AAAAI Meeting Review

I recently attended the 2009 annual meeting of the American Academy of Allergy, Asthma, and Immunology(AAAAI) in Washington, DC. There were five days of extraordinary educational activities (March 13-17, 2009). I thought that while I could still read my notes I would share with you a few things I observed, heard, and learned in the ever evolving world of allergy. I plan to adopt many of these changes in my practice.

The meeting’s agenda covered a wide variety of clinical conditions. It would have been impossible to attend every session. I chose sessions on the allergic environment, eczema, immunotherapy, food allergy, re-certification, headaches, and asthma. There are a number of ideas that are evolving and a number of things currently done in allergy/asthma care that need to change. Each and every one of these topics is truly worthy of more extensive review. I would be happy to use this blog to delve into topics in more detail (per request).

Atopic Dermatitis (aka Eczema)

I still need to be convinced regarding what to call this condition. Dr. Jeff Travers (chief of Dermatology at the IU School of Medicine) and I go back and forth on this topic. During the meeting I heard the concept of extrinsic and intrinsic atopic dermatitis. Extrinsic means from the outside and intrinsic from the inside. These terms have also been used for years to describe two presentations of asthma: extrinsic asthma due to allergy, and intrinsic asthma when no allergy is found. The word atopic means 1) the tendency to come from families with allergy, 2) to make the antibody seen with allergy (IgE, which would be elevated) and 3) to have positive allergy tests. Thus, Intrinsic AtopicDermatitis means no allergy demonstrated (intrinsic) in a condition associated with allergic sensitization (atopic). This blending of terms leads to confusion–why not stick with the simpler term of eczema?

I learned about the use of silver impregnated clothing to decrease the amount of bacteria on the skin. Skin bacteria can cause flaring of atopic dermatitis.

A number of  genes associated with atopic dermatitis have been discovered. These discoveries should increase our understanding on how this condition starts and hopefully how we can manage it better.

There was information on allergens that contain enzymes called proteases and how these protease containing allergens aggravate the skin.

Probiotics have been used to treat allergic conditions especially conditions related to food allergy. A review of studies on probiotics have not shown them to be effective in preventing or treating atopic dermatitis.

I listened to debates about being proactive in skin care therapy vs. being reactive. Proactive would be trying to prevent and reactive being treating only when there is a problem. This idea was particularly interesting. Atopic Dermatitis Guidelines and package inserts for a variety of medications used for atopic dermatitis treatment stress short courses of use, the reactive approach. The proactive debater posed the problem of a chronic disease that will have episodic flaring. The abnormality of the skin is there all the time requiring the need for medication to be used perhaps twice a week to avoid flares (those times when the skin is more itchy, more inflamed, and more broken down). Pediatrics deals extensively with disease prevention. My pediatric perspectives are preventative- proactive. All too often we (as patients) tend to be crisis-oriented or reactive to chronic conditions. I am obviously on the proactive side of this argument.

Therapies emphasized moisture and more moisture. Keep these kids wet! This is clearly a major step that is contrary to previous approaches that recommended the avoidance of frequent soaking/bathing. The avoidance of baths is clearly one of those long established principles of atopic skin care that has fallen by the wayside in contemporary skin care.

Foods are an issue in atopic dermatitis. The protease containing allergens such as molds, pets, and mites may have a role in triggering flares.

In Boston a program that has had success includes insuring compliance with the medications (taking them as prescribed), addressing the parents concerns about medication side-effects (helps with compliance), decreasing the itch, and increasing sleep. These are all essential elements to help with control of the condition.

Of note, we need to re-think the role of a specific therapy and make adjustments. Antihistamines are frequently used in atopic dermatitis. In allergic rhinitis and in hives, these products help control itch. However, in atopic dermatitis, the antihistamines have little effect on itch. The role of the anti-histamine is to sedate. Most of the scratching happens at night. A sedating antihistamine used at night works best.

Asthma

There were a number of new ideas regarding asthma. Look for vitamin D to have a possible role in treatment.

Current recommendations from evidenced-based asthma guidelines point out a difference between adults and children and the use of the long-acting bronchodilators in the two populations. These agents are called long-acting broncho-dilators (LABAs). In children, we should increase the dose of the inhaled corticosteroid before adding a LABA. This recommendation appears in two major asthma guidelines with type A evidence used to support the recommendation. This type of evidence (A) means that there are a substantial number of studies that support this statement.

Asthma may be related to bacterial colonization at birth and to the occurrence of the common cold virus later in life. Evidence was also presented regarding the observation from large population studies that the process of airway inflammation starts well before actual symptoms. We heard about diet, viruses, stress, ozone, and endotoxin having a role in the development of asthma. The gene or genes for asthma need to be present. These genes then need to be activated or expressed for the child to show the signs and symptoms of disease. Bacterial colonization and a variety viruses may have a role in activating the genes.

Headaches

This was a great session. The audience heard from an ENT surgeon, an allergist, and a neurologist regarding their approach to headaches. The consensus was that migraine is the biggest player in these situations. The connection of allergy to headache has always been a concern. However, headache is not a manifestation of allergy. There are many studies that have looked at this. People with headaches can have positive allergy tests but does that make the allergen the cause of the headache? Think about other conditions or associations. Could there be an allergic cause for an appendicitis?

I heard of the concept of ‘allergic appendicitis’ during this presentation. It was very odd to hear about this in a headache session, but a valid point was made. This concept of the allergic appendix was compared to allergic headaches. Follow along; data from a national health survey from 1994 indicated that 50% of the population reported that they had allergy. So if someone who had problems with the appendix was allergy tested, the chances are very high that allergy would be found. This however does not make the inflammation of the appendix due to allergy. You can find a significant number of positive allergy tests, be sure of why the tests are being ordered. Think migraine more often as a reason for headache. Allergy is not a major reason for headaches.

Food Allergy

The biggest news from the meeting was the work done by Wes Burks at Duke on peanut allergy. This is exciting and long awaited for those who have peanut allergy and for the families who have someone with peanut allergy. Immunotherapy for peanut trials have allowed the equivalent of about 12 peanuts to be eaten without any problems/reactions. This would certainly take the fear from accidental exposure to peanut especially from tabletops at school cafeterias. I have to check my note again, but I had written down the treatment would be a suppository(?).

There was a very popular abstract (a quick presentation of work in progress prior to it being published in a journal) on food allergy and the over- use of panels for food allergy (pet peeve). A New York Times article a few months ago reported that food allergies were being over diagnosed. Dr. Sears at National Jewish Hospital in Denver, Colorado reported on over one hundred children seen at their center who had food allergy as determined by blood test panels. The average number of food allergies reported were six. After undergoing food challenges the number decreased to only 2 foods. 88% of the foods this group of children were told to avoid based on RA ST panels were added back into the diet. Using a food challenge, no one with meat ‘allergy’ had a positive food challenge (where meat caused a problem), 88% of the grain ‘allergic’ children were negative on challenge, and 83% of the fruit and vegetable group were also negative after a food challenge. Bottom line- the use of these panels is giving falsely positive information and leading to a misdiagnosis of food allergy.

Allergy Testing

I learned that I should no longer use the word RAST. The term is outdated and refers to a technology not used. The blood tests for allergens should no longer have a 0-6 grading scale and should only be reported in what is actually measured kU/l of serum. The test measures a concentration of a specific antibody in the blood. The relationship of that concentration to clinical activity needs to be determined by the clinician. I predict that the interpretation of the blood test results may be a huge issue.

A new in vitro or blood test for specific IgE in the blood is called an ISAC chip. This technology will help with cross-reacting proteins. We see the problem of cross-reactivity with multiple positive allergy tests to legumes (peanut, soy, beans, and peas). I think this will be a very worthwhile test in allergy.

There are three blood tests out there for detecting specific IgE. These are the Immunolite, ImmunoCap, and Hytec. Each of these measure something different. They measure a different population of IgE antibodies and may not be comparable. Caution was advised regarding the blood tests for specific IgE. The physician should know the method used, the validity of the assay, the performance of the laboratory in doing the assay, and realize that no test for allergy is infallible.

Conclusions

Each and every one of these topics could stand alone for more detail and interpretation and I would be most happy to elaborate in more detail. Let me know if you would like more information by adding a comment. If there continues to be an increase in the use of specific IgE panels (as advocated by those who market these tests) we will be doing significantly more food challenges in our office. Usually we are doing food challenges for those who may have outgrown a food allergy. We certainly can offer a food challenge for a child who has been told that food allergy exists based on blood test results. One of my tasks upon my return to the office is to look at our track record of doing food challenges. I hope to report on our successes and failures for our food challenge experience with milk, egg, soy,wheat, and of course peanut.

Respectfully submitted,

Fred Leickly

Docs try waiver as Rx for online ratings?

On March 4th, 2009 the Indianapolis Star had a front page article titled ‘Docs try waiver as Rx for online ratings‘.  In another article on March 9th, 2009 there was an editorial from Angie Hicks of Angie’s List fame explaining her online rating system. With the appearance of opportunities to rate services, there has been concern that negative ratings may have a significant impact. The internet has made it very easy to post opinions and people are always looking for more information to make decisions regarding goods and services. Now the medical profession has become fair game for online commentary.

Let’s step back and look at the issue. Some physician offices are requiring a waiver signed by the patient agreeing that they will not criticize the physician through an online rating service. If the waiver is not signed, the patient could be turned away. The rationale for this is the threat to the physician’s reputation and practice through possible negative reviews.

The other side of the issue is that of our constitutional right to free speech and to express our opinions. This is a new and very interesting area of conflict. I wonder how other professions handle this? Clearly it is not only the medical profession that may sustain a negative or harmful impact.

This whole idea took me aback. I have always tried to place myself on the other side of the argument (since I too am a physician and have a wonderful practice), how would I react as a patient if asked to sign such a document? My instantaneous answer was that I would be out of that office so fast that the door would not have had a chance to hit me on the backside on my way out. I would certainly wonder what prompted this, why be so protective, so defensive? Is there a past history here? Is it a single occurrence or a well established pattern? No, I would not sign such a thing and in turn, I would not ask my patients to sign anything like this. What profession, what practice, is not subject to comment and critique? Can we not learn from commentary and critique to help the next patient? But criticism should be done correctly, without malice, and with the opportunity for the counter argument or case. I would also expect the critic to properly sign their work,  take responsibility and ownership and not be a sniper.

This also caused me to wonder about what could be going on in my own practice.

Many times the clinical experience is not entirely related to the doctor. Think about all the layers that exist in the clinical interaction. There is the health care delivery system that has individuals who make appointments, secretaries who may be looking for referrals, receptionists who are asking for insurance information, technicians who take a variety of measures, the physician, a medical student, possibly a resident, the nurse, the respiratory therapists, and even the phlebotomists in the laboratory. Then after the visit you have the cashiers, the pharmacy, and the insurance people to deal with. That single clinical encounter can result in interactions with up to 13 individuals. Now blend this array of personnel with a patient or family who have their own health belief model and expectations. So with all the possibilities for things to go wrong, it is most fortunate that at least here, they mostly go right.

In my experience over the past 24 years, there are situations that I have come across where things may not go as expected despite everyone’s good intentions. I call these ‘appointments that are doomed to failure’. I try my best to avoid these, but they still happen.

Interactions doomed to failure.

What is all this about? I work with allergy. This is a condition that is relatively common with perhaps up to 30% of the population in this country struggling with some variation of allergy. As noted in the page on allergy, allergy is a specific immune reaction. Sometimes others may state that a condition, an illness, a set of abnormal laboratory values was due to allergy and send the patient on to an allergist. Sometimes the history does not support an allergic reaction and sometimes no allergy is found. A family who has high expectations and firmly believed the illness was due to allergy leaves disappointed. They think that the evaluation failed and the physician was incompetent in not finding anything. An established belief was found to be wrong. An answer for the problem still must be there. The investigation needs to start all over again. The perception could be that the physician failed the patient in not finding anything. This is frustrating for all. There are others things that can make the encounter difficult.

Reasons for a doomed visit-

1. Expectations not met- nothing was found
2. Condition was not allergy as they were told in the past
3. The child may not have been old enough to be sensitized – not knowing the time sequence for the development of allergy
4. Communication gone bad
5. Chemistry – the doctor-patient relationship did not materialize
6. Respect was absent- the doctor for the patient’s time and the patient for the doctor’s time
7. Past experiences with a specialty
8. Conflicts with the art of medicine and the science of medicine- Hippocrates “above all do no harm”
9. Dealing with evidence-based medicine
10. An agenda not met
11. Bad news- not allergy as was expected, if it was allergy it may be a life-long condition, dealing with pets and stuffed animals- parents and kids cry about being sensitive to the family dog or cat and the evil eye was given to me by children who have to consider less soft options because they have to retire their stuffed animals or place them in the freezer for a while
12. Seeking cures vs. control- a considerable amount of allergy is chronic and not one-time fixes, with allergy you are in the game for the long haul
13. Insurance restrictions- a never ending fight with limited choices or sacrifices that need to be made to cover visits, treatments, and medications

Remedies for doomed visits?

I wish that everyone who came to the office had allergy, but they often do not. How can I help avoid a doomed visit? A few things have worked. I think being cheerful and happy with what I do is helpful. I know the limitations of my specialty, and I hope that I am good at listening and establishing a rapport.

1. If I sense that there is someone on my schedule with a condition that allergy care cannot help, we try to talk with both the family and the referring physician to see what is going on and then decide if we can meet their expectations and offer the appropriate service before they take off work, take the child out of school, and take the time to come for the visit. I want to be sure there is value for the visit on behalf of the family.
2. If a family arrives with something that does not fit allergy, I explain things and I void the shortened visit for them.
3. I have learned to ask  ‘ what do you want to know when you leave the office’ – this helps me address the family’s agenda. Sometimes the reason for a consultation is different from what the family wants to get out of the visit.
4. I know what I can do and what I cannot do and I share that with the family. I do not try to extend the bounds of my expertise and specialty, that is being plain honest about things.

Is it always the doctor’s fault?

Good grief, I certainly hope not. Consider all the levels of interaction within the health care system, problems lurk potentially at every level.

1. The physician
2. The system
3. The third party payer (health insurance)

How to make it work?

Physicians need to be caring, to be comforting, to be courteous, to be communicative and of course be competent. Patients/Families are seeking consultation for a problem or a set of symptoms and signs that may or may not be due to allergy.  Patients should be open minded when they arrive. They are asking for an opinion in a consultation. The opinion may or may not be acted upon based on the health beliefs of the patient/family.

Critiquing the critiques

I would advise extreme care with internet resources- not all sites are good. There is no sanctioning of information prior to online publication. Be careful of  what you read. Consider the source, is the author credentialed in the topic area? Where did the expertise come from? Are they trained or self-ordained? Is anything used as a point of reference for the argument or advice? Where did they get the facts or is it opinion? You have to be critical. In my post regarding my letter to the editor of the ‘Bottom Line Personal I looked up the author of the book. There were no publications to show any work in the areas that were commented on. So it was opinion, and not evidence-based.

Also, in regards to complaints – look to see if the author owed up to their comments by leaving their name. If no name is offered, then I would question the sincerity of the comments- the author did not have the intestinal fortitude (guts) to sign their work. No credible signature- no validity.

The individual who was the recipient of the complaint should also have a chance to respond. Angie’s List does this and I applaud her for that. If a complaint/critique is offered the physician is made aware of it and has a chance to respond. I do not know who makes the final judgment on this prior to publication (it would be interesting if a panel of 3 non-medical types, 3 physicians, and a minister/priest would decide the value/virtue of the commentary and majority vote for listing).

People (professionals) like to hear good things too, but all too often it is the negatives that make the headlines. If you ever see a story titled ‘Allergist controls runny nose’ let me know.  If I have had an interaction that I felt went badly, I have called people after the visit to go back over things.

So, online ratings- they were bound to happen sooner or later. No, I will take my chances and you will not have to sign any waivers here. I will just keep on going, learning from miscues when they happen in hopes to make me better at what I do.

Fred Leickly

Peanut Allergy or Peanut Sensitization?

I have many patients and families who have significant concerns about peanut allergy. I have been at Riley for 15 years, and during that time I have seen a significant rise in peanut allergy. Once upon a time I would see a new peanut patient about once a week. Now it is closer to a daily occurrence. I have had a couple of my kids (patients) featured in the newspapers regarding peanut allergy and one of them was the Riley (State of Indiana) representative for the Child’s Miracle Network for peanut anaphylaxis. I am always looking for more on peanut allergy and am eager for a way to take the fear out of this situation.

There has been a considerable amount of research going on with peanut allergy. Most recently,  in the February 2009 edition of one of the premier journals of allergy, the Journal of Allergy and Clinical Immunology, there was an article from the United Kingdom that looked at peanut consumption in a household as a risk factor for the development of peanut allergy. The article was accompanied by an editorial from a dear friend of mine who is one of the lead figures in this quest for answers about peanut allergy, Dr. Wes Burks- chief of allergy at Duke University (actually, Dr. Burks and I trained together at Duke back in the day).

The article concludes that high levels of exposure to peanut in infancy promote sensitization. Low levels of exposure in the environment may be protective. There was no effect of mother’s consumption of peanuts during pregnancy or lactation. The findings supported the idea that sensitization (making an IgE antibody) to peanut occurs through the child’s environment.

Dr. Burks’ editorial urges caution regarding some of the recommendations and conclusions. The editorial also talks about an article yet to be published, including some real world differences in the peanut cultures of the populations in the study.  In the current study, a questionnaire was used to address maternal exposures/consumption of peanut. Dr. Burks points out that there can be problems with recall information used for a questionnaire. The article suggested that avoiding peanuts lessens tolerance and increases the risk of allergy through possible skin exposure to peanut. Dr. Burks issues caution regarding advice about early feeding to prevent food allergy. The theory has not had enough support to make this part of our clinical practice.

The ideas in the article are interesting, exciting, and provocative.

I also had a few ideas on the article. In my professional career I have had great mentors, and one in particular: Dr. Charles Hoppel. I met Dr. Hoppel as a graduate student in pharmacology at Case Western Reserve University. From him I learned how to look at an article with a very critical eye. Here goes my perspective on the article ‘Household peanut consumption as a risk factor for the development of peanut allergy‘.

First, the journal is what we call top tier, highly peer-reviewed. Second, the group has a track record in the area of interest. Third, the work was supported by a government grant. These are all good things.

The purpose of the article was to ‘investigate the relevant routes of exposure to peanut that lead to peanut allergy’.

Now how did they do this or what were their methods? The study was a questionnaire-based case-controlled study of children less than four years of age. There were three groups; children with peanut allergy, children at high risk to develop peanut allergy, and a low-risk control group. The questionnaire was completed by parents before they knew that the child had peanut allergy. There were 133 with peanut allergy, 160 high-risk controls, and 150 low risk controls. If peanut allergy was suspected, the child was excluded from the study. Most of the peanut allergic children had eczema. A case (peanut allergic child) had a positive skin test, a positive blood test, or a positive food challenge. The high-risk to develop peanut allergy were children with egg allergy (about 20-30% may go on to develop peanut allergy).

Detailed questions were asked about peanut consumption by all household members during the child’s first year of life and mother’s peanut habits during pregnancy and during breast feeding. The questions asked about peanut containing foods, frequency of ingestion, and how much was eaten. Household peanut consumption was then calculated.

What did they discover- what were their results?

Eczema was present in 92% of the peanut allergic group and 88% of the high-risk to develop peanut allergy group. Concerning peanut consumption during pregnancy and breastfeeding:

• Peanut allergic cases– mothers ingested 2.4 grams of peanut/week during pregnancy,  0.6 grams/week during breastfeeding
• High risk cases– mothers ingested no peanut products (0)/week during pregnancy, no peanut products (0)/week during breastfeeding
• Low-risk cases– mothers ingested 1.1 grams of peanut/week during pregnancy, 0.9 grams/week during breastfeeding

Household peanut consumption:

• Peanut allergic cases- 18.8 grams/week
• High-risk cases – 1.9 grams/week
• Low-risk cases – 6.9 grams/week

Next the importance of the route of exposure to peanut was evaluated with Odds Ratios and logistic regression. The authors looked at the numbers in the groups who had one of three exposures (environmental, pregnancy, or breastfeeding) in one of three groups (peanut allergy, high-risk to develop peanut allergy, and the normal controls). When the peanut allergy group was compared to the low risk controls, only household peanut exposure was associated with peanut allergy and not consumption of peanuts by the mother during pregnancy/breastfeeding. There were 134 children in which there was no maternal peanut consumption during pregnancy. In this group peanut allergy was more common with increasing household peanut exposure.

The study also looked at the source of the peanut exposure. Most of the household exposure was peanut butter followed by whole peanuts.

The last analysis dealt with that high-risk group who had known egg allergy. This group had low household peanut exposure and tended to not develop peanut allergy. The question was asked as to why those in this group with rather high household peanut exposure did not develop peanut allergy? The suggestion was made that it was due to well-controlled eczema (skin barrier not broken allowing environmental access) or they were tolerant due to ingestion of peanuts prior to age 12 months.

The authors concluded that high environmental levels of peanut during infancy lead to sensitization with low levels offering protection. There was no effect from maternal consumption during pregnancy/breastfeeding. Sensitization occurs through environmental exposures. Early dietary introduction may be the way to develop peanut tolerance.

My take on this:

• This is a new perspective on the issue.  I appreciate the author’s comments that if sensitization is occurring throughout the environment, then this has public health policy implications.
• I am sure we will be seeing more on this to validate the findings in other populations.

My concerns with the article:

• Perhaps the title should be changed from peanut allergy to peanut sensitization (atopy).
• The subgroup analysis on the possibility of early exposure to peanut products was not the purpose of the paper.
• Questionnaires do have limitations.

Why do I suggest that the title be changed? Allergy means a reaction; therefore, peanut allergy would be a reaction to peanut (according to the definition by the World Allergy Organization). I expected, based on the title, that this would involve children with reactions to peanut. The study actually excluded anyone who had a suspected peanut allergy. The population was predominantly children with eczema, a condition in which positive tests to peanut are found with great frequency without symptoms and without exposure. Eczema (atopic dermatitis) is notorious for false positive tests to foods. The definition of a case was a positive skin test, a blood test over a critical level, or a positive food challenge. I think the proper case definition would include: a positive test for specific IgE (skin or blood) and a positive food challenge. We do not know how many children fulfilled the criteria of test and symptoms with exposure.

The authors did point out that the case criteria was validated in study published in the JACI in 2005. In the 2005 study, patients with a suspected history of peanut reactions were used. This type of patient was excluded from the current study. In the 2005 study, 40 children from a generalized health survey were used, but we are never told how many of that group were without a history of a reaction to peanut. I am not convinced that the extension of case definitions from a symptomatic peanut group are applicable to a group in which a history of peanut reactivity was an exclusion criteria. This should be household peanut exposure and sensitization since we do not know who if any in the group will actually react or did react in the food challenge. Perhaps just looking at that group would be of value.

This is very interesting work and very provocative. Should peanut sensitization become a public health issue? Can we validate these finding in our population?

Respectfully submitted,

Fred Leickly

Where oh where has my rescue inhaler gone?

Imagine going out on a boat. Trouble begins and the boat starts to sink. You are some distance from shore. You think about how good a swimmer you are which leads you to consider a few other options. Where is that  life preserver? The recommendations (and hopes) are that it be within reach or that you are wearing it. That life preserver would be of little use if it was left on the dock.

Now think about asthma. You are out there and because this is an unpredictable condition, trouble starts. Where is your life preserver? Where is your inhaler? Should it be on your person just as that life jacket? This is a real concern and an issue that affects life and the quality of that life for those with asthma.

In the world of managing asthma we have two basic categories of medications: the long-term controller medications and fast-acting rescue medications. I like the use of the term ‘rescue’. These agents work fast and when used in a rescue fashion they help open the airways. The rescue medication will work  usually within 15 minutes of application. A few examples of what would be considered asthma rescue medications frequently used for children include:

1. Albuterol- available as ProAir, Proventil, and Ventolin HFA
2. Pirbuterol- available as Maxair
3. levo-albuterol- available as Xopenex

These agents can be effectively given by a metered dose inhaler (puffer) or through nebulization. Everyone who has asthma, regardless if it is intermittent or one of the three types of persistent asthma (mild, moderate, or severe), must have a rescue inhaler! This has been spelled out since the first edition of asthma guidelines (1991) and is an important part of the most recent NHLBI Guidelines for the Diagnosis and Management of Asthma. This is a well established recommendation, but how do we see it in real life situations?

I have always wondered where the rescue medication is kept, and how long it would take for someone to find and use their rescue medication when symptoms began. Recently, I had a chance to investigate that question.

I just  finished a Masters in Public Health program at Indiana University Purdue University Indianapolis (IUPUI). (As an aside, anyone interested in conditions that affect the health of the population would find the pursuit of this type of a masters program most rewarding.) Some courses  required doing field projects, especially in the epidemiology and biostatistics courses. I decided to do a project that involved the use of rescue medications by children with asthma.

In biostatistics you need to have a hypothesis, i.e., a statement that will be supported or found to not be true. My hypothesis was that all children with asthma have a rescue medication with them (or have immediate access). I was also interested whether or not a number of variables such as age, severity, or duration of asthma had any relationship to rescue medication availability. The questionnaire was answered by 124 children with asthma. I found that only 28% either carried their inhaler with them or had immediate (within 2-3 minutes) access to rescue medication. That means 72%, over two-thirds may have had to hustle to find rescue medication.

I asked this question of children who were about 10 years old. Just over half were boys. The group was representative of a suburban population. They severity of the asthma was as follows:

1. Intermittent 10%
2. Mild persistent 29%
3. Moderate persistent 55%
4. Severe persistent 6%

These children were asthma-experienced: the duration of having asthma was 6.6 years. This is where the inhalers were with this asthma-savvy group:

1. Inhaler in a pocket (on them) – 14%
2. Inhaler with a parent – 15%
3. Inhaler at home – 55%
4. Inhaler at school – 14%
5. No inhaler – 2%

The next question was how long would it take to find and use your rescue medication?

1. Immediately (optimal response) – 28%
2. At 5 minutes – 40%
3. At 15 minutes – 18%
4. At 30 minutes – 7%
5. Longer than 30 minutes 7%

The perfectionist in me felt that 5 minutes may be a concern, however there is a real issue with the 32% that needed 15 or more minutes.

There are a number of possible reasons for what I would consider a delay in rescue medication application. Our habits are that when things are going well, we tend to not be as vigilant. A well-controlled child with asthma would have very little additional need for a rescue medication so the lack of  immediate access may be due to the success of other therapies. In fact, only 25% had used their rescue inhaler within the preceding month.

I was surprised by the results of my biostatistics project (not the grade, but the findings). As a specialist in the area of asthma care I learned something new and something that will help me to help my patients with asthma. I did not have to read this in a journal about some other population of children, this was a group of kids here at home, in my own backyard. My lesson learned is to be sure to ask the question and to use that basic principle of pediatrics- prevention. Prevent disasters but emphasize the concept of rescue and support any opportunity for the easy and quick access of that life preserver. I do not hesitate in writing those permission slips so medications can be carried at school. Yes there is concern about ‘medications’ and the possibility of misuse/abuse I fully understand that. I also hear about and see children who are very scared with these sudden, acute attacks of respiratory distress. Acute asthma events are not predictable, they are serious, and they need to be addressed urgently. The rescue inhaler needs to be readily available.

Respectfully submitted,

Fred Leickly

My letter to the editor of Bottom Line Personal

I have never written a letter to the editor that I have actually sent. Most of them wind up in the circular file (aka file 13, trash etc). I usually feel better having written them, but I do not have a track record in this regard. Perhaps doing this blog has emboldened me. After all it is an opinion, but sometimes we see things that we truly feel are wrong and we need to warn others about these wrongs.

The story goes as follows. I have subscribed to a newsletter called ‘Bottom Line Personal’. This publication has short articles on a variety of topics. For example, the last issue has quips on investing, real estate, psychotherapy, painkillers, career starting, bed sharing, and dangers in your garage (as I listed these it made me wonder why I subscribe). There is a page that talks about the purpose of the publication which is to bring to the reader the best information from the most knowledgeable sources in the world in helping the reader gain “greater wealth, better health, more wisdom, extra time and increased happiness” (this is a direct quote). Way at the bottom of the disclosure panel is the statement that they publish the opinions of expert authorities in the fields. I came across an article in the news column that started “If you think you are allergic to a certain food…..” That certainly caught my eye. As I read on my interest turned to rage (not really rage but my feathers were rattled). The first line continued “….. but you aren’t sure which food-consider having a blood test for the immunoglobulin IgG, says the author of a book called ‘The Source: Unleash Your Natural Energy, Power Up Your Health and Feel Ten Years Younger'”.

So I am concerned that my newsletter (one I subscribe to) which focuses on saving money and promoting health would promote this book specifically this concept of IgG to food as being something of value and something well established in health care. So I carefully composed a letter citing references from the Food Allergy and Anaphylaxis Network (FAAN) and from the American Academy of Allergy, Asthma, and Clinical Immunology. I also did a literature search on the author of the book using PubMed and OVID. My letter explained that the measurement of IgG to food is unproven as a diagnostic test and should be considered experimental. It is known that IgG to foods does not sort out a healthy from a sick population. The thought is that we see IgG to food in healthy people. To date, this is a test looking for a disease.

Thinking that I may have missed something, my search for published articles by the author on this topic in peer-reviewed journals came up with nothing.

I went on to point out that IgG to food is on a rather long list of unproven diagnostic tests for allergy. I pointed out that prior to publishing their review on the topic that they should have done more research on the topic, utilizing position statements from the major organization involved with allergy and perhaps used a literature review of evidence-based medicine to see the value of a test for IgG directed to foods.  My bottom line was that this was not money well spent and could possibly lead to more harm for someone. I even went so far as to make some analogy to the use and sale of snake oil.

I carefully looked over my 750 word editorial, criticized the editors for violating their own standards and sent it off. Needless to say, I thought I was doing a service in pointing out my concerns.

Respectfully submitted,

Fred Leickly

Story continued- I got a response from ‘Bottom Line’- “Thank you for your email.  We welcome your feedback.  We find that on occasion even well-respected experts disagree and this appears to be one of those times. Again, I thank you for taking to the time to explore this topic with us.”

Ugh! I still feel better for the effort!

Allergy Pet Peeve #2 Too young to test for allergies?

How about this as pet peeve #2 in my allergy practice? I will share my thoughts and practice guidelines regarding the old adage is “the child too young to test for allergy”. I have heard this countless times from concerned parents. There may be some truth to this, but it depends on the situation. Oh, by the way this pertains to any type of allergy test. Let me elaborate.

First off, allergy takes time to develop. There has to be exposure to cause sensitization. Sensitization involves stimulating the immune system to make that allergy antibody called IgE. That antibody then circulates through the body and binds to cells in the gut, skin, respiratory tract, and cardiovascular system. So we need time, a genetically prone child (thank you mom and dad only please), and exposure.

Secondly the nature of the allergen is important to consider. We get a daily dose of food so food allergy has a chance of developing early in life. Inhalants such as animal dander, insect parts, mold spores, and pollen take longer. We then also need to consider the allergen of concern.

We can see food reactions beginning about 2-3 months of age and usually presenting as a form of eczema (dry, itchy, scaly skin) called ‘atopic dermatitis’. In our pediatric allergy clinic at Riley we can and do test infants with eczema looking to see if a food is a possible stimulant for the condition. We skin prick test for egg white, milk, wheat, soy, peanut, and fish (these foods account for more than 90% of food allergy in children) and provide the family with the results of the skin tests (they take only 15 minutes) and a game plan prior to leaving the office. Here the point is that food allergy can be seen in the very young and we can effectively test. So with the proper condition, that being a skin problem, allergy testing can be done and can be very helpful in the very young. Respiratory tract allergy however is a different story.

Respiratory tract illnesses- asthma, rhinitis, otitis media, and recurrent sinusitis can be due to inhalant allergy. Keep in mind that there are other things to also consider such as day care exposure, irritant responses, and possible structural problems.  Inhalants act differently. The first point to be made is that the child has to be God’s earth for at least one year before inhalant allergy can appear. Furthermore, it may take two but for the most part three outdoor seasons for the child to become sensitive to the pollens of trees, grasses, and weeds. This is obviously dependent upon where you live. In Florida, California, and Hawaii for example, the pollen season tends to be all year round. But here in Indiana the pollen seasons are limited to shorter durations. For indoor allergens such as insect parts, danders of dogs and cats. and mold, it takes at least a year for the exposure, sensitization, and symptom sequence to start. Testing an infant to inhalants/pollens would not reveal clinically relevant sensitivities.

So is the child too young to allergy test? I use these general guidelines-

• Food allergy– early infancy and onward
• Indoor inhalants– needs to be at least one year old to be of value
• Pollens– usually three years old and beyond
• Too young to test for allergy? Yes/No:  it truly depends upon what you are testing for.

FEL

Allergy Pet Peeve #1

Every now and then I will bring in what I call ‘pet peeves’. These are for me everyday experiences that I have developed a humble opinion about and when the mood strikes I will elaborate on my perspective (properly plugged as pet peeve perspectives, perhaps?). So here goes – Pet Peeve Number 1- where to go for allergy care?

There are a number of health care specialists who offer allergy evaluations and allergy directed care. I have seen over the past week three new children who have had evaluations for allergy by someone who offers ‘allergy’ care and they were not allergists. In one instance a type of allergy test was done in the operating room. In one child, intradermal tests for foods were done ( a technique that is replete with false positive results) and most concerning was one child who was tested for foods, found to have a few positive responses, and was given a set of instructions that may have caused a problem. As I reviewed the previous allergy test records with the family I noted that the instructions were “3 days of total avoidance followed by 1 day of exposure to as much as could be eaten of the positive food”.

In the world of IgE-mediated, type-one hypersensitivity food ‘allergy’ reactions (see pages on What is an Allergy and Allergy Tests) the current recommendation is full and strict avoidance of the offending food. There is an evolving science that is helping with prevention and with treatment of some food allergies, but we are not there just yet. I have never come across a program that involves days of avoidance followed by overindulgence, nor could I find anything in the literature regarding this. This could be a very dangerous recommendation especially for a child who may have a systemic response such as hives or allergic shock.

The presenting problem was recurrent ear infections. Now here is where philosophies come into play. The track record even in the best designed study is that at a maximum 1/3 of children with recurrent ear infections may have allergy as a contributor. Between the lines, the allergens were inhalants and the 1/3 of children affected was the one study with the highest fraction. Many of the studies on this connection had fewer children triggered by allergy. In regards to foods, the reports from double-blinded placebo-controlled food challenges (this being the best way to prove a reaction) have shown that foods are a rare cause of isolated respiratory tract symptoms. What was also observed was the fact that if a food was involved, the families suspected it before the evaluation. Again the answer was in the medical history.

Who offers allergy care- well anyone can offer and perform some type of test for allergy. Therein lies the problem. Be ware of what and who is out there. Get the best for your investment of time, money, and safety. The American Academy of Allergy, Asthma, and Immunology (AAAAI) has a issued a position statement about questionable tests and testing procedures for allergy.  The bottom line on these evaluations is that it is not money well spent!

We have primary caretakers, allergists, and otolaryngologists (ENT) tauting expertise in allergy.

Let me describe an allergist- This is an individual who has primary training in either pediatrics or internal medicine. The individual then has done a 2-3 year training program in allergy/immunology and is then eligible to sit for their specialty boards. Allergy/Clinical Immunology is a conjoint board, one of the few that credentials trained individuals to see both children and adults within the context of their specialty. The graduate of the fellowship training program has the opportunity to sit for their specialty boards and they become a board certified allergist-clinical immunologist. They could then join one of two national groups that help set the standards of allergy care, the American College of Allergy, Asthma, and Immunology (ACAAI) and the American Academy of Allergy, Asthma, and Immunology (AAAAI). Through a tenure of membership in these organizations and in their primary specialty, the allergist may become for example a fellow of the American Academy of Pediatrics (AAP) and a fellow of the AAAAI.

Resolves for my pet peeve number 1.

1. Ask about credentials- What is the primary specialty- pediatrics, internal medicine, family practice, or ent surgery?

2. Where was the allergy training – a fellowship, part of surgical training, a course?
3. Is the practitioner boarded in the specialty of allergy? Are they board eligible in the specialty of allergy?
4. Are they a member of a peer group- ACAAI or AAAAI?
5. This one is very biased- although the allergist/immunologist has training in each world I would suggest the pediatric-trained allergist for the children. From my experience at a wonderful children’s hospital- you just have to know about kids and be kid-oriented to be more effective in what we do.

FEL

The Sad Loss of the Patient History

This morning after finishing the Sunday paper, I browsed through one of my recent pediatric journals Contemporary Pediatrics Volume 26 . I was attracted to the ‘Your Voice’ article by Dr. Amar Dave of Ottawa, Ill titled above, the sad loss of the patient history. I applaud  Dr. Dave for the comments. The issue so adroitly pointed out the knack of physicians to depend on some sort of test especially when making a simple diagnosis.

The context is the always fascinating ‘Puzzler’ cases that are submitted by the readers. The case appeared in the September issue of the journal. The letter points out that the case is a “blatant example of what is happening to medical education”. The basic elements of our encounters with patients are the history of the illness and the physical examination. Dr. Dave points out that these skills are disappearing and are replaced by tests, radiographic studies, and more tests. Sometimes the tests are performed prior to taking a history and doing an examination. In this case, a thorough history and physical examination may have revealed the diagnosis. Tests sometimes beget more tests and this may not always be necessary and may be costly.

I see this way too often in the practice of allergy. Allergy tests are done prior to visiting with the physician, they are done as panels, and they are sometime performed in the operating room. Sometimes no relevant history is taken and the tests are used to make the diagnosis and treatment plan. In some situations this may work, however I have seen children who were denied foods that they enjoyed (and needed), families who were told to make drastic changes in their lives, animals that were sent elsewhere, and a significant amount of money spent not only for the test but also for special diets and gizmos to alter the environment. This  is not fair nor is it the proper way to do an allergy evaluation!

An allergist/clinical immunologist spends a significant amount of time deciding if the complaints fit a template or pattern of allergic disorders by taking that detailed history and doing an appropriate physical examination. The relevant allergens are then selected for testing. What is ‘relevant’? What I mean by relevant is that they are items that the child is exposed to and with that exposure there will be a reliable set of symptoms. Cause and effect relationships need to be established. For example, if milk is taken everyday and with the drinking of milk there are no symptoms of allergy, then the test should not have been done (given this history) and if the results were positive, then they are irrelevant. The value of the test results is only as good as the story or history that supports it.

Remember, the tests make no child allergic. The test only means that antibody is made or has been made. The allergic child has a set of symptoms consistent with allergy with positive tests to relevant allergens. I go more into this topic in the What is Allergy and Testing pages on this site.

Thank you Dr. Dave for lamenting the possibility of lose of an important part of medical training.

Fenugreek and Legume Sensitivity

The case of Fenugreek

Up until a week ago, I had never heard of fenugreek.  On my first day back at Riley to start the 2009 new year, I had a young man, just under 2 years of age who presented with concerns about reactions to legumes. The list of suspects included peas, green beans, black beans, baked beans, and lentils. The mother also shared with me that during breast feeding she used ‘fenugreek’. This product is used to help nursing mothers. In our discussion, the mother brought up the concern that the fenugreek may have contributed to the legume reactions.

I had not heard of ‘fenugreek’ prior to this. I have been involved with allergy long enough to know that any food product ingested by mankind for as long as we have been on the planet has been implicated in an allergic response. I wanted to know more about this ‘fenugreek’.

I consulted my online food ‘Allergy Advisor’ regarding fenugreek and got a wealth of information to get me started. To my surprise later that week the Journal of Allergy and Clinical Immunology (JACI) had an article from a group in Norway regarding fenugreek.

Fenugreek (aka Greek hay, Greek fennel, Bird’s foot, Greek hay-seed) is a legume. It is used as a flavoring in many foods including curry, blends of spice, and even tea. As an herbal medication it has been touted as being helpful in initiating and maintaining milk production. There are references for its use in diabetes and hypertension. Importantly, it is a legume and many legumes share certain proteins and may be cross-reactive in some patients.

The purpose of the JACI article was to evaluate the allergenicity and antigenicity of the proteins in fenugreek. There were 29 patients in the study who had specific IgE antibodies to legumes, peanut, soy, pea, lupin, and fenugreek. These patients ranged from 1 to 53 years of age. High levels of antibody to both peanut and fenugreek were found in most patients and the sensitization to fenugreek was believed to be due to cross-reactivity in those patients with peanut allergy. In this study, the reactivity to the other legumes was weaker. Here the other legumes (specifically peanut) were implicated in causing sensitization to fenugreek. With the young lad that I saw I wondered if there is the possibility that the fenugreek may have worked in the opposite direction – fenugreek exposure causing sensitization to the other legumes.

I was not aware of this association: fenugreek and peanut. In my clinic notes I debated about doing the peanut test since he had no exposure, but since he reacted to a large number of the other legumes I had the skin test placed. His response was positive to peanut.

The world of IgE-mediated reactions to foods is growing significantly. Our diets are changing with significantly more opportunities for ingredients in foods from other lands becoming part of our lives. Herbal supplements may contain a variety of items that could lead to sensitization. It is important to inquire about the use of such products.