First “pro,” now add “pre” for even more gut benefits

Over the past five years this newsletter has offered numerous articles about the health benefits of probiotics.

We have learned that because 80 percent of the immune cells in the human body are found lining the GI tract, it is critical that these cells see a normal, healthy microbiome (like a micro-ecosystem in the body.) Altering healthy gut flora leads to both a pro-inflammatory and a pro-allergic state, predisposing to auto-immune and allergic disorders.

Ingesting healthy microbes in the form of probiotics has proven to help. Now, new research is extending this approach to the use of prebiotics — foods that contain oligosaccharides (certain carbs with a few simple sugars) and fiber. These promote the establishment and flourishing of healthy gut bacteria. Some of the best in this category are:

dandelion greens       chicory root

asparagus       garlic           leeks        beans

banana           berries          artichokes

Interesting research on aboriginal peoples in New Guinea and Australia, whose diets are replete in prebiotics, shows almost no problems with autoimmune or allergic diseases.

Flu vaccine meets new booster


Recent research done at St. Jude Children’s Research Hospital in Memphis led to an unusual discovery!

Rapamycin, a drug normally used to suppress the immune system was found to bolster the powers of the flu vaccine.

Rapamycin was originally discovered in a soil sample taken on Easter Island (whose Polynesian name is Rapanui; hence, “rapamycin).” Early on it was found to have antifungal properties, but additional research revealed it to also have immunosuppressant and anti-tumor properties. Giving low doses to healthy mice, it actually increases their life span.

Its main use in humans is to prevent kidney transplant rejection. Taken in small amounts with the flu vaccine, it allows the immune cells in experimental animals to make high-level and broad-spectrum antibodies.

If human results prove similar, we may all end up taking a small amount of Rapamycin prior to our then once-every-10-years flu shot.

When managing iron supplements, turns out that less is more

We are obligate aerobic creatures requiring constant, good oxygenation. Allergic individuals sometimes have less than ideal oxygen delivery because of nasal obstruction or asthma.

If, in addition, they are anemic, then oxygen delivery to the tissues is reduced for a second reason.

Iron deficiency anemia is fairly common, especially in growing children and menstruating females. The usual therapy for this is oral iron supplementation. Until recently, this was recommended on a daily basis. However, recent research published in the Journal Blood is altering this advice.

It seems that within a few days of starting oral iron therapy our bodies make a peptide called hepcidin which inhibits intestinal iron absorption.  And so the very act of taking iron can put on the brakes, so to speak, of absorbing it. Trying twice or thrice a day dosing only increases the hepcidin levels more.

Luckily the researchers found a simple solution:  take the iron every other day.  This keeps hepcidin levels low and iron absorption high.

Battle plan for repeat sinus infections

Dear Dr. K: I don’t seem capable of getting just one sinus infection. Once I get the first one, I seem to get two or three more before it’s all over. Can anything be done?

At the risk of sounding smart-alecky, first and foremost, don’t get the first infection. By this I mean try to avoid catching colds or URIs (upper-respiratory infections). In general people don’t “catch” a sinus infection; it usually occurs as a sequel to a viral cold/URI that sets the stage. Beyond that, the usual advice applies: avoid exposing yourself to people who are acutely ill, use good handwashing technique, etc.

Regarding the repeated nature of your sinus infections, it actually may be one of two scenarios. First: You actually do get back-to-back-to-back infections. Second: You never fully get over the first infection.

Let’s tackle Scenario No. 2 first. It would be like the old Smoky the Bear forest fire ads: “Be sure the fire is completely out.” For most infections there are standard regimens such as 10 days of penicillin for strep throat. This is not true for sinusitis as it tends to be based more on a clinical response sliding scale. Often, sinus infections require 14 or even 21 days of therapy to eradicate.

It is generally best to continue therapy until the symptoms have resolved and mucus is clear in color.

Scenario No.1 is a little tougher. The two main culprits are: a polymicrobial infection or altered anatomy/physiology. In the first case the individual has two or more microbes causing the infection. This could be two or more bacteria, or a bacteria and a fungus. The person improves initially when the first pathogen dies, but if the second bacteria or fungus isn’t killed, it then flourishes to cause the “recurrent” infection.

In people prone to recurrent infections this is when obtaining a culture can be of great help. Cultures generally aren’t necessary and add to the cost of treatment, but if the polymicrobe scenario is suspected, then a culture can expose this issue.


“. . . By “altered anatomy/physiology” I mean the initial infection

either narrows or blocks the sinus entrance. . .”


The best way to get a sinus culture is during rhinoscopy by an ENT (Ear, Nose and Throat) doctor, but a close second is a simple nasal swab.

By “altered anatomy/physiology” I mean the initial infection either narrows or blocks the sinus entrance, or it alters the self-cleaning sinus membrane.

In the first instance, if the original infection leads to narrowing of the sinus entrance or the development of a polyp that blocks the entrance, you have a “closed space” situation. As the sinuses are not sterile spaces, if their opening is blocked, it’s just a matter of time before the native bacteria multiply to the point of infection.

Avoid this by seeking prompt treatment. If allowed to smolder, the original infection is more likely to lead to the tissue inflammation that can block the sinus. Also, use steroids systemically or topically to reduce this inflammation and restore openness. Finally, short (three-days’) use of a topical inhaled decongestant such as Afrin can sometimes pop open the sinus.

By “self-cleaning” sinus membrane I’m referring to the fact that our sinus cavities are lined with tiny cilia that beat in a way that moves bacteria out of our sinuses. Unfortunately, just as a second-degree burn causes the top layer of our skin to slough off, so too does an infection cause this ciliated epithelium to peel off. Just as our skin regrows, so does our sinus membrane — but it can take four-to-six weeks.

In the meantime, your sinuses are sitting ducks for the next virus/bacteria you’re exposed to. The best way out of this dilemma is sinus irrigation with saline solution. By rinsing your sinuses several times a day you provide a surrogate cleaning mechanism, and thus avoid re-infection during this susceptible period.

Q – Tips: venom

  • Stanford researchers found an interesting paradox: Individuals with venom allergy (bees, wasps, etc.) are less likely to die from the toxic poison effect of venoms, such as from hundreds of bee stings or snake bites (!) Reason: The chemicals released by mast cells (the allergy cells that cause allergic symptoms), inactivate the biologic poison of the venom.

News about Vitamin B3 abilities to prevent skin and pre-cancers

Research emanating from Sydney, Australia reports the use of a form of Vitamin B3 (Niacin) to prevent skin cancers.  With the pharmacy name Nicotinamide, it is the “amide” form of the vitamin and as such, doesn’t cause the unpleasant side effects of niacin. These include flushing, itching, headache and changes in blood pressure.

Nicotinamide has been used for its anti-inflammatory properties in some other types of skin conditions such as eczema and pemphigus. It seems to work in preventing skin cancers and pre-cancers because it is an essential co-factor for producing adenosine triphosphate (ATP). Ultra-violet radiation depletes ATP in the skin, which is essential for repairing sun-damaged DNA. If DNA is not repaired, the cells go astray and become cancerous.

Patients in the Australian study had a 23-to-30 percent reduction of skin cancers as compared to the placebo group. Also, there was a 20 percent reduction in actinic keratosis (pre-skin cancer lesions) in the Nicotinamide group as compared to the placebo group.

EoE: Feeding, swallowing issues differ from symptoms of GERD

EoE is the acronym for eosinophilic esophagitis. Once thought to be an uncommon condition, it is now recognized as one of the most common reasons for feeding problems in infants and for dysphagia (difficulty swallowing) and food impaction in adults.

Until the early 1990s EoE was lumped in with the GERD diagnosis (gastroesophageal reflux disease). But in the ‘90s researchers started to recognize that EoE was a different critter. The clinical symptoms were different from classic GERD, and the patients tend not to respond to acid suppression therapy, or anti-reflux surgery.

In children EoE causes feeding problems, vomiting and abdominal pain. In adolescents and adults it causes discomfort with swallowing and food impaction episodes. The reason for these symptoms is inflammation in the esophagus caused by the presence of the white blood cell – eosinophil (as opposed to acid-related inflammation in GERD).

The eosinophil can be seen on biopsies taken from the esophagus during upper endoscopy. It is believed the eosinophils infiltrate the esophagus in response to either or both allergens and altered microbiome. The allergens can be either food allergies or airborne. It may sound weird, but part of the self-cleaning process of our sinuses is to filter allergens, wrap them in mucus and then send them out of the body via swallowing them. As these aero allergens pass through the esophagus they can elicit the eosinophil response.

Treatment consists of two main approaches. First is to identify and then avoid food and airborne allergens. Second is topical corticosteroids. These can be administered either by swallowing the spray from a steroid asthma inhaler, or by viscous preparation of a liquid asthma steroidal normally used in a nebulizer.

Dear Doc: New drug helps certain types of asthma

Dear Dr. K: What can you tell me about the new asthma drug, Nucala?

It is just newly released by the FDA, seems very promising; unfortunately, it is not for you.

Because I’ve helped you with your asthma for several years, I am aware that you don’t have eosinophilic asthma, and thus, would not be a candidate for this new drug.

Nucala’s pharmacologic name is mepolizumab is a monoclonal antibody whose target is interleukin–5 (IL\-5). It is delivered in a subcutaneous injection that is given once a month in a doctor’s office. It is designed for severe asthmatics aged 12 years or older, who have the eosinophilic type of asthma.

IL-5 is the main cytokine responsible for growth, recruitment, activation and survival of eosinophils – one form of white blood cell that causes airway inflammation in a large number of asthmatics. By inhibiting IL-5, you prevent the eosinophils from getting into the lungs to create their mischief.

One criterion for being a candidate for Nucala is having a blood eosinophil count of 300 cells/mcl.

The drug trials revealed excellent improvement in target patients who received the drug, including better control of their asthma with fewer exacerbations. Also, a large percentage of asthmatics on oral steroids were able to reduce their steroid dose or go off oral steroids while receiving Nucala.

Several patients on Nucala had shingles during the trial, so a shingles vaccine is recommended prior to starting treatment.

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