Journal

Where are today's Leonardo's?--blocks to creativity in the Allergist

2009-06-28T18:55:34Z

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

Among Allergists, Where are Today's Leonardos?

2009-06-21T17:17:05Z

It is truly rare that I read a newspaper article that resonates with my opinions & beliefs like the article, "Where are Today's Leonardos?" by Dr. Howard Zucker in USA Today. Although the article was officially addressed to the graduating class of 2009, it could just as easily have been addressed to our professional allergy community. In his article, Dr. Zucker (a resident fellow at the Institute of Politics at Harvard University), states

"Perhaps it is time for a rebirth, a time to create a better world through the energies of the Class of 2009"...The Renaissance was a period when our search to perfect one's worldly knowledge transcended obstacles and bridged intellectual divides. Students of creative thought--including da Vinci, Michelangelo, Copernicus and Galileo--questioned conventional wisdom... Just as the Renaissance masters cast away conventional concepts, so too shall we discard friction that creates inertia in our thoughts."

Conventional Wisdom in the allergy community today involves several key underpinnings, which permeate all thinking and research in the field and (in my humble opinion) don't exactly "transcend obstacles and bridge intellectual divides". Here are 3 key points in allergy Conventional Wisdom:

1. Since IgE mediated disease is the only "true" allergy, it is the only sensitivity we should be concerned about. Delayed food reactions, mold reactions, etc. really aren't our concern...so let's sweep them under the rug. Let them die a death of benign neglect, not flourish in an atmosphere of curiosity...

2. Asthma and upper respiratory disease should encompass what the allergist is "all about". Other organ systems (besides pulmonary) should (once again) die a death of benign neglect as it regards interest in them as allergically responsive systems.

3. Other chronic disease states--chronic fatigue syndrome, fibromyalgia, migraine headaches, interstitial cystitis, have no allergic component, because everybody knows they don't. So let's not be curious and study if indeed they DO have an allergy component to them.

Examples of this "intellectual straightjacket" abound. You can generally pick up any current issue of any allergy journal and see Conventional Wisdom at work--and trumpeted...Here's just one small example: In the June issue of Current Opinion in Allergy and Clinical Immunology DRs. Randhawa and Bahna wrote a comprehensive review entitled "Hypersensitivy reactions to Food Additives". They comprehensively review the protean manifestations of food additive reactions, and I heartily recommend the article for those allergists who see this problem in clinical practice. However, near the end of their article, they state:

To our knowledge, there are no published reports on successful desensitization procedures.

What? You mean there isn't even a single case report in the entire body of medical literature on successful desensitization to food additives, despite multiple articles on successful aspirin desensitization? Hello--isn't anyone anyone curious & interested? Where's creative thought?

It was this form of unconventional thinking that drove me to try oral desensitization to yellow dye #5 in a patient I had seen in my office earlier, who had presented with a history of seasonal allergic rhinitis, and repeated urticarial reactions to foods containing yellow dye. As with many allergy patients, she wanted help with the "difficult issue" (dye sensitivity), and not the "easy issue" (allergic rhinitis). As a businesswoman, she frequently went on trips and ate at restaurants, and found it always a risky procedure

We began her on a progressive program of yellow dye oral desensitization, starting with dilution #9 of yellow dye #5, and working progressively up to a dilution #1 without serious problems. We knew we had successfully desensitized her when she told me she was on a business trip and gulped down a glass of Tang, which she had mistaken for Orange Juice, and had no reaction. Conventional Wisdom would have just treated her for her allergic rhinitis (which she could handle just fine with an OTC antihistamine, thank you).

So here's the thought for the day--are we graduating Leonardo's from our allergy training programs, or just good Asthmalogists and technicians?

Do allergists think "outside the box"--or inside a straightjacket?

Later, Dude

Dr. William W. Duke: Pioneer in Platelet Research...and forgotten Renaissance Allergist

2009-06-06T21:07:31Z

It was with bittersweet pleasure that I read the "JAMA Classics" article "Dr. William W. Duke: Pioneer in Platelet Research" that was just published June 3, 2009. Dr. Kickler, in his commentary on this classic article (first published in 1910 by Dr. Duke) states:

...when Duke published an article in JAMA on the role of platelets in hemostatis, probably few individuals realized that this report would be judged as one of the outstanding contributions to the science of medicine during the first half of the 20th century...this JAMA Classics article by Duke is historically important for 2 reasons: it defined the role of platelets in hemostasis and it documented the therapeutic efficacy of blood transfusion in treating thrombocytopenia..."

There is always a danger in "cherry picking" a great physician's body of published work--you might give the erroneous impression that's ALL they really accomplished.... I pointed this out in my earlier commentary on a recent article on Dr. Warren Vaughn, another Renaissance Allergist, published in the JACI that didn't (in my humble opinion) adequately due justice to his contributions to the field of food allergy.

In truth, I count 97 total publications by Dr. Duke over his lifetime. Less than 10% of these actually deal with platelets. Dr. Duke was fascinated by the wide range of symptoms that food sensitivity could cause, and abided by the maxim "one mucosal surface" instead of the mantra "one respiratory tract" (used by so many "allergists" today) to describe the wide range of manifestations that allergic disease could cause. Here are some articles he also published:

Duke, WW: Food Allergy as a cause of abdominal pain. Arch Int Med. Chicago 28:151, 1921.

Duke, WW: Food Allergy as a cause of abdominal pain. South M J Birmingham 15:599, 1922.

Duke, WW: Food Allergy as a cause of bladder pain. Ann Clin Med 1:117, 1922.

Duke, WW: Food allergy as a cause of irritable bladder. J Urol, Baltimore 10:173, 1923.

Duke, WW: Meniere's syndrome caused by allergy. JAMA 81:2179-1923.

Duke, WW: Urticaria caused specifically by the action of physical agents (light, cold, heat, burns, mechanical irritation, and physical and mental exertion) JAMA 83:3, 1924.

Duke, WW: Mental and neurologic reactions of asthma patient. J Lab & Clin Med 13:20, 1927.

Duke, WW: Allergy as a cause of gastrointestinal disorders. South M J 24:363, 1931.

Duke, WW: Rapid and more accurate method of determining pollen count in air. JAMA 99:1686, 1932.

Duke, WW: Soybean as a possible important cause of allergy. J Allergy 5:300, 1934.

Duke, WW: Wheat miller's asthma. J Allergy 6:568, 1935.

I stress this is only a fraction of the allergy articles published by Duke--it is by no means a complete list. It is ironic that the commentator of the article on Duke and platelets (Dr. Thomas Kickler) did not at least reference JAMA's OWN TRIBUTE on Duke's life:

William Waddell Duke 1883-1946, JAMA 130:1185, 1946.

Duke was obviously a brilliant allergist who made important contributions to the specificity of food allergy, in addition to making important contributions in the field of hematology. How do I know about Duke? One of my mentors (Dr. Theron Randolph) recalled seeing Dr. Duke at an allergy conference in 1933 in Atlantic City New Jersey, while he was a senior in Medical School. He studied Duke's life, and published his bibliography. I have a copy of that bibliography. Dr. Randolph stated that

"Duke's remarkable book published in 1925 really opened up the field of food allergy...Duke related specific foods and simple chemicals to a wide range of allergic symptoms, including headache and bewilderment resembling delirium..."

William H. Duke: Pioneer in Platelet Research

AND...

Renaissance Allergist.

Something to think about.

Later, Dude

The Strange Case of the Elderly Woman...

2009-05-31T18:07:06Z

It was a beautiful day in May, a few years ago, when she first walked into my office. She had an earnest look on her face...before I could introduce myself and welcome her to our clinic, she blurted out her urgent concern:

"Dr. Kroker, please help me with my Myasthenia gravis..."

Of course, as an allergist, my first thought was "you've come to the wrong place, lady", but I resisted the temptation to say what immediately was on my mind, and asked her to simply tell her story...

"I've had Myasthenia for about 4 years, confirmed at a large tertiary care center...I use Mestinon, primarily for ocular symptoms, but because of GI side effects, I try to minimize it whenever possible."

"I've also had allergy symptoms in the spring and in fall for many years. I was allergy tested in the 1960's and was on injection immunotherapy for about 2 years when in Oklahoma. That helped reduce the respiratory symptoms, but now I've been in the Midwest for about 4 years, and I've noticed that in the spring and fall, when my respiratory allergies flareup, my eyelids will droop, I'll get facial weakness, and need ALOT of mestinon. At other times, I'm relatively fine. I take Flonase for my nasal congestion, and haven't been on injection immunotherapy for many years".

"I also have itchy skin, and use Allegra all the time. I'm also prone to fluid retention, and use "Lasix".

"Do you think you can help me?"

The desperate look in her eyes was accentuated by the drooping of her left eyelid...In truth, I have seen many cases of what I call "The Allergy Interface"--whereby an allergy condition aggravates a coexisting chronic disease. We must never forget that when we read about any chronic illness in a medical textbook, website, or magazine article, there should be a caveat attached to the disease discription: i.e., "this is the disease's presentation, natural history, and response to treatment, assuming that there are no other coexisting illnesses, and the patient is otherwise in fine health" (italics mine). Believe me, I have seen allergic disease aggravate many other coexisting chronic diseases, including chronic fatigue, fibromyalgia, and even more "exotic" illnesses like Hereditary Cerebellar Ataxia (but that's another story for another time...).

We did intradermal testing, and found strong responses to molds, and (very interestingly), a 14mm wheal on dilution #2 of TCE and a 15mm wheal on dil #2 of Candida antigen.

I found the strong immediate responses to molds--and especially Candida intriguing...she had been on multiple antibiotics and steroids in the past, and undoubtedly had significant commensal colonization of Candida.

What was most interesting was that after skin testing her, her left eye drooped further, and became almost totally closed...

We began her on a program of SLIT for molds, and Candida, and a course of fluconazole for 14 days. We subsequently found a RAST positive score for Candida of >100 ug/ml of antigen in her blood. Also elevated antibody levels to wheat and egg. We changed her diet, began SLIT, and had her keep a pill count for her Mestinon useage....

Over the next several years, she has had dramatic improvement in spring and fall respiratory symptoms, as well as her seasonal Myasthenia flares...She stated on her followup visits "my eyes are real good" and took an overseas trip without difficulty. Her use of mestinon has been reduced by perhaps 75-80%. She doesn't want to discontinue SLIT under any circumstances...When I would see her in the clinic, her eyes were bright, not drooping, and...most importantly..she no longer had the desperate look in them that she had on her first visit with me.

The Allergy Interface. Something to think about.

Later, Dude

An Open Letter to a Young Allergist...

2009-05-25T17:34:08Z

Congratulations! After two years of Fellowship Training, you're about to be done...and be certified as an Allergist. The whole "World of Allergy" awaits you...and you're about to take the big step forward into directly caring for patients on your own...As someone who has been "in the trenches" for nearly 30 years in treating allergic diseases, I have a few words of advice. This letter could be entitled many things, but perhaps the best title would be

"Mistakes I've made and Lesson's I've learned"

For you see, I've found that not everything you've learned in your training program applies to the Real World of allergy. Naming and learning leukotrienes is one thing, but dealing with patients is quite another...Here are some things to think about when you begin to see patients--lessons I've learned in the last 28 years that have helped me in my practice:

1. Lesson 1: In the Real World of Allergy, patients don't give a damn whether they're sick because it's "IgE-mediated allergy" or not--they just want to get well. You'll see many, many patients with adverse reactions to foods and molds where your prick test is negative, and telling the patient "they don't have an IgE mediated allergy" is very cold comfort to them. They want answers, and telling them what it ISN'T is not nearly as satisfying to the patient as telling them what it IS. A practical point--they're not likely to refer you a whole lot of future patients, either. Here's the clinical pearl: In the Real World of Allergy, you've got to get comfortable with non-IgE mediated reactions--and fast--if you want to be a superior allergist...

2. Lesson 2: You've got to get experienced in delivering immunotherapy regularly in your practice, and preferably in a well tolerated, safe and effective form: SLIT. If the only thing you're interested in is treating asthma and allergic rhinitis with only drugs, you'll be a very lonely--and poor--Allergist. Face it: we have alot of competition for treating the asthmatic patient, and the allergic rhinitis patient. We've got good symptomatic drugs too--which the family physician and pulmonologist and otolaryngologist can all deliver. You've got to deliver something the family physician and the pulmonologist and the otolaryngologist can't deliver--and that's immunotherapy. SLIT is the wave of the future. Bone up on it. Fast.

3. Lesson 3: There are other things in the Allergist's life besides asthma. Open up your vistas, and start thinking of ALL mucosal organs (and the skin) as targets for allergic disease. Our professional societies have done a good job at "marking our territory" as asthma--that's all well and good, but you'll see plenty of patients with urticaria, migraine headaches, fatigue, and other issues besides asthma. Many of these patients come with a mix of IgE and non-IgE mediated illness. In truth, the allergist who only treats asthma is like the musician who only plays one song: It gets pretty boring, and is an incredible waste of talent...

4. Lesson 4: Revel in the mystery of allergy--and develop your sense of curiosity in your practice. Just because we can't EXPLAIN a patient's reaction in terms of what we presently understand from our training program, there is no need to deny it exists or delight in the mystery of how it happens: Why does Mrs. Smith get tired shortly after eating wheat products? Why does Mr. Smith get a headache 12 hours after cleaning up a moldy basement? Why do Mr. and Mrs. Smith have negative prick tests and IgE negative RAST tests to wheat and mold? There is a subliminal tendency in many young allergists to not be interested in anything they can't explain. An observation is DENIED because the PATHOPHYSIOLOGY is unclear. That's backwards. It is the patient reactions we can't explain that should interest us the most! Thinking should begin with the NEGATIVE prick test and the NEGATIVE RAST test...not the positive ones. There are many, many, things we do not understand about how food and aeroallergens affect the patient, and the sooner we humbly acknowledge this, the better. This is the "Grand Mystery" of allergy. Accept it, embrace it--and study it...

Keep these four lessons in mind as you start your practice--you'll have a satisfying and rewarding practice for many years to come.

Later, Dude

Morris's Sign: Neurogenic Targeting...An Allergist's Observations...

2009-04-13T19:19:05Z

week ago, I celebrated 60 years of life on this planet...and I began to reflect on 25+ of those years dedicated to studying and treating allergic disease...It continues to amaze me regarding the sheer diversity and variety of allergic manifestations that the human body can manifest. However, after nearly 3 decades of experience, certain "patterns" seem to show themselves amidst all of this diversity. I have already reported on what I termed "Eaton's Sign", whereby a patient's site of former skin testing can unexpectedly erupt again, following a cross-reacting allergenic exposure. Here's another:

Morris's Sign: An allergic reaction to an inhalant or food may preferentially target a site of prior neurogenic trauma in a patient.

I have seen multiple examples of this sign over the years:

Case Example 1: A previously diagnosed food-sensitive patient develops the shingles. Now, with accidental ingestion of corn, a faint tingling and burning occur in a dermatome distribution site where the patient previously experienced shingles.

Case Example 2: A patient with prior reflex sympathetic dystrophy accidently ingests milk. Her right arm flushes and reddens immediately after ingestion.

Case Example 3: A patient tells me that she always experiences her urticarial eruption first at a small site on her abdomen. On examination, the spot turns out to be a small scar from a prior laparoscopy procedure.

Case Example 4: A former food allergy patient returns to see me. In the interim since I had seen him, he was in an automobile accident, and suffered a seriuous whiplash accident in the neck. Now, when he accidently ingests his allergen, he not only gets nasal and sinus congestion, but his neck and shoulders ache intensely, just as they first did after the accident.

To my knowledge, this observation has not been commented upon or officially published in medical journals. And yet allergists like myself see this sign "play out" on regular encounters with our patients, often on a near-daily basis. Why have the presumption to name it myself? Well, somebody has to do it. Why name it Morris's sign? Easy--Dr. David Morris, a consumate allergist and my mentor in sublingual immunotherapy (SLIT) has just retired after a profoundly productive lifetime of caring for patients. The tribute is inadequate, but it's one small thing I can do to show my gratitude for all of the knowledge on SLIT he has passed on to me and my colleagues.

Later, Dude

On Accepting Sublingual Immunotherapy...Part Deux

2009-03-01T23:01:29Z

In my last entry, I talked about 3 reasons why sublingual immunotherapy (SLIT) has been slow in gaining acceptance: "turf wars" between ENT's and allergists, the "tomato effect" in medicine, and the commitment and work it would take an allergist to change his/her practice from SCIT to SLIT.

But wait...there's more.

In pondering this issue and discussing it with my colleagues, an obvious answer exists--the proverbial "elephant in the room" that nobody discusses:

Allergy society leadership.

Let's face it--many of our society leaders are academic allergists. Their viewpoint--philosophically AND financially--is far different than the allergist "in the trenches" coping on a daily basis with competition for patients between ENT's, family physicians, chiropracters, etc...

Although I love to read the Annals, and the JACI, and delve into the esoterics of various allergy issues (I didn't know that prostatic kallikrein was a major dog allergen until now), I was trained as an engineer. I do what works. Practicality and positive results are what count--for my patients and for myself. I've utilized SLIT in my practice since Feb, 1981. And despite "competition" from local allergists using SCIT, I've more than managed to survive. This "real world" experiment answers the question "can an allergist convert from SCIT to SLIT and still be successful?" It's been done. At least once!

Later, Dude

On Accepting Sublingual Immunotherapy--A Denial of Reality...

2009-02-22T21:45:48Z

In my last entry, I've written about the extensive history of SLIT--going back over one century...many, many years prior to the European literature,which largely began in the 1980s...Invariably, in any discussion about SLIT the one key question that arises is...

Why has recognition of this technique as a safe and efficacious treatment for allergic disease taken so long?

To my knowledge, there has never been a medical article that addresses that question...and it seems to be a perfect blog topic...so here goes...

Lack of American acceptance of SLIT as a viable treatment modality is probably because of several factors:

1. The "turf wars" between ENT's and Allergists: Face it. The majority of early proponents of SLIT were not allergists. They were ENT physicians (Hansel, Pfeiffer), or non-ENT non-allergists (Dickey--a urologist by training). Medical history has a tendency to repeat itself...when Edward Jenner discovered vaccination for smallpox, his discovery was unrewarded by the medical establishment, largely because of bias against him--he was a rural general physician and his 1798 paper was rejected and never published by the medical establishment. Similarly, why would a board-certified allergist look kindly on a technique condoned--and discovered--as effective by his non-board certified colleagues??

2. The profound implications of SLIT--it's potential to revolutionize the office practice of allergic disease: Let's face it. As allergists, we can rapidly incorporate a new medication into our practice with minimal problems...but incorporation of SLIT into an office practice would take far more work, and (according to conventional wisdom), considerable financial risk. Technicians would have to be trained, and a doctor would have to be educated and confident of his success in using it...in the face of non-insurance coverage. The American allergist, before he/she dives into a SLIT-based practice, simply wants iron-clad, irrefutable, American-based evidence that SLIT is safe and effective. Anything less is simply unacceptable...Money can be made with SCIT, and with SLIT...well, insurance coverage just isn't there...yet...so "let's wait and see", right?

3.The "tomato effect". Allergists were trained during fellowship to believe that SLIT didn't work, because...everyone knew it didn't work. This is an example of "The Tomato Effect", written about by Goodwin, JS & Goodwin JM, JAMA 251: 2387-2390, 1984. Briefly put, the tomato effect is defined whereby a potentially efficacious medical therapy is discounted because "it doesn't make sense". The conventional wisdom--common knowledge--is that "it just doesn't work". In 1560, the tomato was becoming a staple of the European diet, having been brought back from Peru. As the Goodwins put it,

“Of interest is that while this exotic fruit from South America was revolutionizing European eating habits, at the same time it was ignored/actively shunned in America.

"The reason tomatoes were not accepted until relatively recently in North America is simple: they were poisonous. Everyone knew they were poisonous, at least everyone in North America. “Not until 1820, when Robert Gibbon Johnson ate a tomato on the steps of the courthouse in Salem, New Jersey, and survived, did the people of America begin, grudgingly, we suspect, to consume tomatoes..."

4. If SLIT is accepted, we have a technique safe enough that potentially even non-allergists will do it and create increased competition for the allergist. This gets into my "hidden agenda" blog post from earlier. To the trained allergist using SCIT, there is only one solution to the dilemma of having a form of immunotherapy that is simply "too safe"...and that is to "spin" SLIT to make it as dangerous as possible...this benefits the allergist--since it keeps the treatment "in his camp". No one but the board-certified allergist would dare to do it (pretty much like injection immunotherapy presently). Presentations and studies by American allergists will therefore be overly cautious and negative in their portrayal of the benefits of SLIT...

In short, the American allergist (unlike their European counterpart), comes with psychological "baggage" of years past regarding inherent bias against SLIT (a technique largely proposed by non-allergists), and a fear about maintaining financial security when adopting this technique and giving up SCIT. Instead of objectively looking at European studies and aggressively pursuing SLIT, we employ a strong "denial of reality"--a defensive, fearful posture--we think "if we just don't think about SLIT, it'll go away"...And we employ tired, worn arguments (i.e., "it's not FDA approved, we don't have American studies...") that don't even make rational sense (after all those of us who use SLIT use FDA approved extracts in an off-label useage--something perfectly legal).

It's hard to be creative and innovative when you're fearful, and that's just the place where the American Allergist is...now, more than any other time in our history, the American Allergist needs to be resourceful, creative, and innovative. Not fearful. Our attitude with SLIT is but one example of something that needs to be changed...and soon.

Later, Dude

Sublingual Immunotherapy (SLIT): The early studies

2009-02-03T20:14:07Z

I was on the phone recently with a colleague whom I admire...we were discussing an allergy case at his request when he said..."You know, it does my heart good to see you've gotten over your anger issues and renamed your blog "The Renaissance Allergist"...

Inwardly, I beamed...maybe getting in touch with my Inner Child was finally doing me some good...it was amazing...maybe, just maybe, all that hard work I had done in resolving my previously unresolved suppressed anger at my father for not taking me to a Chicago Bears game in 1955 was finally coming to fruition...

And I was in a truly mellow mood when I picked up the latest issue of Current Allergy and Asthma Reports, Volume 8, Number 4, 2008. In it, the lead article was entitled "Recent Advances in Immunotherapy of Allergic Rhinitis", by Lee & Mo. Not surprisingly, their first topic of discussion was Sublingual Immunotherapy (SLIT). They had this to say in their first sentence of their first paragraph:

SLIT was first introduced in the 1980s in Europe."

Say whaaat?

Screw my Inner Child. I'm mad.

Hey, wait just ONE minute....it may be becoming fashionable to quote the newer European literature on SLIT, but it's important not to ignore the "pioneers" when it comes to this technique. How long has SLIT been around? 20 years? 30 years? 40 years?

How about 109 years...

In 1900 a New York physician H.H. Curtis relieved his patients' hayfever by placing pollen antigen drops in their mouths. Yes, 1900. Not 2000. Written up in "The immunizing cure of Hay Fever" Medical News, New York 1900; 77:16-19. In 1905 German doctors used oral immunotherapy to desensitize infants allergic to cow's milk (Finkelsteim, H. Kulmilch als Ursache von Ernahrungsstorungen bei Sauglingen Mmonatsschr Kinderheilk. 1905; 4:65-72.) Actually allergy injection immunotherapy (SCIT) was first used 11 years AFTER oral immunotherapy by English physicians John Freeman and Leonard Noon.

In the 30s and 40s, doctors used oral immunotherapy, mostly reporting favorable results. Black desensitized 150 patients to pollen using oral drops--40% of them got satisfactory symptom relief. (Black, J. The oral administration of ragweed pollen. Journal of Allergy and Clinical Immunology. 1939. 10:156.) Leo Conway began using oral antigen drops to control seasonal allergies by 1934. (Conway, L. Pollen allergy. South Med Surg. 1943; 4.). Gutterdam in 1933 reported on 85 patients receiving oral antigen drops, finding good symptom relief in 75-85% of patients. (Gutterdam, E. Oral administration of pollen extracts. Southwest Medicine. 1933:17:199.) They took 3-15 drops of pollen extract twice each day. In 1937 Hollister & Stier reported good results in 78% of hay fever patients and in those allergic to animal dander and foods. (Stier, R. Hollister, G. Desensitization by oral administration of pollen extracts. Northwest Medicine. 1937; 36:166).

Were there others? Of course. Schofield, Walker, Stuart, Farnham, Keston, Waters, Hopkins to name a few. I have written a previous entry on Oscar Schloss who had successfully desensitized a child with anaphylaxis from eggs with serial dilutions of oral egg drops administered orally....in 1912.

But for my money, the three real pioneers in the field were: French Hansel, Larry Dickey, and David Morris...

I have been extremely privileged in my life to have known all three.

French Hansel can be called the modern "father of sublingual immunotherapy". Hansel experimented with sublingual drops for dust mites while he was a Mayo Clinic Fellow in the 1920s and published his results in 1936. (Hansel, F. Allergy of the nose and paranasal sinuses. CV Mosby. 1936). He was the first physician to observe that actually placing antigen drops specifically under the tongue prompted faster, more effective desensitization than in any other part of the mouth. He had this to say:

It is not unreasonable to assume that this highly absorptive sublingual area has definite immunologic function. Through this route practically all the injectables, many of which are not well tolerated, can be introduced without apparent injury to or reaction in the local tissues" ((Hansel, F. Clinical Allergy. CV Mosby. 1953)

He later described in greater detail sublingual treatment in "Sublingual testing and therapy. Trans Soc. Opthalmol Otolaryngol Allergy, 11: 93, 1970. During my early training, I was fortunate to have lunch with Dr. Hansel, and to discuss his experience with SLIT in particular. How fortunate! Guy Pfeiffer, MD, a student of Hansels, developed sublingual drops for foods. Like Hansel, he was an ENT physician, who presented his five years of experience with SLIT at a 1963 ENT conference.

Lawrence Dickey, a Colorado surgeon and urologist by training, started offering shot immunotherapy to his urology patients who had allergies, and after hearing Pfeiffer, he stopped treating his patients with shots and started treating them with SLIT. Dickey wrote about the use of SLIT in Trans Soc Ophthalmol Otolaryngol Allergy 5:37, 1964, in an article entitled "Sublingual therapy in Allergy", and he also wrote in JAMA in 1971, with an article entitled "Sublingual Antigens", JAMA 217: 214, 1971. Once again, I had the enormous priviledge of knowing Dr. Dickey; he was exceedingly gracious and generous in sharing his knowledge in this area. At a 1964 ASOOAS conference, Dickey had this to say about SLIT:

'sublingual therapy is more acceptable to our patients sand more convenient for our office personnel. There have been fewer drop-outs from sublingual therapy than we had with injection treatment".

Finally, my own colleague, to whom I owe such a personal debt of gratitude, wrote truly groundbreaking articles on SLIT. David Morris, MD was at the ASOOAS conference in 1966. He heard Pfeiffer and Dickey presenting at the conference. And he became interested in SLIT and subsequently published in the Annals of Allergy in 1969 on SLIT for foods and in 1970 on SLIT for molds. His 1970 paper on SLIT for molds broke new ground--he was the first to report success using SLIT specifically for treating respiratory diseases caused by mold allergy.

I wish to thank Dr. Morris for his historical lectures on SLIT, which are the foundation for this lecture (diatribe??) But this raises a bigger question...if SLIT has been around for over 100 years, why haven't we heard more about it until now, and why do we promulgate the misplaced notion that "the Europeans discovered it?" What does this imply about our specialty?

My next post will address that intriguing question. Until then, I'm back to my anger management program.... Again.

Later, Dude

Pattern Recognition: Intermittent Allergic Attacks due to "Critical Mass"

2009-01-18T21:43:02Z

In my last entry, I promised to write about one clinical pattern (mold and Candida cross-sensitization) but that all changed when I recently received the following e-mail from a savvy Physician's Assistant who is a friend of mine. Here's the key excerpt:

"...13 year old with 5+ years of vomiting 10 to 12 times daily on and off. Had seen gastro multiple times with no answers. Saw me and I suggested wheat free, dairy free diet and ran a RAST IgE food panel on him. He came back positive to eggs at 3+, dairy 2+, wheat at 2+ and soy at 1+. Took him off of all of these and his symptoms resolved almost completely...He did see GI after this again and was told he may have eosinophilic esophagitis based on endoscopy and some "general inflammation". Also sent him to allergy and they said he didn't really have true food allergies despite positive RAST and a clear improvement off of the offending atents. They in fact suggested he go BACK on his foods and that his underlying issue may in fact be eosinophilic esophagitis.

Are the allergists here in question total morons...? My understanding is that studies have been done show that an elemental or elimination diet can resolve some cases of Eosinophilic esophagitis and patient symptoms. Isn't this a clear allergic issue? I also suggested to my patient's mother to ask about SLIT to the allergist just to see what would occur and the note returned to me clearly states "patient's mother asked about SLIT which we discouraged considering because it hasn't been shown to work".

This letter pretty much sums up the frustration many primary care doctors have in dealing with allergists...in this case, there is a failure by the allergist in question in two separate areas:

1. A failure in focusing on a disease and disregarding potentially causative triggers of the disease.

2. A failure in recognizing that a fluctuating load of "low grade" allergens can cause a "critical mass" effect of an acute allergic reaction...i.e., a failure in "pattern recognition".

Let's discuss the first of these two failures:

I have previously written on Jerome Groopman's excellent book, "How Doctor's Think" In the book there is an interesting story told by an ER doctor...a elderly man presented with a broken ankle. The ER physician focused on fixing the ankle...and the man presented later to the ER...having fallen again. It turned out the reason he had fallen--and broken his ankle--was because he was weak and anemic. And it turns out he was anemic because...he had colon cancer. So the ER doctor focused on the illness, to the exclusion of inciting triggers for the illness. With disastrous results. In a similar manner, the physician's assistant is really asking in his email: "do we really do a "complete" service to our patient by focusing on whether or not he has an illness (i.e., eosinophilic gastroenteritis--or eosinophilic esophagitis) if we ignore possible causative triggers--in this case the dietary management that put the child in remission?

The second failure in the above case is the failure of pattern recognition: we can often have patients present with intermittent severe allergic-type reactions. More often than not, there are only two possibilities for these intermittent severe reactions: i.e., a HIGHLY allergenic item (usually hidden to the patient) that he/she intermittent has exposure to, or (and this is far more common), an accumulation of MILDLY alllergenic products reaching a "critical mass" in unfortunate circumstances. I have seen this scenario played out multiple times in diseases such as "idiopathic anaphylaxis".

It's important to understand that low grade food sensitivities can be responsible for intermittent severe attacks of GI upset. The child's symptoms were "off and on", and resemble the clinical entity Cyclic Vomiting Syndrome. There is medical literature to support the idea that Cyclic Vomiting Syndrome can be a manifestation of allergic gastroenteritis, which in turn can be triggered by food allergy. Tokodi et al presented the case of Cyclic vomiting syndrome in a child which resolved on elimination of milk from the diet. Further, Lucarelli et al, writing in the Eur J Pediatrics had this to say:

Cyclic vomiting syndrome (CVS) is characterized by repeated unpredictable, explosive and unexplained bouts of vomiting. The episodes have a rapid onset, persist over a number of hours or days, and are separated by symptom-free intervals. Despite the recent interest in this disorder, its aetiology, pathogenesis and even its target organ remain unknown. The purpose of this study is to investigate the role played by food allergy in CVS. The report concerns eight children (five male, three female), mean age 8 years (3-13 years), suffering from CVS for 2 years at least. The diagnosis of CVS was based on characteristic history, normal physical examination and negative laboratory, radiographic, neurological and endoscopic studies. Despite the absence of clinical signs typical of food allergy, skin prick tests were positive in six of the eight patients (75%). Specific IgE were present in 4/8 (50%) of the patients. Skin tests and specific IgE were positive for cow's milk proteins, egg white and soya. IgE levels were higher than the mean + 2SD in 5/8 (63%) of the patients. A double blind placebo controlled food challenge (DBPCFC) was carried out on seven of the eight patients who displayed clinical improvement after an elimination diet for cow's milk (and other foodstuffs indicated by positive skin tests). The DBPCFC was positive in all seven children. Clinical follow-up revealed a state of well-being over the 6 months of observation. CONCLUSION: It appears reasonable to suggest that food allergy plays a role in cyclic vomiting syndrome.

I have seen the pattern of intermittent GI upset (particularly in children) from mild food sensitivities in many children. More often than not, the mother or father will bring their child in to me because they are having a few episodes a month of severe gastrointestinal distress. Very often, there is a low grade reaction to one or more foods responsible for the episode. Remember: it takes 3 1/2 days for food to completely transit the GI tract, so a "load effect" can take place. Case in point:

A minister sees me in the office. He has ice cream as his "special treat" every Friday night. Last month it was his birthday--on a Saturday--so he had his ice cream Friday AND Saturday--and he suffered a horrible attack of GI distress and upper respiratory congestion on Sunday morning!

This is graphically illustrated in the following slide:

In this slide, the fluctuating size bars represent the fluctuating levels of food allergens present in the patient's system, which in turn are shown by the different colored boxes. The threshold for reaction, shown as a dotted line, can be lowered by stress (viral infection, emotional trauma, etc).

In another part of his email, the physician's assistant related that "the allergist said that those RAST levels were not positive enough to be a problem". Nothing could be farther from the truth. Like the statement by the allergist that "SLIT doesn't work". Enough now. I'm going to take my high BP pill and sign off.

Later, Dude