One of the truly nice things about a blog is the truly remarkable people that you can meet...Dr. Clifton Meador dropped by and mentioned I might like his book, "Symptoms of Unknown Origin". 

How right he was... 

I've been slowly reading it, kind of like sipping a fine glass of wine...savoring a chapter or so every few days...and afraid I'll come to the end of it too soon.  Every allergist should read this book.  Although an endocrinologist by training, Dr. Meador's insights reasonate with me.  In the next few blogs, I'll sermonize on various aspects of his book, but let's just take a few excerpts for starters"

"Scientific reduction is not the same process as clinical medicine...It is the sheer scientific power of the biomolecular model that has blinded so many as to its clinical limitations and restrictions...The biomolecular model is so pervasive that unless one can posit a possible molecular explanation for a phenomenon, the subject is excluded from research.  In other words, until the molecular basis is known, no phenomenon exists..."

Note to allergists:  replace the words "biomolecular model" with "IgE immunological model", and re-read the above paragraph. 

What "nonphenomena" exist in the allergy world today?  Many.  Here are just two examples (among many):

1.  What is the clinical significance of the late phase skin test reaction?  This is a phenomenon I see every day.  Most allergists ignore it because it doesn't fit into a nice "IgE model" of illness.  Since we don't understand it, it doesn't exist.  So it's not something to talk about in polite allergy circles.  Yet, for example, it is certain that the strong delayed reaction to molds is not without biological significance.  In my experience, delayed mold skin tests correlate with delayed sickness in these patients. 

2.  How much of a role does the central nervous system have in responding to allergens?  This is a subject also not talked about in polite allergy circles.  Since this is an organ system that isn't "ours" like the sinus and respiratory tract, we simply exclude it from our interest...to the detriment of our patients.  The patient who gets extremely tired after breathing mold or eating the wrong food is...simply put...a nonphenomenon. 

What distinguishes superior physicians like Dr. Meador, in my opinion, is an overwhelming sense of curiosity...I've blogged about this before, in my entry "Curiosity Killed the Cat"  When approaching a difficult or challenging patient with a sense of curiosity, an open mind, and a strong sense of compassion, often unexpectedly great insights can be obtained.  Too often the allergist is trying to "document" or "not document" IgE mediated allergic disease.  Nothing wrong with that--provided we're open to other avenues of immunologic aberrations.  Too often, however, curiosity is an inadvertant casuality of the visit to the allergist.  Nonphenomena happen.  And the allergist has one of the longest lists of "nonphenomena" that any specialty has. 

Later, Dude

 

 

 

 

 

 

I have said before that our field of Allergy is most similar in dimension to that of Infectious Disease. Simply put, the infectious disease doctor is interested in a wide array of pathogens that affect a variety of organ systems.  The allergist, in contrast, should be interested in a similarly wide array of allergens and how they affect a variety of organ systems.  We should accept (like our infectious disease brethren) than a pathogen or an allergen can attack a wide variety of organ systems simultaneously.  It is my contention however, the the infectious diseae specialist is a better diagnostician than the allergist in many cases.  Because in "real life" the allergist comes up short in  two critical areas.  

First, the "usual" allergist is just interested in how allergies affect  ONE organ system (the respiratory tract) and gives lip-service to other target organs.  We've even changed the name of our official societies to include the word "asthma".  Now how would it go over if The Infectious Diseases Society of America changed its name to "The Infectious Diseases and Pneumonia Society of America?"  (For example, how many allergists got excited and wrote Letters To the Editor on the recent article on "Atopic Irritable Bowel Syndrome" Published in The Annals of Allergy by Tobin et. al? Any lectures or talks on this topic at our recent annual allergy meetings??)

The second area we come up short in is our emphasis on CONTROL of symptoms, and our poor diagnostic skills in finding the CAUSE of symptoms.

Here's a scary thought:  What if the Infectious Disease Specialist behaved like the typical Allergist?  A quick scenario:

...the patient is in bed, hot and feverish, with a stiff neck and drifting in and out of coherancy.  The Infectious Disease specialist is called in...he examines the patient and makes the diagnosis of "Meningitis", and promptly tells the nurse of the Meningitis Action Treatment Control Plan.  Temperatures are bracketed into green, yellow, and red zones, and a peak temperature monitoring system (PTM) is used to chart the temperatures. The patient's relatives are taught to use the thermometer and record the peak temps.   Intense attention is paid to using cold packs and aspirin in escalating doses based on the PTM.  Even an algorithm is derived for optimal control. ("more fever?"--add a step two medication to the regimen, like tylenol, in addition to the basic aspirin) The action plan is written down by the nursing staff.   Everybody's happy.  

Except the patient.

Another specialist is called in.  He agrees with the diagnosis, but isn't satisfied it's the ultimate diagnosis.  He's not satisfied with only symptom controlling measures.  A spinal tap reveals meningococcus.  Now real treatment--based on the underlying cause--can be begun.  

I don't know how many patient's I've seen who come into the office "patched up" on Advair, Singular, topical nasal steroids, and who had been shipped off the the GI specialist for "irritable bowel syndrome" and then to the psychiatrist for "chronic fatigue"--when it's all connected to issues the allergist diagnostically is responsible for, and unfortunately missed.  Patients come into my office with a bevy of prior peak flow readings, asthma action plans, and yet...feel miserable and frustrated.   

...This issue is almost a philosophical one. There are "layers" of diagnoses, like Russian Dolls.   What we may think of at first as the "real" diagnosis may be, upon further investigation,  only a secondary issue behind a primary allergenic cause.   There are "layers" of diagnosis, aren't there?  Was the correct diagnosis in the parable above "Meningitis"?  Technically it was, but the causative agent is critical to treatment.  

Jerome Groopman in his book "How Doctors Think"  tells the poignant story of the man who came into the ER and had fallen--he was diagnosed as having a broken leg from the fall.  The leg was casted in the ER.  He went home.  He became progressively weaker, and was found to have fallen and broken his leg because of anemia.  The anemia eventually was found to have been because of colon cancer.  ...layers of diagnoses.

The Allergist should NEVER be content in labeling a disease and forgetting about looking for underlying triggers.  Diagnoses often come in layers, like Russian dolls.  A compassionate ear, an attentive manner, and an inquisitive mind in the allergist can often unravel all manner of puzzling problems.  Diagnostic excellent can never be fully attained, but should be constantly sought.  

Later, Dude 

I'm thirsty...a drink of water wouldn't hurt, would it? Yet most of us are aware of water intoxication from using water (in a sense) "the wrong way".  Should we therefore regard water with a serious degree of danger? Should we all "just play it safe" and stop drinking water?  

...Such were the thoughts in my mind when I read the report in the August issue of The Journal of Allergy and Clinical Immunology by Cochard & Eigenmann entitled "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy".  

In their article, they present 2 cases of patients who suffered serious consequences when they took undertook SLIT.  Each patient had stopped prior SCIT also because of side effects.  Their conclusion?  "Special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."

hmmm.  And as I showed above, water is not totally safe either...

As some of you know, I've used SLIT for 29 years (this coming Feb), and as someone who has had not inconsiderable experience in treating patients who have experienced prior anaphylaxis from injection immunotherapy, I just have to weigh in on this one. I think the following comments are in order:

First, remember the literature---most of the published European literature is on monosensitized patients.  Both of the patients reported in the article were multiply sensitized.   

Secondly, the literature comments on the use of protocols designed for the stable allergy patient--the protocols weren't specifically designed for highly sensitized patients with prior reactions to SCIT.  

Thirdly, why would one give an ultra-rush protocol to patients previously found so reactive to SCIT that they had to discontinue it.  In short--what's the rush?  Looking for trouble?  

Fourthly, I have a suspicion that the total allergy load of at least one of the patients was not completely addressed. Something was missing.  Here's the story--the first patient (a 14 year old girl) was successsfully able to work up 8 drops a day with no major problem, but then 1 week later--at home--she reported a severe asthma attack together with mouth itchiness immediately after SLIT, lasting several hours.  Well, how come she could handle the SLIT the other 6 days without problems?   Most likely, she has some other stressor affecting her system, and partially limiting her response to the treatment...since she was birch, grass, ragweed, and alternaria sensitive, could she have had a hidden concomitant food reaction going on?  How about a hidden cereal grain allergy since she's grass sensitive?  Or a fruit sensitivity to banana, melon, apple, etc. ??  Furthermore, the authors were not, from my understanding, treating her alternaria allergy--just grasses. What were the Alternaria mold counts on the day of her severe reaction?  Incompletely treating allergy load doesn't help the situation here.  

In my opinion (after nearly 3 decades of experience), these authors would have more likely had a successful outcome with both patients if they used multi-antigen threshold dosing, and perhaps selective preseasonal moderate dose therapy as an add-on, after thoroughly looking for hidden food sensitivies that could make  these patients brittle.  It works for me.  

Indeed, often when I see a patient poorly tolerating SCIT, (like these 2 patients), it's because of usually only 2 reasons:  either the doseage administered was technically a failure, or there was a hidden sensitivity in the patient that hadn't been addressed, and stressed their system, making them "brittle".  More often, it's choice number 2 rather than choice number 1.  Although it could be either.

Soooo, what's the verdict?  I agree with the authors conclusions--"special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."  Yes, and water can be poisonous.  In my opinion, a better title for the article (rather than "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy" would be

"Sublingual immunotherapy  in ultra-rush protocol to multiple sensitized patients who may have other hidden sensitivities is not always a safe alternative to subcutaneous immunotherapy" would be a much better title.   

My real fear is that the typical allergist likely perusing this article will go AHA!  SLIT ISN'T SAFE!  SEE! SEE!  And he/she will settle back comfortably into the complacent shot-giving attitude that is so common now-in-days, making the search for a better form of immunotherapy nonexistant.  And you know what?  The allergist is being bypassed in all this--by the ENT physicians and others who are increasingly using SLIT. Most ENT's  know SLIT can have side effects, and the one's that are friends of mine aren't using ultra-rush protocols on their patients either...

The search for a "universal" dose of SLIT that fits all patients in allconditions is nonsense.  To apply the European protocols for monosensitized patients to multi-sensitized patients with severe SCIT reaction histories should only be done at the doctor's (and patient's) own peril...SLIT is incredibly versabile, and like any oral therapy (antibiotic treatment immediately comes to mind) different dosing protocols, depending on the condition you're faced with, make intuitive sense.  (I won't treat an acne patient and a lyme's patient with the same dose of doxycycline, would I?)

So think about these things, and while you're at it--pour me a glass of water, would ya?

Later, Dude

When I first started to blog, I read a cardinal rule--"post on your blog site regularly"...as those of you who follow my blog are well aware, I have violated this rule repeatedly...and as a result, I've probably lost most of my readers...but such is life.  I blog for myself, and to divulge the innermost secrets--my passions--in the allergy profession I've dedicated my life to.  I've been busy getting lectures ready for our annual allergy meeting, so I suppose that is a meager excuse for my tardiness on my blog site.  But in the process of giving a talk on diagnostic techniques used by the allergist, I once again come back to the critical importance of the history in allergy diagnosis...

It's funny that when I take a past medical history on my patients, so many of them say "I went to an allergist and had skin testing"...but none--and I mean none--have ever said 

"I went to an allergist to get a good allergy history and appropriate testing"

It's as if the procedure of skin testing tells the whole story.

It doesn't.

...I'll be getting a colonoscopy in the near future.  I really don't expect the colonoscopist to know my whole story...he's a technician designed to look at my colon--and to see if anything is abnormal. But he can't put the findings into any clinical context.  That's for my doctor to do...I don't expect him to give me any answers except for what he sees at the moment.  

I saw a patient last week...the man looked absolutely miserable. He had a history of sneezing, congestion, facial swelling initially beginning in the spring, but then building up and getting worse each summer and fall.  The problem had been going on for several years.  He had a nice skin response to a histamine control, but his skin tests were largely negative.  It has been an aphorism of mine that the allergist can stop thinking when the skin tests are strongly positive, but needs to start thinking when the tests are negative in someone with a clinical history of allergic problems. He'll undoubtedly be a delayed reactor to molds on is skin tests in 24-48 hours. I'll be interested in his delayed-reaction report.  

Another patient had seen me recently, with the onset of congestion in the summer of 2008, continuing throughout the winter and into the summer of 2009 when I had seen her.  She was also miserable. My initial impression of possible dust mite sensitivity didn't show up on skin testing--in fact, skin testing failed to reveal anything of importance.  More significantly, further history-taking had revealed she had traveled from Minnesota to Arizona over the winter, with absolutely no improvement in her symptoms.

So it was back to the history, once again...

What was going on last summer 2008 that was "out of the ordinary?" I asked.  "Nothing, she replied, except that I had had diverticulitis and was hospitalized briefly for it", she stated.  "Did anything change after that?" I asked.  "No, except that I began eating very large quantities of yogurt to help my intestine, she said".

It turns out that after additional testing I found out that she was milk protein sensitive, and the dramatic increase in milk protein beginning last summer was enough to cause her problems from that point onward--and would explain why she hadn't improved with a change in climate from Minnesota to Arizona.  

The most important diagnostic tool we have is not the needle we stick in the skin, but the grey matter between our ears.  

Skin testing and colonoscopies are fine, but only tell part of the story.  The rest is up to the doctor and the patient.

Later, Dude

In my last entry, I asked the question "Where are today's Leonardos?" in the allergy community. If I was the head of an allergy training program in a University (which thankfully I am NOT), I would not only (of course) emphasize superior critical analysis and clinical problem solving, but also very unconventional creative thinking sessions among all trainees. Why? Because I firmly believe that the clinical triad of a superior allergist is technical knowledge (i.e., thoroughly knowing disease states we deal with), wisdom (which comes from experience in dealing with patients), and...curiosity (i.e., creative stimulous).

The Book by Von Oech, "A Whack on the Side of the Head" would be mandatory reading for every allergy fellow.

It is my contention that truly creative allergists are in short supply...and that's because of blocks to creativity that every allergist subconsciously "employs" in his or her practice. And these blocks to creativity slow down advances in the allergy community. Advances that are within our reach if we think creatively. How can we have a Renaissance of creative thought in our Allergy Community?

By removing the Roadblocks to Creativity...

Allergy Creativity Roadblock #1: There is only one "right answer".

To quote Von Oech, "Nothing is more dangerous than an idea when it's the only one you have". Example: SCIT works for immunotherapy. Stop there. Don't ask the question--can we deliver immunotherapy more safely, effectively, than with SCIT? We have one idea. SCIT works. Nothing else does. And nothing else is even considered.

Allergy Creativity Roadblock #2: Logic can kill creativity.

As a former engineer, this rule absolutely kills me, but it's still a rule we have to follow for creativity. Simply put, there is a time and a place for logic--I use it minute-by-minute to solve clinical problems daily encountered in my practice--but there is a time and a place for creative thinking as well. What we need as allergists is a "time out" from logic so we can get as many ideas as we can, no matter how crazy--the crazier the better. For the Creative Allergist, it is the patient who "doesn't make sense" that is the patient we can learn the most from.  Last month, I mentioned the recent review by Bahna on food additive sensitivity, in which he concluded that there was not one report in the medical literature on desensitization to food additives (despite of course multiple reports on successful ASA desensitization). Well? Doesn't anyone have a crazy idea?

Allergy Creativity Roadblock #3: Break some Rules

As creative, Renaissance Allergists, we need to ask ourselves the tough question, "What 'unwritten' rules are currently in place in my profession that are stopping me from helping more patients productively?" Here are a few "unwritten rules" in our profession--1. To paraphrase Patrick Henry, "Give me IgE or give me Death", 2. Head, neck, lungs. The allergists domain. Nothing else. We all need to break a few rules, and see where our thinking leads us. The pathetic tragedy is most allergists can't think outside the box, because they don't even realize they are in one.

Allergy Creativity Roadblock #4: Being Creative is 'Not my Job'

The good allergist, we're taught, plays by the rules, and follows the lead of our professional societies--we rely on them to be creative. Nonsense. We can never rely on a professional society to be creative, when it has vested political, financial, and other outside interests which can atrophy any feeble attempts at creativity. As individual allergists, we have to realize that we are NOT fully doing "our job" UNTIL we approach our field in a creative fashion. Creativity starts with the individual allergist, not the professional allergy societies. Not the other way around.

Allergy Creativity Roadblock #5: Fear

I've saved what I feel is the most potent roadblock to allergy creativity to the end: Fear. Face it: It is hard to be creative when you are fearful. And if there is one disease that Allergists suffer from currently, it is a (possible terminal) case of fear:Fear of declining reimbursements from insurance carriers--especially if we use SLIT and not SCIT. Fear of increasing competition from ENT's, Family practitioners, etc for our patients. Fear of SLIT-based pracitioners and pharmaceutical companies making better and better treatments that "take away" the need for an allergy referral and put allergy management back into the hands of the primary practitioner. Fear of "internet educated" patients desiring help with delayed food sensitivities and other areas we aren't really interested in or know how to deal with. In truth, we are a fearful lot. And, as I've said, it's hard to be creative when you're fearful. But there's a cure:

There is no fear in love [dread does not exist], but full-grown (complete, perfect) love turns fear out of doors and expels every trace of terror! For fear brings with it the thought of punishment, and [so] he who is afraid has not reached the full maturity of love [is not yet grown into love's complete perfection]. —1 John 4:18

Simply put, if we love our profession, our patients, and our calling with enough passion, we'll approach creativity without fear.  And then advances in allergy can really be made.

Later, Dude