All posts by Stephen J. Klemawesch, MD

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.

Asthma, stress and depression in women studied

Asthma worse? Being female and a list of other factors might be the cause — based on Columbia University’s recently published data on research about women and asthma. They found that a number of factors led to greater difficulty with asthma including: hormones, obesity, stress, depression and PTSD (Post Traumatic Stress Disorder).

The researchers note that hormone levels (especially estrogen) impact the Th-2/ Th-1 balance that has been previously discussed in this newsletter. High estrogen leads to Th-2 predominance, which promotes allergy. Increased estrogen can come from the normal wax and wane of the menstrual cycle, pregnancy, hormone replacement or oral contraceptives.

Obesity is also pro-inflammatory via the Th-2 mechanism. Columbia found that as little as a 15pound weight loss by obese women asthmatics resulted in 20 percent improvement in their asthma.

The issue of stress and depression is a double bind. In general, women experience depression more frequently than men. The asthmatic condition itself can cause life stress and depression, but the opposite is also true: stress and depression cause worsening of asthma. The Columbia group found that upwards of 15 percent of women with poorly controlled asthma had unresolved issues from childhood sexual trauma. They consider this a form of PTSD.

Interestingly, they found strong correlation of PTSD and worsening asthma in military women who had service-related traumas. Stress, depression and PTSD all lead to a number of stress hormone changes by way of the adrenal glands, along with production of inflammatory molecules such as interleukins, substance-P, and natural killer-cell function.

African-American women seemed more prone to depression and PTSD than their Caucasian, Asian and Hispanic sisters. In yet another fallout from racial discrimination, Columbia found a strong correlation between African-American asthmatics who had experienced significant racial bias versus women who had not, in terms of severity of asthma and frequency of exacerbation.

The researchers’ take-home message is that both patients and doctors should be aware of the interplay and dynamic force of stress/depression and asthma.

Anaphylaxis episodes stats in schools show need for emergency supplies

The Journal of Allergy and Asthma Proceedings contained a study survey of more than 6,000 schools and the occurrence of anaphylaxis. The numbers reflect how frequently this scary condition threatens lives, and which forms of treatment were most effective.

There were 919 reported events over a one-year period. Ninety percent of the events were in students and 10 percent were in teachers and/or staff.

Sixty percent of the events were due to food allergy; twenty percent to an unknown cause; ten percent were due to insect stings.

Seven percent were caused by a drug allergy or environmental exposure and 2 percent were caused by latex allergy. Eighty percent of the cases were treated with injected epinephrine. Twenty percent were treated with antihistamines and of these, most were transferred to an emergency room. There were no deaths reported in the study.

The study’s researchers editorialized that it makes good sense that all school offices have adrenalin injections available, such as epinephrine pens. This strengthens a law signed by President Barack Obama two years ago (The School Access to Emergency Epinephrine Act) to encourage schools to prepare for these emergencies.

Common fungus no allergy friend

Alternaria is one of the most common airborne funguses. Found indoors and out, it is typically the fungus most prevalent in the daily “pollen count” done by this office.

It has been known for many years to be a major contributor to respiratory allergy, both upper airway (rhinitis) and lower airway (asthma).

New research done by the National Heart and Lung Institute in the U.K. has revealed a second mechanism whereby it causes respiratory mischief. In addition to its “allergenic irritability,” Alternaria wreaks further havoc because it prompts protease-activated receptors found in human airwaves to release the inflammatory molecule IL-33 (interleukin-33). IL-33 is an extremely vitriolic molecule and causes both airway inflammation and airway remodeling (scarring).

Epidemiologic studies have found a strong correlation between environmental Alternaria levels and hospital admissions for asthma.

In some studies it is believed to cause 30 percent of asthma exacerbations.

The thunderstorms of summer and fall lead to dispersion of Alternaria spores, plus all molds tend to be higher in autumn.

The British researchers are looking at ways to try to abrogate the IL-33 release.

Allergic to one drug, maybe to all – or maybe not

Cephalosporins constitute a large family of antibiotics. They are “kissing cousins” to the penicillin family, but are unique in their own right. Until recently it was thought that if a person was allergic to one cephalosporin, they would be allergic to the entire family.

Several research groups have questioned this conventional wisdom. Most recently the Italian Ministry for University Research did a large population study on this issue. They did both skin testing and clinical challenges (giving the patient a test dose) with several hundred patients known to be allergic to one type of cephalosporin.

As it turns out, most of these individuals were found to be skin-test negative and patient-challenge negative to at least one different cephalosporin. The basic cephalosporin molecule consists of a ring structure with variable side-chain molecules. The greater the difference in the side-chain molecule,

the greater the likelihood of no cross-reacting allergy.

The Italian researchers concluded that – especially in people with limited choices for available antibiotics and who have a known cephalosporin allergy – it is worth testing them to a cephalosporin with a different side-chain structure so as to find a safe alternate therapy.

Dear Doc: My wife says if I don’t wear my hearing aids I’ll get dementia. Could she be right?

The answer to your question is yes; and, furthermore, I personally always follow the mantra: “Happy, wife; happy life.”

Unfortunately, hearing loss is very frequent: 3 in 10 over age 60; 1 in 6 aged 41-69 (Baby Boomers), and 1 in 14 aged 29-40 (Generation X).

However, untreated hearing loss leads to loss of gray matter (the thinking part of our brains). Also, the extra effort used by people straining to hear interferes with normal cognition. Finally, the social isolation that can occur from hearing loss leads to mental stagnation.

Neuroscientists have actually found that correcting hearing loss in individuals already diagnosed with dementia slows the progression of the disease.

Two other reasons to listen to your wife have to do with heart disease and the risk of falling. The Framingham Heart Study found a correlation between low-frequency hearing loss and heart disease. As it turns out, having uncorrected hearing loss leads to higher levels of adrenal gland output which can elevate heart rate and blood pressure.

The CDC (Centers for Disease Control and Prevention) found that a 25-decibel hearing loss increased the risk of falling three fold. Hearing loss makes an individual less aware of their overall environment, thus increasing fall risk. Straining to hear and process auditory input distracts the brain from other activities such as maintaining balance.

Finally, cochlear (the hearing part of your ear) disorders can impact vestibular (the balance part of the ear) function.

Bottom line – listen (pun intended) to your wife.

Water sports draw attention

The School of Sports Science in Australia recently completed a research study on Olympic athletes regarding aquatic sports and asthma.

They found the highest incidence of asthma in aquatic athletes as compared to all other Olympic athletes. Among aquatic athletes pool swimmers had the most asthma, and among categories of swimmers it was the endurance swimmers who again had more asthma than the sprint and intermediate swimmers.

After pool swimmers, the water sports associated with asthma in decreasing order of frequency were synchronized swimming, water polo, diving and then open-water swimming.

Also the researchers found that asthma was more common in all groups if they trained in indoor pools as opposed to outdoor pools. They posit that the pool chloramines are the cause of the airway irritation and that indoor pools trap higher levels of the chloramines.

The researchers were very careful to endorse the overall health benefits of swimming as an excellent form of exercise. They simply want people to be aware of the asthma issue so it can be properly addressed by the swimmers’ physicians.

Roach dust has value? Who knew?

Just when you think the wacky world of immunology can’t get any crazier, new research turns another corner. Readers of this newsletter have previously been exposed to the hygiene hypothesis of allergy; that is, because we are “so clean,” our idle immune systems find a mischievous outlet in the form of allergic diseases.

Now researchers at the University of Texas have looked into the role exposure to cockroach dust might play in this regard. As it turns out, exposure to cockroach dust serves as a proxy to microbial exposure as a protective factor in reducing the risk of children developing allergy and asthma.

The benefit was quite dramatic as it led to about a 50-percent reduction in the development of allergy.