Sometimes, our greatest insights can come in the most unexpected places...I'm reading a very interesting book entitled "The Trouble With Physics" by Dr. Lee Smolin.  His book is a spot-on critique of the modern physics field as it exists today.  Basically, his thesis is that after decades of impressive breakthroughs in the field, physics has come to a virtual grinding halt since the early 1980s, largely because (he posits) there has been an overemphasis on String Theory as the means to make further key breakthroughs in the field.  

He feels the physics community has not encouraged much discussion or investigation into other theories that could bring greater insight into the field.  And hence, the field languishes.  

What does this have to do with our field of Allergy?  Plenty. Our over-emphasis on IgE mediated diseases, and narrowing of our interest into Allergic Rhintis and Asthma nearly exclusively, is our own version of narrowing our view to "String Theory".  

In his first Chapter, he writes an interesting exposition on "The Five Great Problems in Theoretical Physics". As an Allergist and clinician, I have my own list of "Five Great Problems in Allergy".  Unfortunately, I don't think you'll see these "problems" talked about much at our national meetings.  They are truly the "Elephant in the Room" that nobody talks about.

Here's my own list of the Five Great Problems in Allergy:

 1.  The failure of the Allergist to think in terms of "one mucosal membrane" instead of just "one respiratory tract" in holistically looking at the target organs for the allergic patient.  Many asthmatics, for example, come to see me because of irritable bowel symptomatology that their allergist has chosen to  ignore, focusing solely on the respiratory tract.  More often than not, hidden food sensitivities are being missed...

2.   The nature of delayed food sensitivities and the development of a reliable test to diagnose them.  Just yesterday I got (still) another brochure from a lab expounding on their proprietary lab test for delayed food sensitivities.  The investigation into delayed food sensitivities, critiquing the current tests available, etc. has been largely ignored in our profession. Meanwhile, I find increasing numbers of non-allergists using these tests to diagnose delayed-onset food sensitivities.  Where is our research and interest in this area?  Occasionally, there is an oasis in this desert, and one of the articles I've found fascinating is the one by Lied, et al. entitled "Intestinal B Cell-activating Factor:  An Indicator of Non-IgE mediated Hypersensitivity Reactions to Food" published in Alimentary Pharmacology & Therapeutics this year.   The authors correctly point out that "Patients with self-reported food hypersensitivity complain of a wide range of unexplained somatic symptoms related to the intake of food."  In these patients, B cell activating factor levels in serum and gut lavage fluids were significantly higher in these patients than in controls.  Unfortunately, articles like this are "few and far between" and notice that this particular article wasn't published in a "mainstream" allergy journal at all!  Maybe if we ignore delayed-onset food sensitivity, then it will go away, right?  Wrong. 

3.  The lack of understanding and investigation into the nature of delayed sensitivities to mold allergens.  Traditionally, we're told not to be concerned that delayed reactions occur on skin testing to patients because we don't really know what they mean.  But does that mean they aren't important and worth investigating?  I think not.  The fact that some patients have delayed reactions to molds strongly suggests the plausibility of biological significance in the patient.  We ignore it.  At our own detriment--and our patients.

4.  The lack of understanding and investigation into the nature of illness related to Candida Albicans.  I've got an entire lecture on this subject in my "powerpoint lectures and annotated bibliography" section on this blog, so I won't go into this further.  Suffice to say, it made by list of the top 5 problems.

5.  The lack of enthusiasm regarding alternative forms of immunotherapy.  As a professional society, we seem to have a defensive posture on sublingual immunotherapy (SLIT).  I truly believe that the defensive posture is borne largely of fear--fear of change and fear of financial discomfort for the practicing allergist.  And it's hard to be creative and open-minded in an atmosphere of fear.  

None of these 5 great problems will be answered by studying IgE mechanisms further, continuing to principally treat asthma, and giving injection immunotherapy in the conventional manner.  What's the risk of not pursuing these Great Questions?  Simply irrelevance for the profession, and further atrophy in our field.  Patients will go to whomever seeks answers to these questions.  And it may not be the board-certified allergist, but the ENT, chiropracter, family physician, etc. that the patient sees.    

These, then are my Five Great Questions in Allergy  Are these your questions too?  

Something to think about.

Later, Dude