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Author: Stephen J. Klemawesch, MD

Mosquito Advisory

Mosquito Advisory

The Florida Department of Health has issued a statewide mosquito advisory.  In the past two months there has been an increasing number of malaria cases in the state.  Malaria is transmitted by infected Anopheles mosquitos.  The Florida cases have all been due to these mosquitos transmitting Plasmodium vivax.  So far, there have been no deaths but several people required hospitalization. 

The health department recommends reducing the chance for bites by wearing long pants and sleeves and using repellant (either on skin or on clothing) especially at dawn and dusk when mosquitos are most active.  They also recommend “cover and drain” measures to eliminate standing water where mosquitos breed:  garbage cans, house gutters, buckets, pool covers, flowerpots and plastic children’s pools. 

The symptoms of malaria include; fever, chills, sweats, nausea, vomiting and headache and should prompt individuals to seek immediate medical treatment. 

New Strategy for Lyme

New Strategy for Lyme

I’ve been privileged to be in the medical field since the discovery of Lyme disease and witness the ongoing research to understand it and to treat it.  I happened to be an intern at Yale when a mother returned her child to the medical center insisting that the original diagnosis of juvenile rheumatoid arthritis, they had received on their initial visit might not be correct.  After her first visit, she returned home to Old Lyme, Connecticut and by talking to neighbors found out that several other children in her neighborhood had gone to Yale and received the same “rare diagnosis”.  A team of epidemiologists was dispatched to Old Lyme and indeed found a number of additional cases. 

Thus, the research ball started rolling.  I’ve often thought the illness should have been named after that intrepid mother rather than the town. 

Lyme disease is caused by the bacteria Borrelia burgdorferi.  Initially, the bacteria and the disease were limited to New England but have spread throughout the eastern states including Florida.

A vaccine for humans was developed and became available in 1998.  But since consumer demand was low it went out of production in 2002.  But because of increasing cases in the US a new vaccine is undergoing clinical trials by Pfizer pharmaceuticals. 

Meanwhile, a different strategy is being implemented, a vaccine for mice.  Mice are one of the most important reservoir hosts for Lyme disease.  Living in the wild they transfer the bacteria via the ticks they carry and the ticks’ progeny.

The mouse vaccine is in edible pellets.  It’s interesting that both the human vaccine and the mouse pellet vaccine contain a protein called OspA which is found on the surface of B.burgdorferi.  The OspA spurs antibody production in the vaccine which in turn prevents infection. 

A recent five-year study done in New York state using the mouse pellets found a 23% reduction in infected ticks after two years of distributing the pellets and a 76% reduction after five years. 

Tezepelumab-ekko 

Tezepelumab-ekko 

Tezepelumab-ekko (Tezspire) is the first and only biologic agent approved by the FDA for severe asthma that is not limited to a specific asthma phenotype. 

Biologic agents have ben a true god-send in terms of helping patients with severe asthma.  The underlying cause for asthma is inflammation.  But the cause of the inflammation varies from patient to patient.  This variability is where the term phenotype comes into play.  Identifying the specific immune mechanism that instigates the inflammation and thus the asthma has proven extremely useful.  There are already a number of biologic agents that are extremely effective but to date they tend to target a single specific inflammatory mediator.  In most cases that is all that is required.  However, asthmatic inflammation can sometimes be multifactorial or what is referred to as a cascade effect.  Think of dominoes falling into one another.  This is where Tezepelumab-ekko can have utility.

Of course, every coin has two sides.  With its broader impact on immune modulators there is also a potential for reducing desirable immune function.  If a patient had a helminth infection this could worsen.  Also, live vaccines must be avoided. 

Leatherman Drug

Leatherman Drug

My favorite companion on woodland hikes (other than my wife and dogs) is my Leatherman, the ultimate multitool.  It seems that the biologic agent dupilumab (Dupixent) is also becoming a multitool.  It was initially approved by the FDA for people with severe eczema (atopic dermatitis).  It works by preventing the inflammatory eosinophils from entering the skin.  But since eosinophils also cause other types of allergic inflammation dupilumab’s role has expanded to include severe asthma, chronic rhinosinusitis with polyposis, eosinophilic esophagitis, and urticaria.  It is both an expensive and potent medicine so it is not considered a first line treatment for any of these conditions.   

Guts

Guts

Arnold Schwarzenegger once said “don’t be a girly man”.  Perhaps this was meant to toughen up timid men with the unfortunate inference that girls are intrinsically timid.  New research has found that women have more guts than men.  This is a newly found anatomic difference but perhaps the metaphor applies as well. 

Duke University has done comparative anatomical studies and found that women’s small intestine is 30 centimeters longer than men’s.  This newly discovered difference has led to both speculation and possible explanation.  The speculation is that since women bear children and the small intestine is where nutrients are absorbed that women have evolved a greater absorptive surface area to provide for fetal growth and development.  Having a longer small intestine lessens the chance for escape of absorbable nutrients. 

As a possible explanation it might play a role in weight issues and GI disturbances.  How often have you heard of a husband and wife going on the same diet and the husband loses 10 to 15 pounds while the wife loses 3 to 4?  Could this be due to greater absorptive efficiency? 

SIBO (small intestine bacterial overgrowth) is a fairly common reason for GI tumult, either in its own right or as a confounding variable for IBS.  SIBO tends to be more common, more severe and more difficult to treat in women.  Again, is it due to greater length of the small intestine?  Since the anatomic difference has been newly identified there is ongoing research to better understand its ramifications.  Stay tuned.  

Gum Disease and Arthritis

Gum Disease and Arthritis

Researcher at the University of Leeds in the UK have completed a four-year study that links gum disease to rheumatoid arthritis.  They found a direct correlation between gum disease and both the severity of and exacerbations of

rheumatoid arthritis.  Various species of the bacteria Streptococcus are the culprits.  When a person with gingivitis

chews or brushes their teeth the bacteria enter the bloodstream.  This activates the immune system to make antibodies.  As it turns out the antibodies that attack the Strep are the same ones that attack joint cartilage.  They are called citrullinated antibodies and measurement of them is one of the diagnostic tests for rheumatoid arthritis.  It probably shouldn’t have been a surprise as the Strep germ that causes Strep throat has a long legacy of causing the autoimmune phenomenon called rheumatic fever which can lead to rheumatic heart disease.  The cartilage in our joints is the same as the cartilage that makes our heart valves. 

Although it wasn’t part of the initial study, the UK scientists found that people with the oral bacteria Porphyromonas gingivalis and gum disease were much more prone to Alzheimer’s disease.  The bottom line is to practice good dental hygiene both at home and with your dentist.    

Dear Dr. K; 

Dear Dr. K; 

I recently heard about a mental technique to help me cope with tinnitus.  But for the life of me I can’t remember what it was, can you help? 

I think so.  I suspect you heard about a form of cognitive behavioral therapy called somatic tracking exercise.    There are good academic studies instantiating its benefit.  It has proven effective not only for tinnitus but for other unpleasant or painful sensory inputs. 

Basically, you pretend you are a non-emotional observer of yourself.   With respect to tinnitus, you describe to yourself the volume, frequency, pitch, and the variance in laterality (right versus left).  You do this with no emotion attached and you tell your brain that this is of no threat.  You do this briefly several times a day and over time you will find the sound decrease on its own. 

This technique can also be used for anxiety, nausea, dizziness and pain.  Remember that unpleasant sensory awareness is the brain’s alarm system to try and protect us.  By being an unemotional remote observer of your own unpleasant sensory input, you can teach the brain that this is nothing to fear.  The

goal of the exercise is not to get rid of the pain/sensation.  In fact, the more you try to accomplish this the worse the symptom becomes.  But the goal is to persuade your brain that its’ safe and therefore no need to continue “sounding the alarm”.  Another way to approach it is to tell yourself that these are just unbridled neurons firing off and you’re going to put a bridle on them.  When you are doing this mental exercise, it is also helpful to use avoidance strategies that lessen or minimalize the pain/sensory sensation. 

Indoor Pollution

Indoor Pollution

In 1986 the World Health Organization (WHO) coined the term “sick building syndrome”.  It was the dawn of understanding that indoor pollution can have health consequences.  WHO has concentrated its research on “the big six”: tobacco smoke, radon gas, carbon monoxide, the volatile organic compounds

(VOC’s) trichloroethylene and benzene and tiny agglomerate particles smaller than 2.5 micrometers (PM 2.5). The average American spends 88% of their time indoors.  The higher the levels of these pollutants the greater the health consequences.  Illnesses linked to indoor pollution include sinusitis, asthma, dermatitis, migraines, cardiovascular disease and cancer. 

Indoor ozone is generated when sunlight coming through windows reacts with certain VOC’s.  Synthetic dyes known as azo dyes can outgas from furniture and drapes, especially ones with darker colors.  Formaldehyde is another VOC that creates a toxic environment.  It outgasses from new carpet, flooring, pressboard cabinets and new furniture.  Another VOC that seems to be particularly irritating is trichloroethylene which outgasses from glues, solvents and cleaning fluids. 

Even cooking can be a source of pollution.  Frying foods generates acrolein, a chemical also released from E-cigarettes and known to be harmful.  A recent study done in gyms found high levels of N-chloraldimines, toxic chemicals generated when bleach cleaners interact with the amino acids found in human sweat.  Aerosol deodorants, cleaners and hair sprays add to the morass. 

What can be done?  Choose safe cleaning products.  Stop using aerosols.  Stop frying foods or at least have a good exhaust fan running.  Allow new carpet and furniture to outgas in the garage before moving indoors.  HEPA filters on the HVAC system remove the PM 2.5 particles.  Smoke outside.  Houseplants help remove a myriad of chemicals.  For those who like data, indoor air quality monitors and radon detectors are readily available. 

Processed Foods and Health

Processed Foods and Health

The industrial techniques used to make processed foods not only add unhealthy ingredients but also change the foods themselves and therefore how they interact with our bodies.  In Western countries half the food consumed is processed. 

Over one hundred scientific studies have all shown that diets high in processed foods lead to earlier death, more cancer, inflammatory bowel disease, obesity, dementia, stroke, diabetes and heart attack.  Such diets also compromise immune function. 

It’s not the fat, salt and sugar that are most problematic but rather the removal of fiber, micronutrients and the added chemicals, especially emulsifiers, that cause the greatest harm.  The fiber and micronutrients are essential to a healthy microbiome, which in turn is critical for most of the physiologic processes in our bodies and especially our immune systems.

It is well documented that emulsifiers harm the gut.  Emulsifiers are chemicals that bond fat to water.  Soap is an emulsifier which is why it helps us cleanse oil and grease from our hands.  Our intestines are covered in a layer of mucus which is the nesting ground for all our healthy microbiomes, scrubbing this mucus away with emulsifiers severely disrupts the bacteria.  This in turn can lead to greater gut permeability (leaky gut) and local inflammation.  Carboxymethyl cellulose is one of the worst of the emulsifiers and is found in thousands of processed foods. 

Other chemical additives turn off our normal satiety hormones which tell us we’ve eaten enough and thus leads to overeating.  Curiously, this includes artificial sweeteners. 

Q – Tips:

Q – Tips:

Group Weston has developed a user-friendly micro air screen face mask, Q Mask Pro, that uses a unique accordion pleated design that makes it highly efficient at removing pollen and dust.   Web site www.groupweston.com

With increasing pollution of our planet’s oceans and seas there is a rise in ciguatera fish poisoning which is often mistaken for a food allergy.  The symptoms include nausea, vomiting, diarrhea, itchiness, hot/cold sensitivity and numbness.  The culprit is a dinoflagellate that prospers in polluted waters and is ingested by fish.  Its toxin is not inactivated by cooking.