduce by Excellent Training!**less than 1 year’s training resulted in 2.07 adverse events less than 1 year’s training resulted in 2.07 adverse events per year; per year; 37 to 48 months’ training reduced this to 1.35 adverse 37 to 48 months’ training reduced this to 1.35 adverse events per year; and events per year; and 49 to 60 months’ training reduced this further to 0.92 49 to 60 months’ training reduced this further to 0.92 adverse events per yearadverse events per year

*Bensoussan A, Myers SP. Towards a safer choice. The *Bensoussan A, Myers SP. Towards a safer choice. The practice practice of traditional Chinese medicine in Australia. of traditional Chinese medicine in Australia. Sydney, Australia: Sydney, Australia: Macarthur; 1996.Macarthur; 1996.

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