Allergic Rhinitis, Sinusitis and Asthma

Posted on March 17, 2011 by John & Barbara Connor
by John G. Connor, M.Ac., L.Ac., edited by Barbara Connor, M.Ac., L.Ac.

TABLE OF CONTENTS


INTRODUCTION

Barbara and I treat many patients with allergic rhinitis, sinusitis and asthma.  We have found that sinus problems can often be due to vertical strain patterns in the skull and that these strain patterns can be corrected with the combination of acupuncture and craniosacral therapy.  Craniosacral acupuncture also works to improve the body’s assimilation and elimination mechanisms thereby diminishing the severity and duration of allergic rhinitis, sinusitis and asthmatic attacks. We also get very good results treating all these conditions with specific herbs and supplements. We hope the following article helps give you a better understanding of these conditions and how you can overcome them.

UNDERSTANDING ALLERGIC RHINITIS, SINUSITIS AND ASTHMA

Allergies are inappropriate responses by the body’s immune system to a substance that is not normally harmful. In some persons, the immune system wrongly identifies a nontoxic substance as an invader and the white blood cells overreact and do more damage to the body than to the invader. Thus, the allergic response becomes a disease in itself. Allergic rhinitis is an example of an unruly immune response to pollens in the upper respiratory tract.

Sinusitis is the blocking of the sinus passageways because of inflammation or excess mucus. These passageways are located in the bones surrounding the eyes and nose. If the sinuses are too small or poorly positioned to handle the volume of mucus produced they can become clogged. Pressure in the sinuses increases causing pain. Sinuses that are clogged for a long time seem to invite infection. Symptoms are nasal congestion, discharge, fatigue, headache, earache, pain around the eyes and face, mild fever, cough and increased susceptibility to infection.

Sinusitis may be the result of an injury, viral or bacterial infection like a cold, sore throat, tonsillitis, allergies, swimming or poor oral hygiene. Recurrent attacks could mean that the cause is an allergy. Recent studies indicate that a deficiency of vitamin A, which helps maintain the health of the mucous membrane of the nose and throat, may predispose one to the condition.

Food allergies occur when a person’s immune system generates an antibody response to an ingested food. They manifest as gastrointestinal upsets, diarrhea, irritable bowel and brain fog type symptoms or hyperactivity as seen in children. Food allergies should be distinguished from food intolerances, which are the inability to digest and process certain foods correctly, usually due to a lack of a certain enzyme or enzymes.

Asthma is a lung disease that causes obstruction of the airways.  During an asthma attack, spasms in the muscles surrounding the bronchi constrict, impeding the outward passage of air.  These spasms are a result of chronic inflammation and hypersensitivity of the airways to certain stimuli.  An attack may be triggered if a susceptible individual is exposed to an allergen or irritants.  Common asthma -provoking allergens include animal dander, chemicals, drugs, dust mites, environmental pollutants, food additives  Asthma attacks can also be triggered by conditions such as anxiety, fear and stress.

The underlying process driving and maintaining the asthmatic inflammatory process appears to be an abnormal or inadequately regulated CD4+ T-cell immune response.  The T-helper 2 (TH2) subset produces cytokines including interleukin-4 (IL-4), IL-5, IL-6, IL-9, IL-10, IL-13, which stimulate the growth, differentiation, and recruitment of mast cells, basophils, eosinophils, and B-cells, all of which are involved in humoral immunity, inflammation, and the allergic response.  In asthma, this arm of the immune response is overactive, while Th1 activity, generally corresponding more to cell-mediated immunity, is dampened.  For more information on the connection between asthma and inflammation we invite you to read our article entitled Inflammation and Its Role in Disease.

HOW WE DEVELOP ALLERGIES

Over a period of years a combination of bad diet and a buildup of toxins can gradually unbalance the immune system and eventually a situation occurs where the normal checks and balances that regulate immune function begin to break down. The person starts reacting to triggers in the environment that previously were not a problem. Furthermore, if the diet has been lacking in nutrients – such as antioxidants – that help dampen an excessive immune response, the situation escalates. Suddenly the production of inflammatory mediators spirals out of control and the person begins to react to a wide variety of triggers.

Substances that provoke allergic responses are called allergens. The most common allergens are mold, pollen, dust, some cosmetics, lanolin, animal hair, insect venom, some common drugs such as penicillin and aspirin, some food additives such as sulfur dioxide etc.•    No one knows why some people are allergic to certain substances. However, allergies do run in families, and it is believed that babies that are not breastfed are more likely to develop allergies.

CHINESE MEDICAL EXPLANATION OF ALLERGIC RHINITIS,  SINUSITIS AND ASTHMA

Allergic rhinitis is caused by repeated invasions of Wind Cold or Wind Heat, which is not treated properly, combined with a pre-existing deficiency of Lung and Kidney Defensive Qi systems, leading to the retention of what could be described as chronic Wind in the nose.

There is also an important connection between Kidney Qi Deficiency and the Governing Vessel in the hyper-reactivity of the immune system seen in allergic rhinitis. The Governing Vessel emerges from between the Kidneys and flows up the spine to the top of the head and then down to the nose and lips.

Sinusitis is caused by repeated invasions of external Wind (either Wind-Heat or Wind-Cold) which impairs the dispersing and descending of Lung Qi in the nasal passages so that fluids stagnate in the nose and sinuses. The long-term stagnation of fluids leads to Phlegm and Heat which manifest as a yellow, purulent nasal discharge.

Although repeated invasions of external Wind is the main cause of sinusitis, excessive consumption of greasy-hot foods leading to Phlegm and Heat may predispose one to this condition. This type of food may lead to the formation of Damp-Heat in the Stomach and Spleen, which may be carried upwards to the sinuses via the Stomach channel.

Asthma during attacks is caused by Wind-Cold or Wind-Heat and in between attacks is caused by Lung and Kidney Defensive Qi systems Deficiency.  Wind is the main pathogenic factor in asthma: not in the sense of an invasion of external Wind, but as a kind of chronic external Wind locked in the bronchi. This can happen against a background of deficiency of the Lung and Kidney’s Defensive-Qi systems which allows Wind to penetrate and lodge in the bronchi for a long time causing bouts of bronchospasm.  The Chinese idea of Wind may be compared to the Western concept of allergens.  Allergic asthma is therefore due to Wind in the bronchi causing periodic bouts of wheezing.  The reason this is difficult to expel is not that it is particularly deep in the Interior, but that it is linked to a deficiency, as we have mentioned, of the Lung and Kidney’s Defensive-Qi systems.  Until this deficiency is addressed, the Wind cannot be expelled.

RESEARCH ON HOW ACUPUNCTURE BENEFITS ALLERGIC RHINITIS AND ALLERGIC ASTHMA

The results of a study published in the Am J Chin Med 2002;30(1):1-11 by Xue et al entitled “Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial” found that acupuncture is an effective and safe alternative treatment for the management of seasonal allergic rhinitis.

A study entitled “Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study” published in Altern Complement Med 2000 Dec; 6(6): 519-25) by Joos et al showed that 79% of the participants suffering from allergic asthma indicated an improvement in general well-being with acupuncture treatment. It also concluded that acupuncture performed in accordance with the principles of Traditional Chinese Medicine showed significant immune-modulating effects.

A German study by Wolkenstein and Horak entitled “Protective effect of acupuncture on allergen provoked rhinitis” published in Wein Med Wochenschr 1998;148 (19): 450-3 showed that patients receiving acupuncture for nasal allergen-provoked rhinitis showed a definite reduction of the subjective complaints.

A comparative study done in China and published in J Tradit Chin Med  1993 Dec; 13(4): 243-8 by Lal entitled “Observation on the curative effect of acupuncture on type I allergic diseases” showed that acupuncture had an extensive and remarkable action against allergic asthma and allergic rhinitis.

A study entitled “Immediate anti-asthmatic effect of acupuncture in 192 cases of bronchial asthma” by Zang published in J Tradit Chin Med 1990 Jun;10(2):89-93 found that in 192 cases of bronchial asthma which were treated by acupuncture the immediate total effective rate was 98.8% and the rate of clinical remission plus marked improvement was 76.5%.  The author deemed that 40 minutes of needle retention after the treatment took effect was desirable.

The  NIH (National Institutes of Health) Consensus Statement on Acupuncture (1997 Nov 3-5;15(5):1-34) concluded that asthma was one of the situations in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.

MEDIATORS INVOLVED IN ALLERGIES AND INFLAMMATION

Histamine is a mediator secreted by mast cells, basophils and blood platelets. It is released in direct response to the injury of cells that contain it and it is also released in response to stimulation by certain components of the complement system. It is the mediator responsible for constricting bronchial airways, dilating blood vessels and increasing the permeability of blood vessels which permits fluid to move from the blood into tissue spaces causing the swelling of inflammation. The pain of inflammation can be caused by nerve damage, irritation by toxins or the pressure of the swelling.

Histamine is the principal inflammatory mediator in allergic rhinitis being released by mast cells in the immediate-response phase and by basophils in the delayed-response phase. By increasing vasodilation, capillary permeability and smooth muscle contraction it results in rapid fluid leakage into the tissues of the nose as well as swollen secretory nasal linings.

Most cases of allergic rhinitis are due to a specific allergen-reagin reaction in the nasal mucosa. The immediate-response phase consists of an allergen binding to the IgE component of the mast cell. This initial event results in recruitment of numerous chemoattractants and inflammatory mediators, which signal eosinophil, basophil, neutrophil and monocyte infiltration.

IgE – Allergic responses are marked by an increase in IgE antibodies that cause an immune system reaction promoting inflammation. IgE is involved in allergic reactions whereby mast cells are encouraged to release histamine. If IgE is present in your lung tissue, it frequently causes symptoms such as shortness of breath or asthma. If present in the skin it can cause hives. If it is present in the wall of the intestinal tract it can result in severe pain, gas or bloating.

Free radicals.  One of the most potent mediators of inflammation is a group of toxic substances known as free radicals. Free radicals are unstable molecules produced as a normal byproduct of respiration. In excessive amounts these free radicals can fuel the flame of inflammation and damage healthy tissues. Antioxidants neutralize these free radicals and prevent them from doing further harm.

FOUR TYPES OF ALLERGIC REACTIONS

1) Type 1 (anaphylaxis) reactions are the most common and occur within a few minutes after a person sensitized to an allergen is re-exposed to it, Anaphylaxis results from the interaction of allergens with IgE antibodies on the surface of mast cells and basophils. Basophils circulate in the blood; mast cells are especially numerous in connective tissue of the skin and respiratory system and endothelium of blood vessels.

In response to certain allergens, some people produce IgE antibodies that bind to the surface of mast cells and basophils. The next time the same allergen enters the body, it attaches to the IgE antibodies already present on the surface of mast cells and basophils. In response, the cells release the chemical mediators such as: histamine, prostaglandins, leukotrines and kinin. Collectively these mediators cause vasodilation, increased blood capillary permeability, increased smooth muscle contraction in the airways of the lungs and increased mucus secretion As a result, a person may experience inflammatory responses, difficulty in breathing from constricted bronchial tubes, and runny nose from excess mucus secretion.

2) Type II (cytotoxic) reactions are caused by antibodies (IgG or IgM) directed against antigens on a person’s blood cells (red blood cells, lymphocytes or platelets) or tissue cells. Type II reactions, which may occur in incompatible blood transfusion reactions, damage cells by causing lysis.

3) Type III (immune complex) reactions involve antigens, antibodies (IgA or IgM) and complement. When certain ratios of antigen to antibody occur, the complexes are small and escape phagocytosis. The complexes become trapped in the basement membrane under the endothelium of blood vessels, activate complement and cause an inflammation. Type III reactions include glomerulonephritis, lupus erythematosus (SLE) and rheumatoid arthritis.

4) Type IV (cell-mediated) reactions usually appear 12 to 72 hours after exposure to an allergen and occur when allergens are taken up by antigen presenting   cells which then migrate to lymph nodes and present the allergen to T cells. This results in sensitization and proliferation of T cells, some of which migrate to the site of allergen entry into the body. There they secret cytokines, such as gamma interferon, which activates macrophages, and tumor necrosis factor (TNF), which stimulates an inflammatory response. Poison ivy toxin is an example of a Type IV reaction.

CHINESE HERBAL THERAPY

There are a number of remarkably effective Chinese herbal formulas for treating allergic rhinitis, sinusitis and asthma. As these are based on Traditional Chinese Medical pattern discrimination you would need to make an appointment in order for us to give you the appropriate formula.

FOODS TO AVOID

Avoid these most common allergenic foods: chocolate, dairy products, eggs, shellfish, strawberries, wheat, bananas, beef products, caffeine, citrus fruits, corn, oats, oysters, peanuts, processed and refined foods, salmon, tomatoes and white rice.

Avoid any food products that contain any additives, artificial color, especially FD&C Yellow No. 5 dye. Other food additives to avoid include vanillin, benzyldehyde, eucalyptol, monosodium glutamate (MSG), BHT-BHA, benzoates and annatto. Results of a study reported in Arch Otolaryngol Head Neck Surg 114(5):525-30,1988 reported that foods are more commonly involved in allergic rhinitis than usually expected.

According to Chinese Medicine the Spleen is one of the key organs involved in allergic rhinitis and asthma. Foods to avoid which damage the Spleen are sugar, sweets, ice cream, chocolate, milk, butter, cheese, raw salads, chilled fruit juices, fatty meats, fried foods, refined flour products, yeasted bread, nuts and alcohol.

Do not eat ice cream or drink extremely cold liquids if you are prone to asthma.  Cold can shock the bronchial tubes into spasm.

USEFUL FOODS, HERBS & VITAMINS FOR ALLERGIC RHINITIS & SINUSITIS

Bromelain – has been found to be an effective mucolytic agent in respiratory tract diseases. It acts to deplete kininogen and it activates plasmin thereby reducing the edema and inflammation associated with allergic rhinitis. Dosage: 400-500 mg three times a day.

Chinese sage or dan shen (Salvia miltiorrhiza) – has been shown in test-tube studies to inhibit release of histamine from mast cells.

Fish oils – exert positive effects on arachidonic add metabolism. Arachidonic add is responsible for making the prostaglandins that cause inflammation and aggravate certain allergic symptoms.

Niacin – may be beneficial in seasonal allergic rhinitis.

Quercetin – inhibits inflammatory processes attributed to activated neutrophils, has potent anti-oxidant effects and inhibits the enzyme hyaluronidase (which prevents the breakdown of collagen matrix). Quercetin promotes membrane stabilization by preventing mast cell and basophil degranulation, and it decreases inflammation by inhibiting neutrophil lysosomal enzyme secretion and leukotriene production. Quercetin is chemically similar to cromolyn sodium a drug used to treat hay fever and asthma.

Food sources include onions, broccoli, grapefruit, red wine, apples, garlic, cayenne pepper, cabbage and black tea. The quercetin concentration is greatest in the skin and outer rings of onions and in apple rinds. However, because the body doesn’t absorb quercetin well one would have to eat 2.2 pounds of outer onion rings to get 345 mg of quercetin. Dosage: 250-600 mg three times a day five to ten minutes before meals.

Red and purple grapes – have anti-inflammatory properties.

Reishi mushroom (Ganoderma lucidum) – contains triterpenes, which are anti-inflammatory and have been shown to inhibit histamine release from human mast cells.

Selenium – is essential to the production of glutathione peroxidase, which is important in detoxifying the body of environmental toxins.  Selenium has been shown to reduce inflammatory prostaglandins and leukotrienes as well as free radicals.

Food sources include Brazil nuts, brewer’s yeast, broccoli, brown rice, chicken, dairy products, dulse, garlic, kelp, liver, molasses, onions, salmon, seafood, torula yeast, tuna, vegetables, wheat germ and whole grains. Dosage: It is not recommended that more than 200 micrograms of selenium be taken daily in any of the forms, since the different selenium compounds have varying degrees of toxicity.

Sterols and sterolins– Preliminary results of a clinical trial in South Africa have shown that Sterinol (a combination of sterols and sterolins) is effective at alleviating the symptoms of allergic rhinitis. Sterols and sterolins stimulate the release of THI-type cytokines from helper T-cells and as a result control the allergic condition by decreasing the manufacture of IgE. They also reduce the synthesis of interleukin-5, the inflammation factor.

Food sources are raw unprocessed nuts and seeds and their oils; olives, cloves, oregano, paprika, thyme, shrimp, lobster, crab, oyster, clams and scallops. Unfortunately, only about 5% of plant sterols are absorbed from food. Sterols and sterolins should not be taken with animal fats as their absorption is thereby inhibited.

Stinging nettle (Urtica dioica) – particularly the leaves’ stinging hairs, are rich in histamine and other chemicals that modify the inflammatory response. It also contains anti-inflammatory substances, flavonoids and a host of vitamins and minerals. Contradictory as it might seem, research does suggest that nettle works.

Vitamin C – has been found to exert a number of effects on histamine. It appears to prevent the secretion of histamine by white blood cells and increase its detoxification. Dosage: at least 2 grams per day.

Yogurt – One study found that yogurt containing acidophilus eaten over several months increased gamma-interferon, an important immune-enhancing protein that prevents viruses from reproducing themselves. Also noted was a reduction in inflammatory responses of the gut. IgE, an immunoglobulin that is effective in destroying parasites, is enhanced when lactobacillus bulgaricus is added to the diet.

USEFUL HERBS AND SUPPLEMENTS FOR ASTHMA

 Tylophora – In a double-blind, placebo-controlled study of 195 individuals with asthma, participants given 40 mg of tylophora alcohol extract daily for 6 days showed significant improvement in symptoms as compared with placebo. (Shivpuri et al 1972)

Boswellia – In a 6-week, double-blind, placebo-controlled study of 80 persons with relatively mild asthma it was found that treatment with 300 mg of boswellia three times daily reduced the frequency of asthma attacks and improved objective measurements of breathing capacity.  70% of patients suffering from bronchial asthma improved. (Gupta et al 1998) In clinical trials of Boswellia, promising results were observed in patients with bronchial asthma. (Ammon 2002)

Quercetin – In vitro studies suggest that quercetin may inhibit the release of pro-inflammatory substances from mast cells. (Ogasawara & Middleton 1985; Pearce et al 1984)• A review done at UNC found that antioxidant nutrients (vitamin C, vitamin E, selenium and carotenoids) especially those from food sources, have important roles in preventing pathogenic processes related to asthma. (McDermott 2000)

RESEARCH BEING UNDERTAKEN ON BAICALIN FOR ALLERGIES

Eosinophils are good in the bone marrow but in excess they can cause nasal congestion and asthma. Asthma is basically eosinophilia. Baicalin (Scuttellaria) is  useful for asthma. Baicalin reduces eosinophils in the lungs and nasal passages. (Helminths are also destroyed by eosinophils.)

Eotaxin is produced by fibroblasts in the connective tissue. (See Journal of Allergy & Clinical Immunology, 2001: Vol. 107, p 607-614) Fibroblasts if challenged by an insult, release eotaxin. The eosinophils sense the eotaxin and go to the site of the insult and start working to repair everything. If the response is measured everything is OK. But if it keeps going on damage is done. If inflammation is persistent that is the problem.The baicalin binds to eotaxin and reduces its impact. (See “Flavonoid Baicalin Exhibits Anti-Inflamm. by binding to Chemokines” Immunopharmacology 2001, Vol 49, p. 209-306.) Eotaxin is a chemokine. If given orally or locally it could be very useful.

SIDE EFFECTS OF ANTIHISTAMINES & DECONGESTANTS

The side effects of antihistamines include drowsiness, dry mouth and interference with normal heart rhythm. They can also aggravate glaucoma, prostatic obstruction and certain kinds of peptic ulcers.

The side effects of decongestants include insomnia, rapid heart rate, nervousness and weight loss.

ADVERSE EFFECTS OF ANTIHISTAMINES & DECONGESTANTS

The first-generation antihistamines contain ethylamine moieties that make them highly lipophylic and readily able to cross the blood-brain barrier. This characteristic partly explains the numerous adverse effects associated with sedating antihistamines, including dizziness, tinnitus, cardiac arrhythmias, gastrointestinal distress, lassitude, incoordination, blurred vision, diplopia, and tremors.

The piperazine- or piperidine-like structures of the second-generation antihistamines do not cross the blood-brain barrier and have not been found to cause significant sedation, fatigue or anticholinergic effects. However, astemizole (Hismanal) and terfenadine (Seldane) can cause torsades depointes (a potentially fatal cardiac arrhythmia) if given concurrently with macrolides (erythromycin and trolean-domycin), imidazole antifungals (ketoconazole and itraconazole), or to a person with liver disease.

Oral decongestants are likely to create more adverse systemic effects, including cardiac arrhythmias, hypertension and CNS disturbances. They are contraindicated in individuals with heart disease, hyperthyroidism, glaucoma or diabetes mellitus.

Anticholinergic agents control the vasodilation and secretion of serous glands in the nasal mucosa. Reportedly, these drugs can affect visual perception, reaction time, coordination and memory.

Intranasal corticosteroid treatment has local side effects, including nasal irritation and bleeding and septal perforation. Their mechanisms of action involve modification of gene expression, formation of cell-regulatory proteins and inhibition of inflammatory mediators.

REFERENCES

Ammon, HP (Article in German)  “Boswellic acids (components of frankincense) as the active principle in treatment of chronic inflammatory disease” Wien Med Wochenschr 2002;152(15-16):378-8

Balch, James F, M,D., and Balch, Phyllis A., C.N.C, Prescription for Nutritional Healing Garden City Park: Avery Publishing Group, 1997

Bratman, Steven, MD & Andrea M. Girman, MD MPH, Mosby’s Handbook of Herbs and Supplements and their Therapeutic Uses, St Louis: Mosby, 2003

Dharmananda, Subhuti, Ph.D., “Herbs and Drugs for Asthma”, Institute for Traditional Medicine, Portland, Or., March 1999

Dharmananda, Subhuti, Ph.D., “Acupuncture Treatment for Asthma”, Institute for Traditional Medicine, Portland, Or., March 1999

Flaws, Bob, Curing Hay Fever Naturally with Chinese Medicine, Boulder Blue Poppy Press, 1997

Gupta I et al, “Effects of Boswellia serrata gum resin inn patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study” Eur J Med Res 1998 Nov 17;3(11):%11-4

Joos, S, Schott, C, Zou, H., Daniel, V & Martin, E., “Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study”, J Altern Complement Med 2000 Dec; 6(6): 519-25

Kirschmann, Gayla J., and Kirschmann, John D., Nutrition Almanac, New York: McGraw-Hill 1996
Lal, X, “Observation on the curative effect of acupuncture on type I allergic diseases”, J Tradit Chin Med 1993 Dec; 13(4): 243-8

Maciocia, Giovanni, The Practice of Chinese Medicine, Edinburgh: Churchill Livingstone, 1994

McDermott J H “Antioxidant nutrients: current dietary recommendations and research update” J Am Pharm Assoc (Wash) 2000 Nov-Dec;40(6):785-99

Miller, AL. “The etiologies, pathophysiology, and alternative/complementary treatment of asthma”. Altern Med Rev., 2001 Feb;6(1):20-47

Mindell, Earl, RPh., Ph.D. & Hopkins, Virginia, Prescription Alternatives. New Canaan, CT: Keats Publ, 1998

Narula, Acharan, Ph.D., Notes from a conversation with Dr. Acharan Narula, 6-6-0

1Rountree. Robert, M.D., “Allergic”, Herbs for Health, March/April 2000 p.46-49

Thornhill, Stacy M., DC & Kelty, Ann-Marie, BS, “Natural Treatment of Perennial Allergic Rhinitis”, Alter Medic Review, Oct. 2000, Vol 5, No.5, 448-454

Tortora, Gerard j., Grabowski, Sandra R., Principles of Anatomy and Physiology New York: Harper Collins, 1993

Upledger, John E., DO., Verdevoogd, Jon D,, M.F.A, Craniosacral Therapy Seattle: Eastland Press, 1995

Vanderhaeghe, Loma R, & Bouic, Patrick J.D., Ph.D., The Immune System Cure, New York: Kensington Books, 1999

Werbach, Melvyn R, M.D,, Nutritional Influences on Illness. Tarzana: Third Line Press, 1996

White, Linda B,, M.D, “The Sneezin Season” Herbs for Health, March /April 2001 54-59
Wolkenstein,E & Horak, F. “Protective effect of acupuncture on allergen provoked rhinitis” Wem Med Wochenschr 1998,148 (19): 450-3

This entry was posted in acute conditions, allergies, asthma, chronic conditions and tagged , , , , . Bookmark the permalink.