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Author: Stephen J. Klemawesch, MD

Dear Dr. K;

Dear Dr. K;

I recently underwent food allergy testing at the behest of my gastroenterologist to see if food allergies are causing or contributing to my irritable bowel syndrome.  It turns out I’m allergic to five foods.  My question is how do I determine if all five are causing my symptoms or just one or two?

That is a great question.  The guidelines I’m going to share with you were worked out in clinical research units.  In these settings patients are kept in a controlled environment (typically a hotel appended to the university hospital) and avoid the implicated (food allergy test positive) foods for two weeks.  It seems to take this long to fully “clean the system”.  Then, one food at a time is re-introduced.  In the research setting this is done double blinded and placebo controlled by putting the food to be tested inside gel-caps.  On a given day the patient may receive a placebo or an actual food.  Now, obviously this is a very tedious and protracted protocol.  But it has led to some basic rules to be used at home.

So, first of all, you need to avoid all five foods at the same time for two weeks.  If food allergy is causing your IBS, you will feel better at the end of two weeks. 

Then start adding a single food. You should have this food in “a usual portion size” and have it at least three days in a row.  If you have “tummy troubles” the very first day it could be due to the food or serendipity.  So, you need to repeat the experiment to verify. 

Now here is the hard part.  If you have symptoms you need to go back to the elimination diet until you feel well again before you try the next food.  Unfortunately, this could take up to two weeks again.  But you need a symptom reduced baseline to have clarity. 

Once you’ve tested all the foods there is another step you might need to take.  But this is necessary only if all the individual tests were negative.  This step involves testing food combos.  By way of example let’s say you tested positive to cheese, tomato and wheat.  Tested individually: no issue.  But tested together might reveal synergism.  So, pizza would be a mechanism to test all three.  Good luck, be patient. 

Omalizumab for Food Allergies

Omalizumab for Food Allergies

The FDA recently approved omalizumab (Xolair) to treat patients with food allergy including children as young as one year.  The approval came from several research trials including one recently published in the New England Journal of Medicine (NEJM) that was conducted at John’s Hopkins.  This particular study looked at allergy to peanut, cashew, egg, milk, walnut, hazelnut and wheat.  In the case of peanut allergy 67% of the test patients were able to consume 600 mg of peanut (equivalent to four peanuts) without adverse symptoms. 

The current recommendation is to only consider this therapy in people with severe (anaphylactic) food allergy.  In addition, the intent is not to enable ongoing ingestion of the food but to protect against anaphylaxis due to accidental exposure.  

An accompanying editorial in the NEJM was a bit of a devil’s advocate pointing out that the treatment is not curative but only works as long as the medication is continued.  It further argued that avoidance is still the lynch pin of therapy in severe food allergy.

The editorial did point out the potential safety net for children who otherwise run the risk of anaphylaxis from accidental exposure. 

That’s Bananas!

That’s Bananas!

By:  Sasha Klemawesch, MD

If I asked you to tell me one fact about bananas, you’d probably cite how rich they are in Potassium.  And you wouldn’t be wrong.

But, in addition to having approximately 10% of your daily value for potassium, they also contain about 10% of your daily needs for Magnesium, Vitamin C and Fiber.  While potassium is great for lowering blood pressure, maintaining muscle (including heart muscle) strength, and avoiding certain types of kidney stones, foods with high potassium content may also be slightly radioactive!

This is because included in their potassium stores is a tiny bit of Potassium-40, which is a radioactive isotope. But don’t worry, there is not a human being out there – or monkey for that matter – who could possibly consume the volume of bananas necessary to incur any harm from them (it’d take like 20 million to reach a dangerous dose).

There is enough of the isotope however that you wouldn’t be allowed to bring bananas into a nuclear power plant due to their potential to trigger the (highly sensitive) alarms.  So, while you may not need to worry about getting radiation poisoning from bananas, if you have a latex allergy; you should probably avoid them. It seems unusual for a man-made material and a natural fruit to be related, but latex actually shares several allergens in common not only with bananas, but also avocados and kiwis.

Other groups who should avoid bananas are male mice. If you are one, #1 congratulations on becoming literate enough to read this! and #2, you have probably already realized that you feel stressed out when you smell banana pudding. This is because pregnant female mice’s urine contains n-pentyl-acetate; the same compound that imparts bananas their distinct odor. It’s also the hormone pregnant mice secrete in

order to repel males, thereby preventing them from eating their babies.

Lastly, if you still enjoy listening to CD’s, and you have run out of toothpaste to fix your favorite one’s scratches, try rubbing a banana peel over the defect. The oils in it will do the same thing the toothpaste does and repair the skip!

Plastics

Plastics

There is a memorable scene from the movie The Graduate where Ben (Dustin Hoffman) is taken outside at his college graduation party by a friend of his fathers’.  The friend says (regarding Ben’s future) “I have just one word for you: plastics”. 

Fifty years ago, plastics seemed to be a boom in terms of both convenience and commerce.  Now, plastics are doom in terms of environmental harm and human health.  Once plastics are released into the environment (soil and water) they gradually degrade, leading to the formation of micro plastics (smaller than 5mm) and nano plastics (smaller than 1000 nanometers).  These in turn can enter the human body through ingestion, inhalation and skin absorption.  Ninety five percent of Americans have micro/nano plastics in their bodies.  The health consequences are myriad:  interstitial lung disease, increased rates of premature birth, asthma, certain types of cancer, and liver and kidney disease. Now a new concern has recently been reported by scientists at the University of Campania in Italy regarding cardio vascular events.  Their research found 60% of their patients having surgery to remove arterial plaque had micro/nano plastics (MNP) in the plaque itself.  More distressing was that the 60% with MNP had much higher risk for heart attack, stroke or death in the ensuing 34 months than the 40% who did not have MNP. 

What to do?  Unfortunately making a personal choice to use less plastic will not protect individuals since it is primarily the degradation of discarded plastic that is the prime mover.  It will take a global initiative to make a difference. 

Aw, Nuts! By: Sasha Klemawesch, MD

Aw, Nuts! By: Sasha Klemawesch, MD

Conventional wisdom for decades has been to avoid nuts and seeds if you have diverticulosis; however official Gastroenterology literature now says otherwise. Actually, it has for some time, but old habits die hard, and anecdotal rumors still heavily cloud the discussion both in the medical community and among lay people. While it’s not surprising that patients’ impressions may be skewed by rampant Reddit forums on the subject, doctors should be aware of the change in recs, seeing that literally hundreds of studies (more than 300 in the past decade) exist evaluating a variety of dietary effects on diverticular disease. Many of those specifically focused on seed and nuts, and none of them showed any increased harm or risk. The one diet that was affiliated with diverticulitis bouts? No surprise here: “Standard American Fare.” (fried foods, red/processed meats, heavily refined grains, sweets and high fat dairy products). I personally think a big reason why those are correlated with worse outcomes in diverticulosis is that they are all so constipating; and avoiding straining and incorporating fiber and hydration into your diet has long been known to be beneficial (both for diverticulosis as well as in people w/o it).

Now speaking of trying to turn the cruise liner that is diverticulitis management…. Antibiotics. The American Gastroenterology Association has had data out for years showing that we only started treating diverticulitis with antibiotics because “that’s what they always did.” When docs first started doling out Cipro/Flagyl to everyone, it wasn’t based on any scientific trials or evidence, it came more from a logical, hypothetical theory and resultant trial and error approach, and then got passed down from generation to generation. But we now have actual research data showing that uncomplicated diverticulitis in an otherwise healthy patient is more of an InFLAMMatory process, not an InFECTious one, and therefore treatment should include anti-inflammatories, not antimicrobials. Myself being a huge proponent of antibiotic stewardship, I love this change in practice, but it has been pulling teeth to get patients to accept it, and even to change the minds of my fellow colleagues; many of whom say “yeah, I heard about that literature, but I still cover them.” (meaning they prescribe them antibiotics) …  Cut to 4 days later when I see the patient back for their even worse diarrhea due to the antibiotic side effect. Now certain patients and certain cases (i.e. those w abscesses or perforations), still do need antibiotics, but your run-of-the-mill mild case, those do not.

I know many of you will have a hard time *stomaching* this news, so here is a high-quality source for you to check out and verify that I’m not blowing smoke up your behind (sorry couldn’t resist two GI tract puns) just copy this into your search bar:  10.1053/j.gastro.2020.09.059

Tincture of Time By: Sasha Klemawesh, MD

Tincture of Time By: Sasha Klemawesh, MD

In the preceding article I mentioned how antibiotics became accepted as standard treatment for diverticulitis; doctors considered which pathogenic bacteria would typically invade the gut, and drew a logical conclusion that if the colon was infected, then Cipro/Flagyl would treat it. The practice had staying power because patients seemed to get better while on said treatment. However, like many other entities commonly “treated” with antibiotics, it is not the antibiotic that is making the patient better, it is so-called Tincture of Time; the issue either has an inherently discrete duration and/or the patient’s body heals itself. It just seems like the antibiotics are helping because those two things coincide. This same phenomenon is the reason that so many people swear they MUST be prescribed a Zpack for their mild URI, or some Amoxil for their sinusitis. Both of those illnesses are far more commonly due to a viral trigger than bacterial, but because lazy doctors write for Zpacks at the drop of a hat, patients come to expect it. This is not good medical practice and is the reason for so much of the antibiotic resistance we have accrued in the US. While just like in diverticulitis, there is a role for antibiotics in certain cases of sinusitis or bronchitis, withholding them should be the rule for 90% plus of the cases, not the exception. So next time a doctor “refuses” to give you your precious Zpack, please know that it is more work for them to not simply acquiesce to your request, and thank them for actually having your best interest in mind.

O O O….Oh no! By: Sasha Klemawesch, MD

O O O….Oh no! By: Sasha Klemawesch, MD

If you are a non-streaming luddite like me who still watches cable, then I’m sure you could not only sing the Ozempic jingle on command, but probably do the Jardiance-Lady’s dance as well. There’s been so much hype around the novel diabetic agents, I thought it worth discussing some of their downsides, since otherwise mainly what you hear are social media-ites & bravo-lebrities lauding them as quick & easy weight loss hacks.

While it’s true (especially for the Ozempics/Mounjaro’s of the bunch), that they do help you lose weight, it’s also true that along w that desired benefit comes the potential for many adverse effects. 

Let’s look at Jardiance – aka – Empagliflozin first. This is an SGLT-2 Inhibitor, which is a different class from the others. It essentially makes your kidneys pee out boatloads of glucose, which in turn causes you to pee out high volumes of urine. The medical term for this is “osmotic diuresis.” If you remember from high school science, when you have two containers of water connected by a semi-permeable-membrane, one side w salt water, the other w tap, the tap water will selectively flow through to the side with the salt, in attempts to balance the ratio of salt: water on both sides. The kidneys do the same thing when you have excessive sugar in the urine; they send excessive water/fluid after it; which is why Jardiance not only lowers Blood Sugar, but also (partially) why it has a proven benefit in Heart Failure patients. (a key component of treating heart failure is keeping body fluid low, keeping patients ‘dry’). However, Glucosuria (glucose in urine) is also the reason for the main adverse effects I see time & time again in the ED; the 3 main ones being UTIs, Dehydration/Acute kidney failure, and Euglycemic Ketoacidosis.

UTI is simple enough. Bacteria love sugar, they need it to live and thrive. When you have too much sugar coursing through your genitourinary tract, bacteria show up to party, increasing the likelihood of infections throughout it.

Dehydration and Kidney Failure. Sounds scary, but Dehydration IS (in medical terms at least) the mild form of         “Pre-Renal Acute Kidney Failure.” It simply means that you’re so dehydrated that your creatinine level (aka “kidney number”) goes up a little when you run lab work. Treatment is very simple. IV fluids (or oral), and your labs go back to normal and everything is fine. Occasionally though, the degree of renal dysfunction can get severe enough to necessitate admission to the hospital for ongoing fluid resuscitation and lab monitoring.

Euglycemic Ketoacidosis. This is the most severe of the adverse sequalae that I have personally seen come through the ED. Most people have heard of DKA, Diabetic Ketoacidosis. This is similar in that it involves the pH level of your body becoming dangerously low, and requires treatment in the ICU w an insulin infusion. The difference here is that your glucose level is normal, and because of that, many times this condition can be overlooked and underrecognized, especially if you happen to be seen by a provider who is not aware of what it is or how it presents. Unfortunately, that is not uncommon, and it doesn’t help that its symptoms are quite vague; nausea, stomach upset, fatigue, weakness, etc. 

Now to the other family of meds which includes Ozempic, Victoza, Wegovy, Saxenda, Rybelsus, and Mounjaro. All but Mounjaro are GLP-1 Agonists. Mounjaro is both a GLP-1 and GIP Agonist. GLP-1 Agonism exerts several effects. It slows gastric emptying, so food stays in your stomach longer, you feel fuller longer and therefore naturally start eating smaller portions.  It also increases insulin production, decreases glucagon release (a hormone that raises blood sugar), and has direct effects in brain centers involved in both physiologic appetite and psychologic food cravings. It also affects acid secretion in the stomach (which can cause some nausea/ queasiness), and that, combined w the effects in the brain and the slowed gastric emptying all combine to severely curb appetite and food consumption. The GIP in Mounjaro does all the same things since GIP and GLP-1 are closely related hormones, but the addition of it leads to synergism such that all the effects are compounded and weight loss is augmented.

The most common complaint I see in these medicines is the nausea and stomach upset. The worst effect I have seen (and I have personally had 4 patients so far with it) is pancreatitis. Pancreatitis can range from painful but not dangerous to potentially life-threatening. Two of my 4 patients went to the ICU, one went to Med-Surg, and one went home.

Another increasingly common issue coming to light w these meds is that they are forcing surgeons and anesthesiologists to adjust their OR scheduling. While “nothing after midnight” has been the pre-op mantra for decades, nowadays 6 hours NPO is becoming woefully inadequate; patients are regurgitating and sometimes aspirating when they start to get put under, since food is staying in their stomachs for so much longer. They are having to either come off their meds briefly or try and not eat for prohibitively long times before the OR.

But probably the biggest drawback of these medicines is their cost and availability, since they are all quite expensive, and right now the demand is still eclipsing supply.

What is the bottom line of all this? All of these meds are wonderful additions to the diabetes and obesity medicine arsenals, but they are by no means miracle cures. If you are taking one or considering one, just be aware of and be prepared for possible side effects. You can help to avoid many of the common adverse effects of Jardiance by keeping up your fluid intake. Unfortunately, there is not much you can do to avoid being the unlucky one who gets pancreatitis.

But DO feel reassured that my POV is skewed, since I only see bad outcomes in the ED. There are millions of other people out there doing great on them….   And if you need proof, just turn on your TV!

Mushroom Misery

Mushroom Misery

Shiitake dermatitis is a big price to pay for the joy of shiitake mushrooms.  The dermatitis consists of intense itching that occurs shortly after ingesting raw or undercooked shiitake mushrooms.  Characteristic of the rash are raised, red streaks which is also called “flagellate erythema” because it literally looks like the sequela of being whipped.  Other than this characteristic appearance, the dietary history is the cue to diagnosis.    

It responds quickly to oral antihistamines and/or steroids.  It is prevented by adequate cooking of the mushrooms.  But some Eastern health supplements may also contain raw shiitake. 

The shiitake mushroom contains lentinan, a sugar molecule called 1,3 beta-glucan.  In mice experiments when its given intravenously it has anti-cancer and anti-viral benefits.  For cancer it disrupts harmful intra-cellular signaling that helps cancer spread.  For viruses it inhibits tissue cells from absorbing the harmful virus.  Given orally to mice it has no benefit.  It also increases the production of an immune molecule called interleukin-1 (IL-1).  It’s the IL-1 that causes vasodilation (dilation of skin capillaries) and rash. 

Supplements or Not 

Supplements or Not 

The Journal of the American Medical Association recently published a study done by scientists in Cambridge, Mass.  This group did refined chemical analysis on 60 different health supplements.  Their findings were very disconcerting.  Just 11 percent of the products contained an accurate amount of the key ingredients listed on the label.  Forty percent had none of the indicated ingredients.  Forty Five percent had inaccurate amounts varying from .02 percent of the amount listed to 334 percent of the amount listed. Finally, 8 percent of the products contained at least one compound prohibited by the US FDA. 

As opposed to prescription medicines, the FDA does not have authority to approve supplements before they are marketed.  The agency does require that OTC products contain what they indicate. 

Just because a product is on the market does not mean it’s safe, much less effective.  This is probably where an ounce of skepticism is worth a pound of cure.

Thymus

Thymus

Scientists at Mass General Hospital in Boston recently published findings on 1,150 adult patients in their hospital who underwent thymectomy (removal of the thymus gland). 

The thymus gland is a bit of a mysterious organ found in our chest that is most active in early childhood.  It is located in the chest between the lungs and just above the heart.  In infants the gland is large and completely covers the front of the heart. 

Until this recent study scientists have thought that the thymus played its key role in immune development in childhood and then withered away.  After puberty the gland shrinks to a very small size and is replaced by fat.  To surgeons it looks like a little blob of fat. 

In the Harvard study 2,300 adults had chest surgery and in 1,150 of them the thymus was removed during the surgery because “it was in the way” and was not felt to be needed.

For years, the thymus was felt to be only active during childhood.  It pumps out T lymphocytes, immune cells that have many functions.  The “new” T-cells can be formatted to do a variety of immunologic jobs.  Adults rely on memory T-cells, which are long lived cells that can be re-directed (teach an old dog new tricks) for special tasks.  Because of this “standard model of thymic function “the surgeons did not think removing it would be of consequence.  But it turns out that they were wrong. The thymus is not expendable after all. 

Within five years after surgery 8 percent of the thymectomy patients died compared to 3 percent of those whose thymus was not removed during the operation.  Cancer risk within 5 years was also double in the thymectomy group.  Finally, the thymectomy group had double the incidence of new auto-immune diseases. 

Needless to say, the Harvard scientists were shocked by these findings.  It is unclear what removal of the thymus changed.  Perhaps the “blob of fat” is still producing a few new T-cells.  Or perhaps the involuted thymus still subserves some type of immune-protective-surveillance not yet recognized.  At any rate these findings have led to both a change in surgical tactics and also new immunologic research to study thymic function in adults.