Nutrition and Immunity

We have long known that one cause of secondary immunodeficiency is malnutrition. And we are constantly bombarded by claims that this or that supplement will "boost your immune system," whether they be online, on television or via naturopathic practioners. Many of these 'supplement' claims are overreaching if not downright false. And little scientific evidence seems to validate such assertions.

In contrast, a recent story in the Wall Street Journal has a nice (albeit brief) summary of what we know about nutrition & the immune system. I would always argue that the best way to obtain the proper amount of nutrients is not through a pill, but via a balanced diet.

Does your child have allergies?

Take the Childrens Allergy Quiz

Update: Sakina Bajowala. M.D. asked about the stress reduction therapy mentioned at the end of this posting. I assumed this was an advertisement for the author of the article. I believe that there are neuropsychoimmunologic connections that affect many chronic diseases, including allergies. However, I do not endorse any specific technique unless it's shown to provide efficacy in peer-reviewed, reputable journals. Thanks for the question Sakina.

The Lung Flute

Popular Science has a nice artile on an innovator who created a device that helps those with chronic lungs issues (emphysema, asthma, cystic fibrosis, etc) mobilize their mucus.

Happy Thanksgiving

"A Prosperous Wind" by Mike Haywood.
I am thankful for so much this year. First and foremost for my new wife, who has traveled across country and agreed to a new life far from our native home. Second, for my new position and colleages, who are supportive and highly capable. For my family and our continued good health. And I am appreciative of the sacrifices made by my ancestors, going all the way back to the brave souls who sailed the North Atlantic in the winter of 1620 to find a better life; John Howland, Elizabeth Tilley Howland, John Tilley, Joan Hurst Rogers Tilley, John Alden, Priscilla Mullins, John Mullins and Alice Mullins.

Inspiring quotes from my VA patients, Part XI

Heard during a family meeting discussing palliative care options for a WWII veteran with end-stage pulmonary fibrosis:

"Don't feel bad for me...Every day since '45 has been gravy."

Is it a food allergy or food intolerance?

MSNBC takes this question on

Singulair (Montelukast) & Suicidality

Singulair (montelukast) is a leukotriene receptor antagonist used for control of asthma and allergies. In March 2008, the FDA started a review to investigate numerous postmarket reports of suicidality related to the use of Singulair. Results of those reviews were recently published in the October 2009 issue of the Journal of Allergy & Clinical Immunology.

Each review went back through research data acquired during drug development to look for patterns that may have represented suicidality or "possible suicidality-related adverse events (PSRAEs)." These reviews were ordered by the FDA and completed by employees of the drug's manufacturer Merck.

There were no suicides reported during the clinical trials for Singulair. There was one case of suicidal ideation in almost 10,000 patients taking montelukast and none in over 11,000 control subjects (placebo and active control). The conclusion drawn was that PSRAEs were rare and similar to the control groups.

A related article in the same issue looked at behavioral-related adverse events (BRAEs) during Singulair clinical trials. The frequency of patients with 1 or more BRAEs was 2.73% and 2.27% in the montelukast and placebo groups, respectively. The frequency with a severe BRAE was 0.03% in both montelukast and placebo groups, suggesting no difference. And the frequency of patients being taken off of montelukast because of a BRAE was 0.07% while 0.11% of placebo patients were discontinued from the study for a BRAE.

Potential limitations of these reviews include the fact that they were completed by employees of Merck, and that they only included data collected during drug development, where suicidality would lead to exclusion from the study.

The latter issue is important because severe asthma and allergies have been associated with depression and anxiety and thus, such patients may be more prone to suicidality. Using Singulair in such patients requires proper counseling and close follow-up.

Anecdotally, I have seen patients (especially children) who do experience mood changes on Singulair. We stop the medication and provide other controllers of their symptoms, and there has never been complicating issues. For what it’s worth, I have also seen similar behavioral changes on antihistamines and even certain inhaled corticosteroids. And we commonly screen for depression/anxiety in our patients.

Practioners and patients should discuss the risks of behavioral changes with the use of Singulair before prescribing this medication.

What does your doctor really think about you?

UK Dr Phil Hammond spills the beans.

Images from Clinical Allergy

Percutaneous skin testing to aeroallergens with almost identical sensitivities in identical twins. This is actually not as common as you might expect.

IL-33 is a marker of severe asthma

A nice summary via Allergy Notes

Is there a genetic basis for 'bad driving?"

UC Irvine neurologists seem to think so...

Costco Rocks

I was at Costco yesterday and found some great prices on generic allergy medicines, especially cetirizine (zyrtec) and loratidine (claritin). A full year of cetirizine for $16.29!

Cold-Induced Urticaria

Positive "ice cube test" on a patient with cold-induced urticaria. Top image reveals a ring shaped hive where the ice-filled cup was in contact with the skin. The cup was then removed and the hive continued to grow in size.

This patient had a history of developing hives when exposed to cold air or water for 16 years. The hives were found primarily on exposed parts of the skin (face, upper extremities) and would resolve spontaneously after the patient was re-warmed. She had no symptoms or signs of anaphylaxis and only intermittent nasal allergies during the spring and fall months. There was no other history of autoimmunity in the patient or her family.

Cold-induced urticaria is a physical urticaria. Others include hives caused by sun, pressure, contact (dermatographism), vibration, aquagenic, etc. Symptoms can range from being a mild annoyance to the development of life-threatening anaphylaxis. Treatment is avoidance of precipitating stimuli where possible, and antihistamines. Prognosis varies, but most resolve spontaneously after a period of time (usually months).