Seasonal Allergies, Sinuses and Inflammation
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Kara Wada, MD: Hello everyone my name is Dr. Kara Wada. I am a board certified pediatric and adult allergy immunology lifestyle medicine physician and this session will be all about allergies, sinuses, and inflammation and really exploring the connection between those.
So for those of you who I haven't met before, it's so nice to meet you. I am so thrilled you were here. I have spent the last actually 13 plus years working in academic medicine in the Midwest. As I mentioned, care of adults and children especially focusing on conditions that affect the immune system.
I also have a huge interest in harnessing the healing power of our habits. That is lifestyle medicine, and I love teaching, so I did a little bit of extra training in medical education as well because, as it turns out, they don't really teach you how to be a teacher in college or medical school. Really, my wake up call came a little over four and a half years ago when I was diagnosed with Systemic Sjogren's and my infant daughter had an anaphylactic reaction to eggs within about two weeks of one another, and that was the like, "Timeout, hold the phone, what the heck is going on?" Our family had really no history of food allergies.
We had a real increase in diagnoses of autoimmune type diagnoses in my generation, but prior to my generation, no one had those issues. And that really got me thinking about what was different and what could we do as a family to decrease our risk of future problems?
And that is what all of this work stems out of.
So disclaimer that although I am a doctor, I am not your doctor in this capacity and this information is for educational purposes only. Our objectives for this session are to understand the association between allergies, sinus disease, and respiratory inflammation, things like asthma, and identify common mechanisms that drive the production of those symptoms, and then learn practical tips for managing sinus and nasal symptoms.
We are in the middle of fall allergy season here in the Midwest of the United States. It is a record ragweed season and it's also that time when all the kiddos are back to school and we're seeing a real increase in viral infections as well. And these infections and allergies tend to affect us in our nasal passageways, our eyes, and our sinuses.
So let's look inside, take a look behind the curtain, and see what parts of our body are affected. So we are actually born in part with some of these sinuses. Some will develop as we get a little bit older in childhood. We don't actually know why the human has sinuses. We think it's to lighten the weight of our head.
But the real purpose of our nasal passageways is to warm, filter, and humidify air before it reaches our lungs. It's like an air conditioner of sorts. And so air will pass through our nostrils or our mouths. It will cross over the mucosal tissue. It's tissue that lines the bones that form our facial structure and our sinuses.
This tissue in particular is covered in little hairs called cilia, and it also secretes mucus. That's where the term mucosa comes from. Mucus acts like a protectant layer on top of those tissues. It also helps grab any particulate viruses other things that come in that way and helps us expel them.
They're blowing our noses or swallowing that mucus down to our stomachs where the stomach acid hopefully is digesting it. So here's a little zoomed in view of that nasal epithelium. That mucosal surface, those little cilia that I mentioned, it's interesting when when I have a patient who is a smoker, I talk to them about every inhale on that cigarette paralyzes those little cilia, and the longer you get out from that last puff on that cigarette, or maybe that vape, those little cilia are going to start to wake up. And it's amazing because then the body goes into repair mode. It helps clear out a lot of the toxins and other things that you've been inhaling for all those years. It's pretty incredible. But I mention that because sometimes folks will notice, once they quit smoking, that they will see an increase in mucus production or coughing and that's okay. That tells us that the body is waking up, and it's doing what it's supposed to do. It's healing, repairing as we're made.
Nose and Sinus Symptoms
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Kara Wada, MD: All right, so nose and sinus symptoms are divided into three main categories, at least is how the allergist, immunologist, and the ear, nose, and throat doctors think about it.
About one third of the patients we see, their symptoms will really fall hand in hand with their allergy test results. And what I mean by that is the symptoms and the story of the symptoms, that lived experience you're having correlates 100 percent with what your allergy testing would suggest you have symptoms around your kitty cat, you get symptoms in spring pollen season and fall pollen season, and lo and behold, those are the things that come up on your allergy test.
We'd say, "Yeah, that sounds like your symptoms are being driven by an allergic flavor of inflammation". Type 2 inflammation is another way we might describe that. We also know that about one third of the patients we see, their allergy testing, despite their stuffy noses, runny noses, all the mucus production, is totally negative.
And we say, "Okay, your symptoms are not being driven by this allergic flavor of inflammation. Perhaps it's a type 1 or type 3 type inflammation, but suffice it to say your symptoms are not being driven by that same lock and key mechanism", which we'll talk more about, that we see in allergic rhinitis.
And so our treatments are going to look different for those two groups of people. Some things overlap and some things are very separate. Now the remaining third of patients, a little bit of both. So their allergy testing may say, "Yeah, that makes sense, but that doesn't tell us the whole story." And so those would be folks with mixed rhinitis.
And really what we're talking about when we talk about mucus production, swelling of the nasal passageways, or nasal congestion. Itchy, watery, sneezy. These are all signs and symptoms of inflammation. It's our body's response to infection, like when we get a cold, right? Sinus infection. Or if we get an injury, if we got a bop in the nose.
Or my poor little kiddo who face planted this morning when the sidewalk jumped up in front of him. And then insults. So these are conditions of too much inflammation. Things we're going to be talking about all week. But allergy, autoimmunity, problems with our metabolism being out of whack, and problems with dysbiosis.
This is when our microbiome is not in a good balance. And increasingly, we see that this plays a role in some folks who have chronic sinus problems. Or maybe you have particular types of staph aureus. I've heard of staph infections or MRSA some of these strains of staph aureus produce toxins which are problematic to our lining of our sinuses.
We also can have the development of things called biofilms. So these are essentially, linked together colonies of bacteria within that mucosal tissue that are really hard to get rid of. This will happen with pseudomonas as well, something we see quite commonly in patients with underlying health conditions like cystic fibrosis.
At its core, though, inflammation is actually a very natural and healthy process. And when it's working correctly, its purpose is to protect and to repair. And when we're in the middle of that, and we're in that happy place, never quite stagnant, but in that happy place, it's called homeostasis. It's a happy place.
When we have too much of it, though, that's when we have a problem. And that's what this week is all about.
Understanding Inflammation
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Kara Wada, MD: Alright, so inflammation, as I mentioned, plays a key role in our nose and sinus symptoms. Allergy related inflammation is related to the release of certain substances within allergy cells. Things like histamine and tryptase that are triggered through these IgE, look like the letter Y, allergic proteins that are housed on the surface of these cells.
And we'll take a closer look at that in just a second.
When we think about these non allergic flavors of inflammation, this may be something as simple as irritation. When, interestingly, when pollen counts are so high, like what we're seeing in this particular ragweed season, and actually the last one and the one before that is that it's like we're breathing in sandpaper.
Super irritating. You can imagine inside of your nose, or if you already have inflammation there, think about the last time maybe you accidentally burnt your skin cooking something, and that skin is extra sensitive. We can see this especially with reflux. Some folks will have reflux, comes up the back of their throat, at the base of the sinuses.
The tissue there creates mucus, which is protection factor, right? Makes sense. And then we get that sensation that we're swallowing mucus related to that reflux. All right. And we also can see this inflammation related to autoimmune conditions. In particular, when I look in someone's nose and I see it looks really dry, and maybe they're not really on other medications that could be causing that dryness, I'm always asking other questions about things like Sjogren's or other autoimmune conditions.
And understanding the underlying mechanism or the flavor of inflammation, it helps us get to that root cause, right? Helps us better direct treatments. And personalized treatments to your specific problems.
Understanding the Flavors of Inflammation
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Kara Wada, MD: All right, so this is one flavor of inflammation. This is allergic inflammation. This is a cute little mast cell.
Those who have mast cell disorders would not think that these things are cute. They're actually like little kamikaze cells. And these cells are found all over our body. They're like little watchdogs found primarily in our skin, our respiratory tract, our gut, these areas of our body that interface with the outside world.
And these cells, when we were back in cave people days were not allergy cells, because cave people weren't dealing with allergies, right? They were having to use these white blood cells, these infection fighting cells, to protect themselves from parasites. Knock on wood, we don't have to deal with intestinal parasites like our ancestors did.
And I'm laughing a little bit because parasite infections are not nearly as prevalent as the influencers would like you to think. Okay now, so these cells, they're tiny little white blood cells. You think of a worm, an intestinal worm. It's relatively big compared to this white blood cell, right? So typically, when we think of the white blood cells coming and gobbling up a bacteria and digesting it and killing it.
These white blood cells can't rely on being pac man, pac women because those worms were pretty big, right? So instead of gobbling them up, they developed preformed packets or granules of all of these different substances, histamine, tryptase, PAF, lipid proteases, cytokines, and chemokines, nitric oxide, and endothtelin. Hundreds of these different toxic chemicals. And when these cells trigger, they create the signs and symptoms that we now associate with an allergic reaction. Hives, angioedema, or swelling of the lips, the eyes, the hands. They will create wheezing, profuse runny nose, throwing up, running to the bathroom from the other side of things.
And if you think about it, what this would have done, in cave people times, is this would have helped expel worms from the body, right? That is the way that these function. Now, they just cause symptoms that we attribute to an allergic reaction.
But the reality is that it's not, and I think this is important to know, for other things that can come on. is that although in allergy, these cells are being triggered by this IgE protein, which acts like a lock and a key, it's specific to the allergen, so the little end of it is going to be specific for birch tree pollen, specific for ragweed, specific for peanut.
When those bind, they bring more than one of those two proteins together, it triggers the cell. But here's the thing, this is not the only way that these mast cells can get triggered. Okay, and what you probably will hear if you follow me on social media or listen to my podcast, is that these mast cells also can be triggered for all sorts of different reasons.
Certain medications, pressure, viral illnesses, autoimmune type flavors of inflammation, can all trigger these types of white blood cells, okay? Especially if we're talking about chronic hives, more often, they are not at all related to an allergic trigger. More often, they're related to more of an autoimmune underlying cause.
Alright, so we talked about these non allergic triggers, these irritant triggers that are really common. This summer, we had a ton of wildfire smoke here in the Midwest and on the East Coast. I know those of you joining us from the West Coast, California you're very well familiar with this. This was a new experience for us.
But smoke and air pollution, huge triggers of inflammation. Excessive dryness in your environment or big swings in humidity or temperature can also be non allergic triggers. Medications many times will have side effects. There are certain types of medications. For instance, medications that affect our alpha receptors.
Things like prososin and medications used for PTSD and also for people who have enlarged prostates cause nasal swelling infection, as I mentioned, dysbiosis changes in that microbiome in the sinuses and respiratory tract.
Impact of Chronic Inflammation
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Kara Wada, MD: Now what happens if you have chronic inflammation in this area? You can see enlargement in some of the structures inside of your nose, which makes it harder to get air in and air out.
This is... enlargement of your turbinates, those are the bony structures in your nose. Those potentially can cause obstruction in drainage of mucus. Obstruction, in general, can cause difficulty with nasal congestion, so that stuffiness sensation, difficulty breathing, especially at night, causing sleep disturbances and increased susceptibility to bacterial sinus infections.
So I like to take, along with my colleagues, a three step approach to allergy and sinus care.
One, minimizing our exposure to triggers. Improving our air quality is really what that comes down to optimizing medications to minimize side effects, optimize results. And then consider immune modulating therapies. So these typically are things like immunotherapy if you are allergic, but increasingly I'm continuing this discussion and including in this discussion using lifestyle as medicine because really, truly, this is where we see a lot of immune modulatory benefit.
So say you are dealing with a cold. You just had to turn on the heat or you're planning on having to turn on the heat in the next few weeks. Our nose might get pretty dry or if you're getting over one of these early fall colds. Moisturizing and restoring balance to our sinus and nasal passageways is really important.
It has a lot of science behind it too. So one of the things that I love to recommend is using nasal saline. So this can come in the form of a neti pot like was shown here, a sinus rinse bottle, a little spray canister, but really what we're talking about is a way to maintain the mucosal barrier, loosen mucus, and rinse away debris that includes pollen, and it also increases mucus clearance, flushing things out, giving your nose a little bit of a shower.
What causes indoor allergies?
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Kara Wada, MD: When we talk about trigger avoidance as well, we're talking about indoor allergies, most often we're talking about dust mites. And critters that live in our homes, so our fur babies, like our kitty cats, our dogs, maybe we have some little rodent fur babies, like a guinea pig or a hamster. This also can be pests, so maybe those non pet rodents and cockroaches, depending on where you are as well.
All of these are potential indoor allergens. What is interesting about indoor allergens, they tend to be things... especially if we're living with them, that we're exposed to day in and day out. And our allergy symptoms can present differently in those situations, as opposed to something that we're encountering every once in a while or seasonally.
Those allergens that we encounter every once in a while or seasonally, they tend to be pretty dramatic in their presentation. Itching, sneezing, total obstruction. Feels like you almost have a cold. Miserable. Whereas if you're exposed to these things on a day in and day out basis, they tend to be more of a nuisance and frustrating. And we tend to sometimes get used to these symptoms over time until they hit a breaking point.
So how can we minimize our exposure to these things?
One, we know that we spend 90 plus percent of our time indoors. So we can focus on improving our indoor air quality. So interestingly, dust mites we talked about first and foremost. They... are pretty heavy allergen. The allergen they create is pretty heavy, settles on the floor pretty easily and quickly. So using an air purifier, not particularly helpful for dust mites. What's going to help for dust mites is washing your bed linens weekly on hot and drying on hot and also thinking about getting allergen encasements.
So these are zip up covers for your pillow and your mattress. They're tightly woven. You want something that's breathable but tightly woven and those are going to help decrease your exposure to those dust allergy. That's my allergens.
All right, so what about the other allergens? If you live with pets that you're allergic to using a high quality filter is going to be really helpful.
If you live in an area that has had increased air pollution, or you live in a more urban area with lots of traffic. Again, this is also going to be helpful. So looking at your furnace filter the filters have ratings. You want to look for something that has an M E R V or MERV rating of 10 or greater, 11 or greater, to help take care of pet dander, smoke, smog, kind of air pollution and also some of the infectious particulate.
Now it's interesting, when you look at this rating of these MERV ratings, when you get to the top rating, that's essentially a HEPA filter. So when you're looking at some of these standalone units, for instance our office has a molecule unit or on your vacuum, maybe it's a HEPA filter type vacuum, that's what that means.
If you do not have super significant pollen allergies or it's a low pollen time of year for you, open your windows, get that circulation going. There is something to say about airing out your house and and improving your air quality.
Alright, so a quick little note on dust mites. These are little dust mites.
They are microscopic. Not a hygiene issue. Unless you're joining us from Denver, I can pretty much guarantee you have dust mites in your house. Denver is actually too high and too dry for these little critters to survive. So if you have significant dust mite allergies, it might be a reason to move. And they live off of the humidity in the air.
So if you need an excuse to not make your bed, there actually have been some studies that show that dust mite levels are lower than people who do not make their bed. Because the moisture our bodies give off while we're sleeping is able to fully evaporate and dry out during the day. So you can tell them your allergist said that you don't have to make your bed.
What causes outdoor allergies?
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Kara Wada, MD: All right, so outdoor allergies. As I mentioned from the get go, we're in the middle of fall allergy season when I'm recording this in the Midwest of the U. S. It is a record pollen season and we're only a few weeks in. And the reality is, with climate change, outdoor allergies are going to continue to be an ongoing and worsening problem for many of us.
Trees will start the pollination season. They'll start early spring. As soon as the snow melts, we have a decent thaw. Those trees start to bloom. Yep, the pollen's there. So for where I'm located, this is as early as late February. My sister who lives in Houston, it's maybe December with Mountain Cedar.
As we get to a little bit later in the spring, mid April perhaps, at least in the Midwest, we're going to see grass pollen join the trees. So you get the one two punch if you're allergic to trees and grasses, where you're going to see both of those. One of the visual signs for me to know that we've hit real prime grass season is when I see the cottonwood, those little puffs.
And the air tells me that not only is the cottonwood pollen present, but we also have grass pollen. Fall time, we have weeds. Ragweed is the one we think most about, has some friends too. And interestingly, ragweed levels tend to be up to seven times higher in urban areas compared to the surrounding areas because, one, ragweed thrives in abandoned lots along streets that don't get mowed, railroads, those sorts of things. Each individual plant can release up to one billion, with a B, grains of pollen. And the length of the pollen season for weeds continues to lengthen as the time of our first frost is pushed out.
We also can become allergic to molds. So molds tend to be more of a problem in spring and fall. Especially think of it in fall when we see all the leaves on the ground and it's wet and damp.
All right, we've talked a lot earlier about non allergic triggers. Some other ones that, just to touch on barometric pressure changes. Huge non allergic triggers.
Not only for our sinuses, but for migraines as well. The particulate load, ozone levels, perfumes, candles, strong smells, even if they're pleasant, can be non allergic triggers, walking past the candle shop at the mall or the Abercrombie, pumping through all that fragrance. Spicy food, that's totally one of my triggers. And interestingly, the smell of fresh cut grass is also a really prominent non allergic trigger.
Sleep and Sinus Health
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Kara Wada, MD: Alright, why is it so important to take care of her sinus health? It really can impact our sleep. And we know sleep is absolutely critical for immune system health. So if you are snoring, or if you have congestion that is interfering with your sleep, I really urge you to get it checked out.
Make an appointment with your primary care doc, or your allergist immunologist, if you already have one. They may suggest that you touch base with an ear, nose, and throat doc, depending on what's going on. And if you are someone who is already using something like CPAP or BiPAP, understand that this has implications, especially non allergic implications in your sinus health, potentially allergic implications if you're not cleaning it adequately.
So really know that these are all things that can be optimized. Alright, medication management. A lot of times we were walking a tightrope between getting symptoms and inflammation calmed down, but also trying to avoid some of the side effects, like over drying our nasal passageways, like I mentioned.
Medication Management
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Kara Wada, MD: What meds should you be thinking about, especially those over the counter medications?
First and foremost, if you are dealing with stuffiness, nasal congestion, using something in the family of the nasal corticosteroids. These go by the names of Flonase, Nesonex, Nesacort, Rhinocort that's enough of them. Those tend to be the most helpful at shrinking down those swollen nasal passageways.
Now, some people are going to respond better to certain ones of these, and some may have more side effects with certain ones as well. They have nuances between each of the different varieties. The key to know about these particular medications are they are slow onset. It can take two to four weeks to see their full effect.
So they really take day in, day out usage, similar to a blood pressure medication. Technique is also critical, so if you're using a nasal spray, first and foremost, you want the extra coming out the front, rather than dripping down the back of your throat. This is going to keep the medication where it needs to be. It's also going to minimize how much you're going to taste.
Point your nose towards your toes. Nozzle, point it out towards your ear on the same side. So steer towards your ear, and don't sniff or snort. Just breathe normal, and if you have any extra, you're gonna grab a tissue or a towel, and you're just gonna dab it, okay?
The other nasal spray that you're gonna see on the shelves more recently is something called AstaPro. Generic name is Azelastine. This went over the counter about 18 months ago. This is a nasal antihistamine. This is a nose spray that is going to work a little more quickly, and you can get away with using this one on an as needed basis.
Downsides. It dries actually quite well. A lot of times that's what we're using it for. We want it to dry up that mucus. Sometimes, though, we can overshoot. The other downside. It doesn't taste great. It has a more bitter taste than the other medications. But again, you can use it as needed, you can use it up to twice a day and it can be quite effective.
If you are more opposed to nasal sprays, I getcha we as allergists tend to recommend far and away, more often, the long acting, less sedating loratadine.
Fexofenadine, aka Allegra, and Cetirizine or Zyrtec. Xyzal or levocetirizine is another one that's out there as well. All of these can be quite helpful. They're going to be much less sedating, though I will say Zyrtec, it's about 1 in 10 people will have sedation with that. Far less side effects than something like Benadryl or diphenhydramine, which has been associated with heart rhythm problems, something called long QT sedation, and troubles with falls, and over the long term has been implicated in increased risk of dementia or memory problems.
All right. Are you dry and crusty? This is what I get with Sjogren's, okay? Maybe you overused your nasal sprays, you're getting over a cold, and your nose just feels all out of whack. If you happen to check out TikTok the last year or so, there was this huge push for slugging. It was like this technique to make your eyes just look glowing and smashing by really hitting it hard with moisturizing products.
So we can take a little bit of a guide from the silly TikTok videos, but we can do something similar for our noses. We can use humectants, which are hydrating, moisturizing ingredients. You would look for in products, things like hyaluronic acid, maybe the isotonic or, similar to body concentration saline, and xylitol.
Emollients are going to help add back moisturizing oils, so some of the nasal gels in particular are going to have these in them. And then use an occlusive over top of that. It's either petroleum jelly, or if you're like me and love a little bit of a mental vacation, coconut oil.
Coconut oil also is thought to have some antimicrobial properties, and it can be quite helpful too.
Immunotherapy
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Kara Wada, MD: All right, so say you've been to the allergist. You know what your allergy profile is. This is when immunotherapy really is the long game. It is something that helps change your immune system's response from fighting the allergen to ignoring it for the long term.
You can check out immunotherapy and in particular about a couple types of immunotherapy that are cutting edge.
Those include intralymphatic and sublingual immunotherapy. We are
excited. We already offer sublingual immunotherapy where I practice but we are looking to be trained in intralymphatic immunotherapy in the next couple months.
So really excited about just having all of these different ways to offer long term treatment solutions to our patients. All right, so what we do as an allergist, we sit down with your allergy profile, your test results, and we look at your symptoms. And then we put together a personalized recipe in order to work on desensitizing you to these allergens.
And typically when we're thinking about allergy shots or sublingual, this is a long term process of about three to five years.
So really the side effects are risks of immunotherapy. You can have allergic reactions, so with an allergy shot, we estimate about 1 in 200 will have a little more significant allergic reaction to a shot. And one thing I talk about with my patients that have autoimmune conditions, immunotherapy is not contraindicated.
It means we can do it. There's nothing that says we shouldn't do it in someone who has autoimmune disease, but I think we need to have a real open line of communication to see how you're doing. Because anytime we're you know, messing around with things with an immune system that's already misbehaving, there's a potential that things could go awry.
And so we need to stay in contact and troubleshoot if symptoms are worsening.
ENT and Allergist Immunologist: Collaborative Care
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Kara Wada, MD: One thing I love about where I practice clinically is the collaborative care that we have with our ear, nose, and throat. Physicians. So ENTs specialize in the surgical interventions in diseases affecting the nose and sinuses and really anything else in this area of the body.
And as an allergist immunologist, I am not trained as a surgeon. So you do not want me going anywhere near you with a scalpel. Instead that's where I have the expertise of, you immunotherapy using biologics and other medical management for these conditions and diseases.
All right, so your quick start guide to get you started after this session.
Really think about who needs to be on your care team. Assemble the right care team. Find out your inflammation type using the American College or the American Academy of Allergy, Asthma and Immunology if you're located in the U.S. These are great places to look for a board certified allergy immunology physician in your area.
If you're getting dry and crusty, consider using a sinus rinse and doing that slugging technique I talked about. In general, anytime we are making an intervention on our health, you need to get curious. and experiment a little bit and take some notes so that you can report back to your team about what worked, what didn't work, what was and then be patient with yourself.
Because again, this is the long game.
Allergy and Sjogren's Association
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Kara Wada, MD: I always just like to mention, near and dear to my heart is the association between allergies and Sjogren's. 65 percent of Sjogren's patients will experience allergy like symptoms. And I just always like to share this and so you have something to think about, especially if your allergy testing is negative and you are dry, something to ask your care team about.
Hey, should I worry about Sjogren's? We know that Sjogren's is well underdiagnosed and not always recognized. All right, so what is next?
CTA
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Kara Wada, MD: If you are loving this mix of self discovery and science found here on the Becoming Immune Confident Podcast, I'd love to invite you to sign up for my email list. Hop over to drkarawada.com and hit subscribe to ensure you don't miss out on any insights into new immune system science or how we can harness healing through our daily habits.
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