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Author: Stephen J. Klemawesch, MD

I didn’t even know they had venom!

I didn’t even know they had venom!

By:  Sasha Klemawesch, MD

Most people know the Duckbill Platypus as one of the only two mammals that lay eggs rather than give birth to live offspring (the other being the Echidna (spiny anteater) but no one remembers him!).   However, they are ALSO some of the few mammals who produce venom.  Others on the list include vampire bats, hedgehogs, shrews, and moles.

Researchers in Australia have discovered that the Platypus’s venom contains a hormone called GLP-1.  Humans also have a form of it, but ours has a very short half-life, while theirs is much more durable.  Both of them function similarly though, by stimulating production of insulin, which in turn helps to lower blood sugar, so researchers are studying the monotreme hormone to see if they can manipulate it to use in management of type 2 diabetes.  While there are already several GLP-1 Agonists on the market, (think Trulicity, Saxenda, et al), experts hope that the more natural derivation may provide further benefits; perhaps it may be able to be compounded in an oral tablet, since all the current GLP-1 medications are injections, or perhaps it may even be able to be used in a wider variety of patients, such as those with renal or pancreas dysfunction (in whom use of current GLP-1A’s is still considered controversial). 

Q – Tips : Garlic

Q – Tips : Garlic

Many people suspect they are allergic to garlic owing to “GI tumult” that occurs after eating it.  However, it is more likely due to a genetic deficiency in cytochrome P450 and FAD-linked enzymes which metabolize sulfur containing foods.  Garlic contains very high levels of alkyl and dialkyl sulfide which give it its characteristic taste and smell.

Q – Tips: Mushrooms

Q – Tips: Mushrooms

Another less common mimic of food allergy is mushroom intolerance.  In this syndrome the deficient enzyme is Trehalase disaccharidase.   Mushrooms contain “double” (di-) sugar (saccharide).   If the sugar isn’t broken down into single sugar (mono-saccharide) it ferments in the colon causing bloating, gas, and diarrhea.  

Good News/Bad News

Good News/Bad News

On September 13, 2019 an FDA advisory board recommended approval of an oral peanut vaccine (“OIT” for oral immunotherapy).  If this recommendation leads to approval, peanut allergic individuals will be faced with a tough decision.

Approval is based in part on large studies done in California on children and adults with severe peanut allergy.  In this study, 85% of the OIT treated patients were able to tolerate 4 grams of peanut without serious reaction.  That’s the good news.

The bad news is that stopping OIT lead to a fairly quick return of the severe allergy.  Additional bad news is that despite being protected from severe reactions a large number of patients had frequent mild allergic reactions and were prone to develop a condition called eosinophilic esophagitis – a form of allergic reflux.

High Dose Flu Vaccine

High Dose Flu Vaccine

High dose flu vaccine contains 4 times the amount of antigen (killed flu virus) than the standard vaccine.  People with the highest risk for death from influenza are infants, pregnant women and adults over 65.  The high dose flu vaccine is recommended as an option in the latter group.  People over age 65 have immune systems that are also aged and by giving them a higher dose there is a better chance of stimulating a good immune response.  In fact, research showed a 24% improvement in immune protection.

The tradeoff for some people is a greater likelihood of local reaction or systemic “achiness” after the higher dose.  For those individuals leery of these side effects the CDC proposes as another option receiving two of the regular dose vaccines a couple of months apart.   However, the second dose is not covered by Medicare or commercial insurance plans.

Vaping and Lung Disease

Vaping and Lung Disease

Vaping has become extremely popular in the last few years in part because it has been promoted as “a safe alternative to cigarettes”.  Currently 1/3 of all high school students report “some use” of vaping.

Unfortunately, hundreds of individuals have been hospitalized and died with an acute lung disease.  The most common cause of this lung disease is lipoid pneumonia which can affect multiple lobes of the lungs and lead to respiratory failure.  This form of disease seems to occur if the vaping material contains Vitamin E acetate, which is an unnecessary additive.

The two other forms of lung disease are acute eosinophilic pneumonia which is actually a severe allergic reaction to an excipient in the inhaled material.   A variety of excipients are available to promote usage such as fruit and candy flavors.  The second form of lung disease is cryptogenic organizing pneumonia.  This is a bit harder to diagnose and understand, but basically inhaling chemical and possibly infectious particles through the electronic system can allow direct and deep penetration of the pathogens into the lungs.

In all three forms of lung injury the patient becomes extremely short of breath and may need to be placed on a ventilator.  CT scans often show “diffuse white out” of the lung fields; that is, diffuse pneumonia.

Don’t Worry, Be Happy

Don’t Worry, Be Happy

By:  Sasha Klemawesch, MD

Scientists have known for a while that optimists tend to enjoy better health, and recently, a BU study came out reemphasizing just that.  Their research followed a large and varied group of people for more than a decade, and found that those with the sunniest dispositions lived 11 to 15% longer than their negative counterparts! And the results held even when they accounted for chronic diseases, socioeconomic status, smoking, et al; a Positive Mental Health Attitude was shown to be beneficial and protective.

Multiple previous studies have examined smaller and more select groups but came up with similar results.  Here are some key findings from a few of those past papers:

  • Middle age patients who underwent coronary artery bypass surgery were twice as likely to end up readmitted after discharge, and more than three times as likely to suffer repeat heart attacks if they identified as pessimists.
  • Another study showed that optimism can help stave off heart disease in the first place; a Harvard study followed about 1,000 men without coronary artery disease for 10 years, and the cynics were > 50% more likely to end up developing cardiovascular disease.
  • Optimists are more likely to have lower blood pressure and require fewer or no medications than their negative (hypertensive) neighbors.
  • In 2006, a group of approximately 200 health subjects were exposed to a common respiratory virus, and the happier people were less likely to develop significant symptoms compared to their surly (and now sniffly) peers.
  • In a study of more than 2,000 seniors, a cheery disposition significantly increased their odds of being able to remain living independently.
  • We know that laughter is contagious, but researchers also found that a good belly laugh revs your heart rate and your energy burning; 10 – 15 minutes of hearty laughter can burn 10 to 40 calories.
  • One of the earliest American studies regarding on how your outlook affects your health found that for every 10-point increase on a standardized pessimism rating scale, the corresponding mortality rate rose 19%.
  • Positive attitudes are associated with lower levels of CRP and IL-6, two key inflammatory markers often associated with higher risks of heart attacks and stroke.

Don’t worry if seeing the glass half-full does not come naturally to you though.  Optimism can be learned and taught.  (Ha, I just realized that only those of you who’d be worried or be telling yourself you’re a hopeless case would be those who are naturally more negative, so I guess that was sort of a silly thing to say.)  Nevertheless… if you would like to try and change your innate outlook, but aren’t sure where to start, a good quick overview I found on YouTube is: “Learned Optimism Positive Psychology” – Martin Seligman – Animated Book Review (practical psychology).  And the next video in the lineup is “Optimism – How to Become Optimist Right Now” (actualized.org).  It’s a bit longer, but both videos reference the book “Learned Optimism” by M. Seligman, which is one of the more respected works on the subject. So, if you would rather hold it in your hand than watch it on the computer, you could check that out too.

And finally, right now, before you put this paper down, SMILE!  You may feel silly, but the act of smiling triggers a release of feel-good neurotransmitters in the brain, and if you feel silly enough to laugh a bit, even better.  Laughing does the same.

Ligelizumab

Ligelizumab

Ligelizumab is a “next generation” humanized monoclonal antibody to IgE.  It was designed to be a “better mousetrap” to treat people with severe chronic urticaria.  Chronic urticaria (recurrent hives) is fairly common, occurring in 1 case per 200 people.  In most cases it can be controlled with oral medications primarily in the form of antihistamines.

 

Many people gain control with a single H1 receptor antihistamine such as Allegra or Zyrtec.  Some patients require the addition of an H2 receptor antihistamine such as Pepcid.

 

However, the patients unable to gain control with these simple/safe medications have had to resort to oral steroids, not a good long-term strategy.  Then a few years ago, the earliest developed monoclonal antibody for IgE, Omalizumab, which has been used to treat asthma for many years, was found to be very helpful for chronic severe urticaria.  It truly has been a Godsend, and up until now it was the best resource for these severe patients.

 

Now comes Ligelizumab which seems to be even more effective.  In fact, in head to head comparison studies of Ligelizumab and Omalizumab 51% of the Ligelizumab study group had complete resolution of their hives compared to 26% of the Omalizumab group.  There was a greater frequency of injection site reactions with Ligelizumab then with Omalizumab.  Also, Ligelizumab is so new, its long-term safety is yet to be determined whereas Omalizumab having been available for many years is known to have a fairly safe track record.

Hatfield’s and McCoy’s

Hatfield’s and McCoy’s

The “stolen pig” that set-in motion the famous Hatfield and McCoy feud may have been (excuse the pun) a scapegoat for the underlying medical condition that probably caused all the anger.

 

Because of rural family dynamics and inbreeding among relatives it seems many of these people, especially the McCoy’s may have suffered from a genetic disease, von Hippel-Lindau, that causes tumors on the adrenal glands called pheochromocytoma.

 

The adrenal glands are a normal part of our adaption to stress called the fight or flight response.  However, when a tumor is involved the amount of adrenalin that is released is abnormal in two ways.  Instead of normal “adrenal release” that is just occasional and in response to a threat, these tumors continually release adrenalin.  But then when there is a threat, they release way more than the normal gland does.

 

The excess adrenalin can not only cause chronic irritability but in surges can cause “reactive – combative behavior”.  Sometimes the surges cause a sensation of panic and occasionally people felt to have psychologically caused panic attacks actually have pheochromocytoma.  The low-grade irritability can sometimes cause children to appear to have ADDHD (attention deficit disorder/hyperactivity) SSRI’s used to treat some patients with panic attacks can cause a person with pheochromocytoma to release more adrenalin.

 

Some people who have pheochromocytoma consult allergists thinking that their sudden symptoms of flushing, heart racing, sweating and panic are indications of an allergy attack.  Albeit this condition is extremely rare, but if the Hat(fields) fits you might discuss this rare condition with your doctor.

Dear Dr. K – I heard that there is a new drug to treat flu. Is that true? And, does it work?

Dear Dr. K – I heard that there is a new drug to treat flu. Is that true? And, does it work?

Yes, and yes.  The new drug is Xofluza and it is the first flu drug with a new mechanism of action to come along in 20 years.  It is (hold on to your hat) a polymerase acidic endonuclease inhibitor, (PAEI).  PAEI is essential for the viral RNA messenger that allows the flu virus to replicate itself.  By shutting down viral replication, it shuts down the infection.  It is effective for both influenza A and B.

 

The only other available drugs for influenza all work by the same, but different than Xofluza, mechanism which is to inhibit neuraminidase.  These drugs are:  Tamiflu, Relenza and Rapivab.  Neuraminidase is an enzyme of the virus that allows it to escape from one human cell so it can invade the next cell.  By inhibiting neuraminidase these drugs also shut down the infection.  Tamiflu is oral, Relenza is a nasal spray and Rapivab is IV (used in hospitalized, severely ill patients).

 

The new drug works as well, but not better than the other three.  However, one dose is sufficient.  It works best if started within 48 hours of becoming ill.  Being new it is naturally more expensive.  Unfortunately, influenza seems to be able to develop resistance to the new drug fairly quickly.  Ten percent of patients developed resistance after a single dose.

 

Resistance is also a problem with the neuraminidase inhibitors, so the FDA is studying the possibility of combining both families of drugs for their synergism (killing virus by different mechanisms) and as a means to prevent resistance.