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Farewell to Pontiac

 

I write this entry with a tear in my eye. In the Sunday Indianapolis Star I read the following story ‘Alas, the Pontiac- R.I.P..

My 1967 Lemans-May 3, 2009

Mr. Dan McFeely noted on the next line that ‘Aficionados lament General Motors’ decision to end production of the brand now likely to be a hot classic’. The obituary noted that GM life support for Pontiac was pulled on April 27^th, 2009. Pontiac (nee the Oakland Motor Car Company) was born in 1926 in (appropriately) Pontiac, Michigan. Pontiac was the proud parent of GTO, Firebird, Catalina, Grand Prix, Bonneville, the Chief, the Star Chief, Fiero, and my beloved Lemans (just to name a few ).

I  owned a 1967 Pontiac Lemans convertible in 1973. I had that car for six months before it became car number five in a six car sandwich. The car was totaled in April in Cleveland, Ohio. I never had a chance to put the top down and enjoy it. I owned it for six months of which only one month was considered spring (I lived in Cleveland at the time).

In 2001 I thought I had seen a ghost. Appearing on the internet was the exact same car. It was the same color, the same year, the same make, the same everything. It was for sale in Southern California by its second owner who enjoyed driving the car to the beach with his surf board in the back.

Friends of mine looked at the car and I made the purchase. For the past eight years I have an exact copy of my 1967 Lemans (as I remember it from 1973).

I am sure you have all heard of the GTO and perhaps not so much about the Lemans. The Lemans has been called the poor man’s GTO. It has a very similar shape and look. This is my toy.

1967 Pontiac Lemans and home.                                                       

 

 1967 Lemans – top down and ready to go cruising for burgers.

No 1967 muscle car would be complete without a hula girl on the console. This was courtesy of ‘Old Blue’s’ previous owner.

Fred Leickly

Teaspoons vs. milliliters- It does matter!

I receive the journal Contemporary Pediatrics. I have found the articles to be very practical for everyday use. For the most part the authors are reviewing a specific topic of interest. An author will condense a large volume of literature into a very readable format. Back in the day, I was asked to write an article about chronic hives for Contemporary Pediatrics.  I titled that article ‘When the road gets bumpy, chronic urticaria’.  I enjoy reading Contemporary Pediatrics and I have used interesting findings in this blog (see my note on the ’Patient History’)

I always scan the articles and a while back I came across a little quip that caught my attention. It made me wonder about the many times I had suggested using a teaspoon measure of medication.

When we prescribe medications we all have the tendency to use the teaspoon/tablespoon measure of delivery. Our assumption is that a teaspoon is five milliliters (mls) and a tablespoon is three teaspoons so that would equate to 15 mls. The question was asked whether or not teaspoons are standardized. I discovered that they clearly are not and the use of teaspoons for dosing could lead to more overdosing as opposed to under dosing.

So the question is, do you use mls or teaspoons?

The article was amazing- It was a clinical tip about the timely death of the ‘teaspoon’ at least for giving medications. The work was done by Alvin N. Eden, MD, and Mohammad Mir, MD Department of Pediatrics, Wyckoff Medical Center Brooklyn, N.Y. and appeared in the November 1, 2008 Contemporary Pediatrics.

The background is that more than 50% of liquid preparations given to children are written as a number of teaspoons. This small research project looked at the volume of 53 teaspoons brought in by physicians, nurses, and the receptionists at a general pediatric practice. Only one of the teaspoons actually measured 5 milliliters. The range was 4.3-12.9 mls! Based on these findings, using the tsp format could result in overdosing by 2.5 times the intended dose.

This made me think about the use of oral steroids for our children who have a flare of their asthma. The medications are 15 mg per 5 mls and the dose would be 2 mg/kg of body weight per day. If a teaspoon that measured 12.9 mls was used, then 38.7 mg were given and not the intended 15 mg!  Steroid side-effects could occur due to the over-exposure via generous teaspoons.

Due to this extreme variability in volume and the chance of an overdose, the milliliter format was suggested as the proper way to administer liquid medications.

Go metric- ask for how many milliliters and use the proper dosing apparatus.

 

Fred Leickly

Evidence-Based Medicine

Physicians Practice is one of those many journals that finds itself on my desk. I usually browse through the articles while enjoying a quick lunch. I am on the subscriber list due to my connection with the Indiana University Medical Group. The journal deals mostly with practice management which is great for someone in private practice. In February of this year Physicians Practice did published a case report that I wrote. The case involved the critical role allergy has in asthma diagnosis and management. For the most part this journal has articles about electronic medical records, coding, dealing with health insurance companies and so on. Many of these topics are interesting, but do not have a direct impact for someone working in an academic center. However, the April edition of Physicians Practice has a very interesting article (page 26) on ‘Evidence-Based Medicine’. The attention getting statement certainly made me take a look, “Evidence-based medicine has been around for 16 years. So why are some physicians still resistant to it? And how can you make it work for you?”

Evidence-based medicine (EBM) tries to provide a framework for treatment that is supported by the latest proven research. The article talks about this enhancing a medical practice. I think that patients and families should be aware of EBM. I can see value of EBM in the practice of allergy by board-certified allergists especially in an environment where the label of ‘allergy’ is given too loosely. In my practice I am seeing conditions labeled as allergy (apraxia, autism, sensory integration defects, ADHD to name a few) because tests for allergy return as positive. Many times the clinical condition and the test has nothing to do with allergy. IgG to food would be a prime example. I have seen significant amounts of money spent and hopes of families dashed by the use of tests and therapies that are not evidence-based.

The EBM approach first asks a very specific clinical question. The question could be about a test, a treatment, a diagnosis, or an outcome. Next the literature is searched for information on the topic. The information is then evaluated to see if it is valid, useful, and related to the question. The review of the literature looks critically at many different aspects of the scientific studies. The numbers, the methods, and the statistics are evaluated. The EBM may conclude that there exists type A evidence (great supportive studies in a large number of patients) that a treatment is effective.

Other support for diagnosing and treating can be found in ‘Guidelines’ . Many specialty organizations offer guidelines for common clinical conditions and the guidelines will incorporate EBM.

Resistance to EBM stems from concerns that it is a cookbook approach to medical practice. Another issue is how can a busy practitioner  integrate EBM into a practice. The article provides ideas and links for the practitioner.

Now the journal also had an excerpt from an article written by D. Isaacs and D. Fitzgerald that appeared in the British Medical Journal a few years ago (BMJ 1999;319:1618) that poked a little fun at EBM. What follows was the results of a poll that asked physicians what they would do if there was no solid evidence in the literature to help with a clinical decision. The article was titled, “Seven alternatives to evidence-based medicine”. This made me smile.

1. Eminence Based Medicine- The more senior the person, the less need for evidence. Experience outweighs evidence. Faith in clinical experience was defined as making the same mistake with increasing confidence over an impressive number of years.

2. Vehemence Based Medicine- Substituting volume for evidence as an effective technique for brow-beating a more timid colleague.

3. Eloquence Based Medicine- The perennial sun tan, carnation on the Armani suit, the silk tie accompany a tongue as equally smooth. Tailored eloquence and verbal eloquence are powerful substitutes for evidence.

4. Providence Based Medicine- If the caring practitioner has no clue what to do next, the decision may be best left in the hands of the Almighty.

5. Nervousness Based Medicine- The fear of litigation is a driving force for more tests and excessive treatments.

6. Confidence Based Medicine- Restricted to surgeons

Now I am puzzled- the quip in Physicians Practice said seven, I count only six. This second article ended and I could not find that seventh alternative. Finally, I found the original article at the Ruth Lilly Library on OVID. Here is number seven.

7. Diffidence Based Medicine- Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor’s pride to do nothing (BMJ, 1999).

That was the original article on alternatives to EBM. Now it gets even better. Others have added to this list, we now have the following alternatives; Effervescence Based Medicine, Webidence Based Medicine, Profit Based Medicine, Annoyance Based Medicine, Propaganda Based Medicine, and Arrogance Based Medicine to name a few. We see a significant amount of Webidence Based Medicine. I urge caution with the internet. Look to sites sanctioned by well known organization- the American Academy of Pediatrics, the American Academy of Allergy, Asthma, and Immunology, the Food Allergy and Anaphylaxis Network, the National Institutes of Health, the National Heart, Lung, and Blood Institute to name a few. Profit Based Medicine – as a personal word of caution, ask about insurance coverage. Your insurance may not cover something because it is experimental or without EBM to support what is done. There is usually a reason why something is not covered by insurance. Ask about it.

I do my best to abide by evidence- based medicine. It makes sense to me. Evidence for my diagnosis, evidence for my selection of tests to help with that diagnosis, and evidence for the best treatment for the condition. Medicine is changing all the time. EBM helps evaluate what we have done and helps to consider what we need to do for the benefit of those we are taking care of.

Fred Leickly

Food Allergy Avoidance

Why food allergy avoidance may be difficult in some children.

This is my granddaughter Stella. Stella is about to celebrate her first birthday this week. Her dad took this picture (I found it on his flickr site) and it is precious. It made me think of how avoidance of foods by those allergic to them may be somewhat difficult especially for curious and mobile toddlers.

Cheerfully submitted,

Fred Leickly

Practical Pediatrics- Providence, Rhode Island April, 2009

I had the chance to moderate a course given by the American Academy of Pediatrics (AAP) last weekend. For many years I had the role as a speaker for these programs. These are great opportunities for primary caretakers, pediatricians and nurse practitioners to hear some very practical approaches to common problems in pediatrics.

Providence, Rhode Island was the host city for this Practical Pediatrics offering. In early April Providence does not have a lot going on. The weather was wet and cold. This kept us indoors. The seafood and Italian food were great! I also recommend the IMAX 3-D movie Aliens vs. Monsters. Despite the inclement weather, I did learn a few new things and learned to appreciate many other aspect of care for our children.

Dr. Martin T. Stein, Professor of Pediatrics at the University of California, San Diego shared a few thoughts on pediatrics in general. He presented things that made me stop and wonder about the incredible job that is done by healthcare providers that look after our children. Did you know that for well child care the recommendation is for 31 visits? Back in the day (okay, 1974) only 14 well child care visits were the standard. I am sure this increase is due to the need for guidance, safety, development, and prevention. It makes our pediatricians busier. I also learned that our children benefit from a level of primary care above what is offered in other countries. The United States is the only country where board certified pediatricians provide that essential well child care. I have always held our pediatricians in high esteem. I learned a few things that have increased my respect for them and for what they do.

I learned a few more things about allergy and had a few of my standard issues emphasized by Dr. William T. Boleman, who is the Chief of Allergy at the Keesler Medical Center (USAF) in Biloxi, Mississippi.  I learned that controversies in allergy are not at all unique to Indiana. Mississippi seems to be affected by theories, practices, and therapies done under the name of allergy, but clearly without a shred of evidence that allergy accounts for the problem. Dr. Boleman talked about sugar, wheat, yeast, chemical, electromagnetic radiation, hormones, and voodoo allergy testing including IgG antibodies to foods. One of his messages was to be sure that the story matches a condition in which allergy may be a cause. History taking remains an essential part of any allergy evaluation.

I have always enjoyed listening to the dermatologists. Their lectures are replete with pictures and practical information on a wide variety of things that can affect our skin. Dr. Miriam Weinstein from Toronto Sick Children’s hospital shared her opinion on a condition that is often seen by both the allergist and the dermatologist. That condition is atopic dermatitis, a form of eczema that has associations with allergy. I was surprised and concerned after the talk on evidence-based therapy of atopic dermatitis. She had pulled references from the dermatology literature. The evidence-based review is a critical summary of good and bad studies. One of my courses in the public health program actually taught us how to critique one of these reviews. It is quite an art to go over a vast literature looking for answers to specific questions and making sure that the methods used to get that answer were without any flaws.

The things that I learned and what I thought would be very helpful for the children I see with atopic dermatitis in my allergy practice include the emphasis that it is not just one thing such as a food that will trigger a flare of itchy, dry, flaky skin. There are many different reasons for the condition to flare and sometimes it just happens. When we discover something like a food that could trigger that is great because there is one less thing to worry about.

We also need to keep the skin as moist as possible. Moisturizing the skin can be considered front or first line therapy. These children need to be so slicked-up that they just slide through your fingers.

Using the topical steroid ointments once a day may be just as effective as using them twice a day and using them a few times during the week even when the skin is clear may help keep the skin from flaring.

I now emphasize that the use of the anti-histamines is not so much for the itch component of the skin, but for sedation. A significant amount of scratching of the skin occurs during the night. Helping with sleep by taking advantage of the sedative aspects of antihistamines makes a difference. Choices here would be agents like Benadryl or preferably Atarax (Hydroxyzine).

Skin infection needs to be controlled. The scratching and breakdown of the skin leads to infection. The infected skin then causes further scratching and misery.

Also, contrary to what an allergist would like to believe, being allergic to house dust mites and consequent house dust avoidance techniques may not make any difference in controlling flares.

Food allergy may not be the cause of many of the flares. Unfortunately these children have many positive skin tests and the track record is that the positive predictive value of the food test is about 50%. So when the allergy test for food is positive, there is a 50/50 chance that it is relevant and that exposure to that food causes a flare of the skin. Of all the foods that have been associated with flaring, egg is the most common.

It is important to keep learning new things, new perspectives, and be open to changes that may be of benefit to our patients. Hopefully a few of these tidbits may help.

Fred Leickly

Highlights from the 2009 Allergy Meeting

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

Waivers as a Prescription 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.

Possible Environmental Peanut Exposure (Photo courtesy of Linsey B. Knerl)

 

 

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