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Author: Stephen J. Klemawesch, MD

Dear Dr K:

Dear Dr K:

You tested me to see if my childhood recollection of penicillin allergy was still valid.  Even though the tests showed I was not allergic my PCP still won’t prescribe it when I need an antibiotic.  Why the reluctance?

The simple and short answers are; medical malpractice and labeling.  Roughly 10% of malpractice suits are concerning medication errors.  Physicians are aware of this.  For some reason, once a person is labeled as “penicillin allergic” there is great reluctance to remove this label.  As it turns out, 12% of the American population carries this label.  However, when academic centers have done studies to confirm this diagnosis only 5% of this group is actually proven to be allergic.  So, to look at that in terms of numbers; for every 1,000 Americans 120 carry the penicillin label and only 6 are actually allergic.

The problem is that of these 6 individuals the potential exists for a life-threatening anaphylactic reaction.  So, many people (including doctors) choose what at first blush seems to be the safer route: avoid penicillin.  Unfortunately, this in not always a safer choice.  By denying the patient the “first line” treatment choice it results in utilizing less desirable and problematic antibiotics such as fluoroquinolones, vancomycin and clindamycin.  These antibiotics have their own potential to cause medical mischief such as tendon rupture, Clostridium difficile (C. diff) colitis, and the development of super resistant bacteria such as MRSA and VRE (vancomycin – resistant – enterococcus).  The University of Oregon has done research into this problem.  They posit that roughly 30 million Americans are mislabeled as penicillin allergic.  They found that patients so labeled have increased medical costs and longer hospital stays compared with patients not felt to be penicillin allergic.  The other dynamic that the University of Oregon researchers studied was the question of cross reactivity between penicillin and a separate family of antibiotics called cephalosporins.

Again, they discovered that most doctors will not prescribe cephalosporins to patients with penicillin allergy because of a fear of cross reactivity.  In fact, drug manufacturers include in their package insert the possibility for this interaction even though there is little or no evidence from scientific studies of a cross reactivity.  Most recent research would indicate that the small number of individuals who are allergic to both penicillin and cephalosporin have this dual allergy not because of a direct cross reactivity but because being an allergic individual per se raises their risk for developing separate but individual drug allergies.

Shocking News!

Shocking News!

By: Sasha Klemawesch, MD

 

Electrically augmented wound healing may seem farfetched.  I mean, most people were taught not to stick their finger in the light socket.  So, exploiting electricity to help heal wounds may seem ludicrous.  But when you think about it, doctors have been using electricity in various forms for years.  Even back in ancient Greece, there is evidence of electric eels being used in foot basins to help with circulation and pain.  Nowadays, Pacemakers and AICD’s (implantable defibrillators) are literally lifesaving for some cardiac patients.  TENS units can provide some relief to some chronic pain patients that feels lifesaving.  And ECT (shock therapy) can be life changing in patients with refractory depression.

But how does electricity help in wounds?  Turns out, in several ways.  A diverse array of studies exists reporting on a variety of forms of electric manipulation.  Conclusions from those include: improved surgical results, reduced infection, improved immunity and circulation, shortened healing times, improved flap and graft survival, and novel options for addressing complex and recalcitrant chronic wounds.

Again, you ask, “but how”?  Well, electric stimulation leads to increased fibroblast activity (fibroblasts are some of the building blocks of cells).  It inhibits the growth of many bacteria, and lowered bacterial load in the wound helps mean less hurdles to wound closure.  It increases perfusion to skin and veins, the latter due to increased vascular endothelial growth factor leading in turn to increased angiogenesis (blood flow).  And it also causes increased white blood cell migration to the site, especially neutrophils which help in fighting infection and macrophages which can help clean up the debris of the old dead wound parts.

Knowing all this, researchers have created a self-powered electric bandage (all the aforementioned studies utilized externally sourced/applied electricity).  Their invention is essentially a bandage containing tiny overlapping sheets of copper and other conductive materials as well as a built in nanogenerator.  Everyday movements lead to the sides of the wound moving and thereby sparking tiny electrical impulses across the nodes situated on opposite wound borders.  So far only tested on rats, the results are encouraging; wound closure dropped from 12 to 3 days on average.  Human subject testing is on the horizon.  In the meantime, I’d still stay away from hairdryers in the bathtub.

A Truly Crappy Treatment

A Truly Crappy Treatment

By: Sasha Klemawesch, MD

 

Many people have heard of C-diff.  If infected, you could be stuck at home in your bathroom with annoying (but benign) diarrhea, or you may wind up in surgery or the ICU with life threatening complications.  And while many people have heard of the disease, few are aware of how difficult it can be to eradicate.

Now get ready for a scary fact.  You might have C-diff.  Yes, you.  In fact, up to 3% of healthy individuals are walking around with it right now, a rate that jumps to 1 in 5 people who’ve been hospitalized ending up colonized with it.  Our GI tracts are home to millions of bacteria, up to 1000 different species at any given time.  But when a good & balanced mix of microbes exists, they all stay in check and actually promote health by doing jobs like making vitamin K, detoxifying chemicals, and augmenting the immune system.  They also make sure that “bad” bacteria don’t get out of control and run amok through your bowels.

This is the problem in C-diff; when you are given an antibiotic for something else, say a skin infection, or pneumonia, it doesn’t just target the one culprit bacteria causing that one infection in that one place; it also kills off a multitude of others, including most of the good guys in your gut.  When this happens, C-diff becomes the dominant force and starts causing distressing pathology.

You may say, “if an antibiotic caused it, why give me another to fix it?”  A good point.  Especially because the antibiotics we have to treat C-diff are often ineffective, and up to a third of people will end up relapsing even if the initial treatment helped.  C-diff is a “spore former” meaning it leaves little hard-shelled spores all over which antibiotics cannot penetrate, so even if the medicine got rid of the active bacteria, the spores are left behind which germinate new bacteria to then resume infecting your gut and releasing their toxins.  It is often a vicious cycle, with subsequent relapse increasing your likelihood of another future episode.

So, what to do? Have some poop…

So, what to do? Have some poop…

By: Sasha Klemawesch, MD

 

It may sound crazy, but cure rates for FMT (fecal microbiota transplant) are typically over 90% for recurrent cases.  What is FMT you ask?  Basically, a poop slushy.  Sounds gross, but that’s what it is; poop is taken from a healthy donor who has been thoroughly screened for pathogenic bacteria.  It is then filtered, mixed with liquid and administered to the recipient patient in one of several ways; either capsule pills, NGT or endoscopy (tube from the top into the stomach/small intestine), colonoscopy (tube up the behind), or an enema.  While we only recently adopted it into standard human medical care, vets have been using it for a century.  The idea is similar to that behind probiotics; that if you are restoring the natural flora in your GI tract, this in turn regains the upper hand and tamps down the C-diff. It is becoming more and more commonly adopted into practice, especially at large tertiary centers, but perhaps even more exciting is that now that FMT’s benefits in the treatment of C-diff has been proven, there have been a multitude of off-shoot studies and trials investigating its potential role in the future treatments  of inflammatory and irritable bowel syndromes, obesity, diabetes, MD, Parkinson’s, atopic conditions, rheumatoid arthritis, autism and depression.   And that’s no BS!

Have a piercing migraine? Get an ear piercing! (? or maybe not…)

Have a piercing migraine? Get an ear piercing! (? or maybe not…)

If you haven’t heard of a Daith piercing, you are not alone.  That is the proper name for an earring that is placed through that little triangle of cartilage that sits in the front middle of the entrance to our ear canal.

Whether this is fashionable or not is almost as debatable as whether or not it can help headaches.  There is a large community of migraine sufferers out there who swear that having a Daith piercing has cured or significantly ameliorated their chronic headaches, but just as many people exist who report no abatement in their symptoms.

The idea behind why it may work is rooted in acupuncture/acupressure, since the tragus (that little cartilaginous area) is a known pressure point target in those techniques.  One of the early advocates of this piercing (Dr. Will Foster) believed that having a piercing there provided constant pressure and therefore constant relief/effect on the correlating body systems.

Many people’s migraines correlate with GI symptoms (i.e. food triggers or association with stomachaches) and since that spot relates to digestive organs, it would seem to follow that it could help those select patients, but certainly not all migraines have a GI corollary and that may be one reason for the disparity in the effectiveness of this piercing.  The thing most neurologists would tell you though, is that there is NO evidence or research to back up the claim that a piercing can cure a headache, and most docs would warn against getting one, especially since that specific spot on the ear can take quite a while to heal, and is one of the most common sites to get infected.  That being said, if you are already planning on getting one and happen to be a migraine sufferer, there is a chance that you may get an unexpected side benefit other than the aesthetic.

If you aren’t into body jewelry but are still interested in non-pharmacologic treatments, other options include Botox, acupuncture, massage, biofeedback, cognitive behavioral therapy, chiropractic spinal manipulation, yoga, tai chi, and hypnotherapy.  If you have tried all of that already, and have gone through med after med, then you may be a candidate for surgery.  Yes surgery, for a headache.  MISON and MIGONE are only two of the recent surgeries being utilized for treatment of refractory migraines, but they certainly are not for everyone, and a typically a last resort.  Talk to your neurologist for more information.

Dear Dr. K: I’ve been taking fish oil for years, but just showed up “+” to cod on my allergy testing form. Do I need to stop taking it?

Dear Dr. K: I’ve been taking fish oil for years, but just showed up “+” to cod on my allergy testing form. Do I need to stop taking it?

The short answer is NO.  First off, a single plus sign on your testing form represents the mildest of reactions; more of a potential sensitivity than a truly clinically significant allergy (especially if all your other fish and shellfish were negative across the board).  Secondly, even if you did have major atopic complications due to fish or shellfish, those should not translate to fish OIL, since all allergens, by definition, are (molecular-structurally-speaking), proteinaceous.  Fish oil’s name says it all, it is an OIL, which is a fat, not a protein.  High quality fish oil products should and will be devoid of proteins.  However, when you start bargain shopping and settle for those made under less stringent manufacturing regulations, you can end up with less pure, more contaminated capsules, which may contain not only some tiny modicum of fish protein, but also other fillers which may be allergenic or irritating.

Now for the longer answer:  Even though you should be able to safely take high quality fish oil products, why would you?

The debate over omega 3’s and fish oil has been an exceedingly murky and highly contentious area in medicine for the past decade or so.  In 1999, a famous study showed that patients taking omega 3’s were 10% less likely to get heart attacks, strokes, or die from cardiovascular disease, so for years PCP’s and cardiologists were putting everyone on them.  However, since then, a myriad of studies has come out with varied and conflicting results.  One of the most well known was in 2012 where the highly respected JAMA showed no reduction in MI, stroke or death.  The problem with many articles is that they focused on patients with established CVS disease, who were often taking potential confounding prescriptions, and many used what critics stipulate were subtherapeutic doses of the study drug.  Finally, in 2018, the “VITAL” study came out which looked at healthy subjects.  They found that a gram of Lovaza was effective as a primary prevention for heart attacks – but not for stroke, cancer, or all causes of cardiovascular death.  So, what are you to do with all this gobblygook data?  Even the most recent critical review on the topic from March 2019 hedges a little in their recommendations, saying that better studies need to be done in order to confidently advise patients, but for now, given the fact that omega 3’s pose little risk and have few adverse effects, but great (or as some argue, proven) benefits, they won’t discourage their use in healthy subjects, and they (and the AHA) still advise certain high risk patients to continue supplementation.

The bottom line?  The jury’s still out on if and how much fish oil is needed for cardiovascular health (and even further away from settling the debate over its use for inflammatory, neurologic, and psychiatric conditions), but since it probably won’t hurt, there’s no harm in trying it (other than to your wallet).

The one area everyone is in firm agreement on is that ensuring sufficient daily omega 3 intake, whether through diet and/or supplementation is essential in pregnancy.

Got a Sweet Tooth?

Got a Sweet Tooth?

Maybe not. If you are someone who used to crave salty snacks but recently have found yourself salivating at the thought of a Hershey’s bar, it may not be just a sweet tooth, but in fact, a real medical problem.

Chocolate cravings specifically can often be a sign of Hypomagnesemia, since the Cacao plant is one of nature’s biggest magnesium sources.  You may also find yourself craving sweets if you are lacking phosphorus, sulphur, chromium, or tryptophan (although it is quite uncommon to see deficiencies of the latter in the Western world).

More common deficiencies include calcium, which can manifest as cravings for cheese or soda and fizzy drinks and iron, which can present as cravings for red meat, coffee or black tea, or ice (a condition known as Pica).

There are many reasons for people to become deficient in certain vitamins or minerals.  One of the biggest factors is the generally poor Western diet, which for a lot of people tends to include too much processed fast food, and not enough leafy greens, crisp veggies, or juicy fruits.  Other factors that can lead to an imbalance in nutrients are kidney disease, liver disease, malabsorption from the GI tract, or various side effects of medications.  These tend to increase in prevalence as we get older, but any of these reasons can affect people of all ages, so if you find yourself all of a sudden craving food you never used to care for, it may be a good idea to check in with your primary care doctor to get some of your levels checked.  (Or take a pregnancy test…pickles anyone?)

Q – Tips: “tastes like chicken”

Q – Tips: “tastes like chicken”

The journal “Pediatrics” recently reported cases of severe (anaphylactic) food allergy to crocodile meat in children known to be allergic to chicken.  Chicken and crocodile share a common protein called a-parvalbumin that can lead to the cross-reactive allergy.  Maybe there is some truth to the old expression “tastes like chicken”.

Q – Tips: Nitric Oxide

Q – Tips: Nitric Oxide

Nitric oxide has recently been found to be an effective therapy for people with “atypical TB” known as Mycobacterium abscessus.  The inhaled nitric oxide gas is an alternative to having to take an oral therapy of three different antibiotics.

Q – Tips: Primatine Mist

Q – Tips: Primatine Mist

The FDA has approved the return of Primatine Mist to OTC (over the counter) availability after its removal in 2011.  Many medical organizations, including the American Thoracic Society, have concerns about its misuse which can lead to asthmatic deaths.  It contains aerosolized epinephrine which can serve as a rescue medication but does not act as a controlling medicine for the asthmatic condition.  Also, pure epinephrine has potential to be a cardiac irritant.