All posts by Stephen J. Klemawesch, MD

Asthma in seniors calls for adept diagnoses and care

A review of the diagnosis and treatment of asthma in older adults was just published in The American Journal of Medicine. Asthma in older adults can fall into two broad groups: those with long-standing disease, present since childhood; and those with late-onset asthma. The review was aimed at this latter group.

With late-onset asthma there is greater likelihood for confusing asthma with other conditions, especially COPD (chronic obstructive pulmonary disease) and congestive heart failure. In pulmonary testing, patients with both COPD and asthma will show obstruction of air flow, but this obstruction improves with inhalation of a bronchodilator in asthmatics, but not in COPD patients.

Another distinguishing fact in pulmonary testing is how the diffusion capacity of gas from lung to blood- stream is normal in asthma, but is decreased in COPD.

In comparing lifelong asthmatics with late-onset, the former more commonly have other allergic symptoms, such as hay fever or food allergy. The former respond very quickly to a bronchodilator, while the older asthmatic may need up to 30 minutes to feel the benefit of a bronchodilator.

Also, older asthmatics often will respond better to a combination bronchodilator with both albuterol and ipatropium, rather than albuterol alone. The inflammatory cells that cause airway inflammation are different. In young asthmatics it’s neutrophils. This fact alone, coupled with the burgeoning baby-boomer population has led to intense research to find anti-inflammatories that work better on neutrophil cells.

Older asthmatics seem more prone to respiratory infections which exacerbate the asthma. In part, this susceptibility is from aging of the immune system.

But another recently discovered cause is that older asthmatics tend to not keep their inhalers and spacers clean, allowing them to become colonized with disease-causing bacteria.

This dizziness can be relieved

Benign paroxysmal positional vertigo (BPPV) is by far the most common type of dizziness, affecting 3 -to-4 percent of the population at some point. Some people have a single, brief attack, whereas others can have repeated and sometimes prolonged episodes.

The condition is more common in people over 50, in women more than in men (3:1), in persons with osteopenia or osteoporosis and those low in vitamin D. Dizziness typically occurs while rolling over in bed, getting in or out or tilting the head back or for- ward. Many patients also have nausea.

BPPV is caused by little dislodged crystals getting into one of the ear’s three semi-circular canals that stimulate nerve endings, leading to a vertiginous nerve signal being sent to the brain. Therapy involves special head maneuvers to reposition the out- of-place crystals. An accurate diagnosis and instruction in proper therapeutic maneuvers are best done at a balance center.

New psoriasis treatment effective

Good news for the roughly 50 percent of psoriasis sufferers whose current treatment fails to control their chronic itching — a novel therapy has been re- ported by researchers at Temple University. Instead of indirectly combatting the itching through steroid creams that reduce skin inflammation, their drug goes right to the specific cause of the itch. The new cream, only called CT327, inhibits TrkA kinase, a compound responsible for pruritis (itching).

In the Temple research study there was a 60 per- cent reduction in itching. The therapy was safe with few side effects.

Dear Doc: Is there such a thing as allergy to ‘cold’?

Dear Dr. K.: In cold months I get episodes when my hands get red, swell, itch and burn for days at a time. The problem was even worse when I visited my daughter in Toronto. Could I be allergic to cold?

The answer to your question is yes, but I don’t think that is the actual cause of your problem.

In the past 20 years there has been an extensive amount of research on a group of conditions called “physical allergy.” One common physical allergy is cold urticaria (hives). But your problem sounds more like a condition called pernio. Unlike cold urticaria which comes and goes quickly, pernio symptoms last for days at a time.

Pernio typically affects the acral parts of the body: hands, feet and nose. These are the areas of the body that tend to be coolest owing to exposure and being at the end of the blood circuit. In most cases pernio is a benign condition with no known cause. But in a few individuals it can be a harbinger of some other disease process. It is known to be more common in smokers, which makes sense because it is known that cigarette smoking narrows blood vessels.  Most people with pernio have normal labs, but some show cold-activated proteins such as cold agglutinins or cryoglobulins. These can occur due to an underlying infection such as strep or hepatitis. Other lab results can be abnormal if the cause for the pernio is an autoimmune condition such as vasculitis, lupus, or rheumatoid arthritis.

The onset of pernio can also occasionally be the first sign of a cancer, such as multiple myeloma, breast or colon cancer. Because there is a possibility of underlying disease, it is a good idea to see your primary care doctor and have a good physical.

If no cause is found, pernio is treated by first keeping warm. Smoking cessation is very important. Typical treatments can help, such as cortisone creams and nitroglycerin ointment (it dilates blood vessels). If the symptoms are severe, oral therapies that help blood flow improve include aspirin, minoxidil, nicotinamide and pentoxifylline.

Q – Tips: flu and Q Fever

  • Q-Fever is a flu mimic that causes prolonged flu- like symptoms and pneumonia. It is caused by a small bacterium Coxiella Burnetii, which is re- leased from infected female mammals, especially when they give birth: cattle, sheep, cats, dogs and rabbits. There was a recent series of cases at a Florida school, where a classroom rabbit had bunnies, exposing the children.


Avoiding carbs known as FODMAPS (trust me, you don’t have to know the acronym’s long name), may help prevent irritable bowel syndrome. Vocabulary words to remember for these short-chain carbohydrates include fructose, lactose, fructans (found in wheat), galactans and polyol sweeteners. Remembering this list is important in fending off this painful syndrome because the body has a hard time absorbing these items. They remain in the GI tract and become a source of “GI tumult” when the gut bacteria ferment them. Galactans are found in dried beans and peas, and while polyol sweeteners are in lots of healthy fruits with pits or stones (e.g., peaches), they are also are used in many artificial sweeteners

Q – Tips: Seeds and health

  • Seeds can be a concentrated source of health. Flax seed lowers blood pressure and reduces risk for breast and prostate cancer. Sunflower seeds have also been linked to reduced risk for breast cancer. Other studies show benefits for improved cognitive function. Pumpkin seeds raise the good cholesterol (HDL) and also re- duce breast cancer risk.

Balancing act’s role in prevention

A number of immune-modulator drugs are used today with good success in treating rheumatoid arthritis. The object of a study recently written up in Arthritis Research and Therapy was to see which ones reduced the benefit of flu vaccine.

As it turns out the drugs that work on tumor necrosis factor (TNF) had only a mild effect in reducing antibody production from flu vaccine. These drugs include Humira, Enbrel, Remicade and Cimzia.

Drugs that severely reduced antibody production were Rituxan and Orencia. Because the antibody response with these drugs was so poor, the researchers recommended several options: Vaccinate for flu before starting these medications; or, if the patient is already under therapy, give a second booster flu shot one month after the first shot.

Histamine therapy for eczema back in favor after research

Eczema affects up to 20 percent of the population and its incidence is steadily increasing. Eczema is often difficult to treat because it is a multi-factorial disease with numerous causes and triggers.

One therapy that has gone in and out of favor is the use of antihistamines. Proponents argue about their benefit based on positive responses in many patients. Detractors argue that they don’t help everyone, and that all they are capable of doing is controlling the itch, not really healing the cause.

New research from the Medical University of Vienna is putting antihistamines back in the spotlight. Scientists there have discovered that persistent histamine levels in the skin tissue speed the growth of skin cells, thus contributing to the scaling and itching that are hallmarks of eczema.

Keeping the histamine receptors focused on skin cells blocked with a maintenance dose of antihistamine can prevent the cell growth stimulation.

Mastering asthma rescue dose technique a ‘must’

Dear Dr. K: How can I be sure my four-year old asthmatic daughter actually gets her rescue inhaler dose?

That is an excellent question and one that all parents of asthmatics should ask themselves.

There are actually several ways to answer your question. On a very practical level, if the symptom you were treating (cough, wheeze, shortness of breath) goes away within a few minutes of the treatment, then most likely, your daughter got the medicine and it helped. Also, most of the rescue medicines have mild side effects, especially increasing the heart rate and causing a slight hand tremor.

You could check her pulse before and after the inhalations to see any change.

Your best bet to ensure medicine delivery is to use proper technique. Most research studies looking into whether or not parents use proper technique reveal that only about 10 percent are doing everything right.

The crucial steps include:

  1. 1.  Shake the inhaler before use.
  2. 2.  If the inhaler is new “out of the box,” be sure the indicated priming has been done.
  3. Make sure a good seal is made with the spacer.

              a. For young children the spacer has a face mask that covers the nose and mouth.

              b. For somewhat older children the seal is made by ensuring the lips cover the mouthpiece.

  1. 4.  Do one puff at a time.
  2. 5.  Have the child exhale first, then deliver puff.
  3. 6.  Take six slow, deep breaths for the first puff.
  4. Wait 30 seconds between puffs.
  5. Then repeat steps 5 and 6. If you’re still not sure, bring your spacer and medicine to the next visit with your pediatrician, pulmonologist or allergist, for a critique of your technique.