A voice for reform in the field of allergy...You're entering the no-spin zone of the Renaissance Allergist...Straight talk by an allergist seeking reform in his renaissancepicture3.jpgprofession and a renaissance in the field of allergy...

 

The Cup

The old woman peered around the corner and looked into my office...

"Dr. Kroker", she said, "could I bother you for just a moment?".  Her eyes looked at me expectantly.  

I asked her to come in.  What happened next was something I didn't expect...

"I have something for you..." she said, and handed me a cup to take.

"This cup is something my son wanted to give to your mentor, Dr. Randolph, but since he passed away he asked that it be given to you, since I know you trained under him for 3 years..."

"There is a story behind the cup", she said.  A long time ago, when my son was in high school,  he was quite sick.  He couldn't concentrate, and struggled with his grades.  The school guidance counselor met with us, and in "so many words" essentially said he "wouldn't amount to much" and that pursuing any higher education for him was simply out of the question.  He remained quite ill.

Then we took him to Dr. Randolph.

"After his allergies were discovered and he was treated, he was a different person.  He graduated from high school, and eventually went overseas for study and earned an advanced degree at Cambridge. He's successful and happy in his chosen field.  Dr. Randolph changed his life.  And he wanted to thank him."

I took the "Cambridge Cup" from her, and as I held it, a flood of memories came back to me of my tutelage under Dr. Randolph.  It's fashionable in medicine to think that "if it hasn't been published in the last 10 years, it hasn't been discovered". This short-sighted mind-set has caused many allergists to overlook  Randolph's work and to miss the sheer genius of it and to fail to realize that many questions and concepts in allergy were addressed by him, years ahead of its time.  

In particular, Randolph was so well aware of undiagnosed allergies limiting school performance that he presented a paper on the subject to the Annual Meeting of the American College Health Association in 1951:  

Randolph TG:  Allergic Ills Limiting Student Performance.  Proc 29th Ann Meeting Amer College Health Assn 31:46-48, 1951.  

But there's more.  A whole lot more  In the 397 (yes, that's right, 397) papers and publications he wrote over his lifetime, many were seminal and breakout papers.  A few brief examples of "concept papers" he published 

The link between food allergy and migraines?  Randolph wrote about it in 1935:

Sheldon, JM, Randolph TG:  Allergy in Migraine-like Headaches.  Amer J Med Sci 190:232, 1935.  

The link between allergy and unexplained fatigue?  Randolph wrote about it in 1945:

Randolph TG, Hettig RA:  The Coincidence of Allergic Disease, Unexplained Fatigue and Lymphadenopathy:  Possible Diagnostic Confusion with Infectious Mononucleosis.  Amer J Med Sci 209:306-314, 1945.

Randolph TG.  Fatigue and Weakness of Allergic Origin--to be Differentiated from "Nervous Fatigue: or Neurasthenia.  Ann Allergy 3:418-430, 1945.  

The link between allergy and behavioral problems in children?  Randolph wrote about it in 1947:

Randolph TG:  Allergy as a Causative Factor of Fatigue, Irritability and Behavioral Problems of Children.  J Pediat 31:560-572, 1947.

Randolph's discoveries influence my practice of allergy on a daily basis. As an example,  I had been recently communicating with a patient's mother regarding corn allergy, and advised against corn-based IV's because the dextrose component is corn-based and can cause problems.  And Randolph?  He know about this in 1950 and published on it:

Randolph TG, Rollins JP, Walter CK.  Allergic Reactions following intravenous injection of Corn Sugar (Dextrose).  Arch Surg 61:554-564, 1950.   

Randolph wasn't interested in monitoring Peak Flows.  He was interested in Peak Life  To him (and me) the field of allergy is so much greater than the respiratory tract.  Renaissance Allergists recognize this, and practice accordingly.  

...And the cup?  To me, it represents what a true Renaissance Allergist can do to transform a patient's life. On a larger scale, it also symbolizes the  Holy Grail of Allergy-a treasure of healing once possessed, and now lost to the average allergist.  

And I hope our allergy societies can search for it.

And find it.  Again.  

Later, Dude

 

 

 

 

 

Goals...

Without goals, and plans to reach them, you are like a ship that has set sail with no destination...

--Fitzhugh Dodson

A patient's eyes tell a thousand stories...when I walk in an exam room it's the first thing I tend to notice about a patient.  In Mary's case, they were filled with despair...

"I've had these hives for 2 years, and nobody can seem to give me an answer as to why they occur", she told me.  She told me about the unexpected and frightening trips to the emergency room.  

Then, unexpectedly, her eyes abruptly changed.  They flared.

With anger.  

"You know, my doctor told me HIS goal was to manage my hives to keep  me out of the emergency room."  That wasn't MY goal at all--I wanted to find out the CAUSE of my hives."  

Patient-centered goals:  something we don't emphasize enough when we see patients for their initial visit. I had an interesting experience recently--When we recently had a team of coders here at our office, to help us properly "document" a patient's visit in order to get the best insurance reimbursement, it was once again emphasized how critical it was to have the patient's "chief complaint" listed in each and every initial workup.  

When I asked the coders about the importance of having a patient's goals documented--i.e., whether that was deemed important for insurance reimbursement and coding, I merely received a "deer caught in the headlights" blank look.  Truth be told, the patient's own goals are not even counted as a critical part of an exam for insurance reimbursement.  A chief complaint, pertinent history of illness, review of systems, family and social history, thorough physical exam, and review of outside records are all deemed important.

But not the patient's goals.

They don't make the cut.

And, in my opinion, that's outrageous.   

Why is it important for an allergist to list a patient's goals?

First, we may find that (as doctors) what we ASSUMED the patient wanted to accomplish is not what they wanted to accomplish at all.  This was the case in Mary's own tale.  And I've experienced it myself on more than one occasion...

Example:  one woman came into our office to see me with the "chief complaint" of chronic hoarseness. But her goal?  To be able to sing in her church choir.  In my own mind, succeeding in the latter issue was just as important as succeeding in the former.

Secondly, having a goal established allows us to work towards health with a fixed directive in mind.  As Basil S.  Walsh said, "If you don't know where you are going, how do you expect to get there?"  As I've worked with a patient over time, it's a mutually satisfying experience for myself and my patient to look back on the first office visit, and to celebrate the goal(s) achieved.  

Thirdly, finding out what a patient's goal(s) are on their first visit is important, because sometimes their goals are simply unrealistic.  Having a frank and open discussion, and reformulating goals is then necessary, and prevents alot of future frustration.    

Fourthly, some patient's simply haven't consciously thought of a goal they want to achieve from their consultation.  It is our job to help define a set of mutually agreed upon goals, and then to work towards them...

In my opinion, one of the biggest problems in the allergy field today is the marked discordance between patient-centered goals, and the often unspoken goal of the allergist himself/herself.  Our goals?  "Let's control the asthma" "What's the best inhaler to use?"  "Let's see if this is an IgE mediated allergy, and if not we've done our job?"  "What's another drug I can try on this patient with allergic rhinitis".  The list goes on.  And we rarely see if our own goals match up with our patient's goals.  We usually don't even bother to ask.  Is it because we're afraid?    

It's been my experience that most patient's are like Mary.  They want to accomplish 3 things:

1.  Get to the bottom of what's causing their symptoms.  They've been given the drugs, and they want more...

2.  If possible, be given a disease-modifying treatment (like SLIT) and not simply symptomatic control. 

3.  Get on with their life, and accomplish personal goals XYZ.  

In Mary's case, I verbally acknowledged that we were in agreement on the goal she had--namely, find out what was the cause of her hives.  And with a little detective work, aided by a computer search, we found that the chronic hives were likely caused by a change in medication right before the onset of her problem--all it took was some time and patience, and not a knee-jerk reaction to try another antihistamine on her...  

As allergists, we need a Renaissance in our field.  Not only should we ask every patient what their own goals are for each and every visit to our offices, but we should take a hard look at our own goals for patients when they see us...  Are our goals compatible with our patient's goals?  

In short, can we deliver what our patient's want?

Now that's a goal worthy to have.

Later, Dude 

 

 

 

Posted on Saturday, May 28, 2011 at 07:21PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments2 Comments

The Allergy-Mood link 

I sat stunned in my office chair.  Across from me was my new patient John.  A moment ago I was explaining his skin test results to him. Then suddenly--completely unexpectedly--he burst into tears, and told me he had an overwhelming feeling of depression, "just like I have when I'm in my basement".  As tears rolled down the big man's cheeks, he apologized profusely for what he thought was a "stupid" emotional show, but he simply couldn't help it.  He told me he wasn't upset with my findings.  In fact he was happy someone could come up with an answer.  

But that didn't help his sense of overwhelming depression.  

He had just had skin testing for allergens, and had strong immediate reactions to multiple mold antigens.  When I had initially seen him for his intake history, he struck me as a matter-of-fact business man in a nice business suit who "had it all together".  He told me he had a business at home, and (happily because his internet business was fluorishing) he had to move to less cramped quarters, and moved his computers and hardware from his upstairs location to his musty basement.

The longer he was in the basement, the more sinus congestion he had.  THAT was why he came in to see me.  But upon talking with him further, he had a sense of overwhelming, inexplicable depression that he had never experienced before, and made no personal sense to him because "everything else" was going fine in his life. He couldn't understand why he felt so depressed, even when he was meeting with increasing success in his business.   

In a sense, I was seeing two completely different people today: 1.  John before allergy testing and 2.  John after allergy testing.  The results couldn't have been more dramatic....

One of my fellow colleagues pointed out to me a recent story on CNN.COM called "Sad in the spring?  Allergy-mood link is real".   I recommend reading it.  

Having been a practicing allergist for nearly 3 decades, I think allergies can affect mood two ways:  indirectly AND directly.  

Certainly, the average seasonal allergy sufferer can be more tired, irritable, and depressed during the allergy season because of their chronic recurring symptoms.  That is something we see over and over again in our practice.

But less frequently--but more dramatically--I think I see patients like John who have a direct dramatic effect of an allergen on their mood.  In John's case, he had the onset of severe depressive symptoms (without a preceding history) that correlated with some sinus congestion on moving into a basement environment.  Over the years, I have found that certain allergens seem to do this with greater frequency than others.  In particular, mold, gluten, and Candida sensitivities would head the list as causing a "primary" allergic depressive response, but in reality nearly any other allergen can do it, such as corn and dairy for example.  I have had patients with a so called "primary" allergic depression be able to go off of anti depressants successfully, after years of incomplete and disappointing help beforehand.  (One patient I had seen who turned out to be  severely gluten intolerant had been making arrangements for her burial just before seeing me because she was so depressed and exhausted.  Now she is fine, off anti depressants, and has made referrals for her daughter, son-in-law and grandchildren here at the clinic.)

Am I the only Allergist who has postulated a direct connection between mold exposure and mood?  Not by a long shot.  When I was lecturing several years ago, I was in Manchester England.  The late Dr. Keith Eaton, one of the earliest menmbers of the British Society of Allergy and Clinical Immunology and a physician of impeccable credentials and reputation, excitedly came up to me and asked (as if to affirm his own belief)   "Do you think mold allergy can (directly) cause depression?"  

One of the ways we can truly have a Renaissance in the allergy field is to be more cognizant of this mood-allergy link in our patients, and determine if it is a direct or indirect link. The respiratory tract isn't the beginning and the end of allergy.  It is just the starting point for a thorough and comprehensive allergy evaluation.  We aren't treating lungs.  We're treating patients. 

In John's case, the story turns out happily...he is now out of the basement, on SLIT immunotherapy, and couldn't be happier--even though he is back in his more cramped quarters upstairs.  Allergy?  Depression?  A link?  If you don't think there is, for goodness sake don't tell John.

He's a big guy.  And--believe me--you don't want to make him angry.

Later, Dude

 


Posted on Sunday, May 1, 2011 at 03:11PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments2 Comments

The Ophthalmologist with the Critical Eye

 

The most beautiful thing we can experience is the mysterious. It is the source of all true art and science.
Albert Einstein

Sometimes it just doesn't get any better...I was sitting in the living room, a quiet fire going in the fireplace, and a beautiful view of the lake.  Sitting next to me was one of my closest friends, a brilliant ophthalmologist from a large Midwestern city.  There is nothing I enjoy better than talking to Steve.  As usual, our conversation meandered through a wide range of topics.  Then, somewhat unexpectedly, he said 

"You know, before I die, I would really like to find the cause behind uveitis and pars planitis".  "I sure suspect some of it is environmentally triggered."  He went on:

"I have talked to all of the local allergists near where I practice, but you know what?"  

"They're boring".  

"What do you mean?"  I said.  

"They're boring--they're just interested in asthma, and nothing else. If they even sense it isn't IgE mediated, they're out of the picture".  

Frankly, his comments are a spot-on indictment of the narrow-mindedness of our profession.  We won't look beyond the end of our albuterol inhaler.  Is he crazy to think their might be an environmental trigger to uveitis?  

I don't think so.

About a third to a  half of the cases of Uveitis, (inflammation of the uvea) have an unknown cause.  Old time allergists such as Albert Rowe, writing in their classic text on food allergy  suggested that food reactions could be the cause of some cases (and presented case reports in support of this)  but complained of the lack of referrals from ophthalmologists to give them more experience in the matter.  

There is medical literature supporting the fact that English Walnuts can exacerbate Behcet's syndrome, a condition often associated with uveitis.  Marquardt et. al. wrote a paper entitled "Depression of lymphocyte activation and exacerbation of Behcet's Syndrome by ingestion of English Walnuts."  Steve mentioned that the recurrent uveitis experienced by one of his professional colleagues each Thanksgiving was "cured" by stopping the ingestion of walnuts on that holiday.  

But there's more.  Uveitis peaks in the spring, according to Dr. Samir Tari, the lead researcher in the study.  This possible seasonal linkage needs to be further investigated.  

Finally, there is an intriguing link between autoimmune uveitis and antigenic mimicry of environmental allergens.  In the article "Autoimmune uveitis and antigenic mimicry of environmental antigens", Dr. Gerhild Wildner and Dr. Maria Mohring make the point that one mimicry antigen is from rotavirus, a common pathogen causing gastroenteritis, and another mimicry antigen is from bovine milk alpha-2 casein.  Lewis rats developed uveitis after immunization with both mimicry peptides and casein protein.

Their "take home message"?  

" Breaking oral tolerance to food antigens or defensive immune responses against pathogenic epitopes both mimicking autoantigens are potential initiating events for autoimmune diseases like uveitis"

Oh, and one more thing--just check out a few message boards on the web regarding people suffering from uveitis, and their anecdotal stories regarding environmental triggers.   In my opinion, there's a "smoking gun" here...and precious few people are interested in the connection...

So, could a GI rotavirus infection and casein ingestion trigger a Th1 aberrant response (not Th2) and participate in the initiation of uveitis in susceptible individuals?  I don't know.  But I do know I am "following" some of my patients with non-IgE mediated food sensitivities and uveitis...with very interesting results.  

But my main message...a specialist outside of our own allergy field makes the discovery that allergists are "not interesting people"

They're boring.

And why?  Because we are so narrowly focused on the respiratory tract that we simply aren't interested in anything else.  

And that, my friends, is not only boring...it's tragic.

To have a Renaissance in our field of allergy, we need to break the shackles of artificially demarcating our field to one organ system, and (like our infectious disease colleagues) realize that our field is system wide.  

And that's not boring--that's exciting!

Later, Dude

 

 

 

Posted on Friday, April 1, 2011 at 03:47PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments6 Comments | References2 References

The Question


The young allergist walked out of the exam room...the picture of Mrs. Shelby was fresh in his mind--a young mother afraid of her increasing asthma...but the picture faded away, and was replaced with

                                               The Question

Everytime he saw a new patient, the Question loomed in the foreground, like the dark clouds of an overwhelming storm, and threatened him with dark foreboding.  What was he to do with The Question?  His best teachers had not prepared him for it.  He had gone through 4 years of medical school, a year of internship, 3 years of residency, and 2 more years of fellowship, and hadn't really had to face The Question seriously.  It wasn't deemed really relevant to his education. Until now. Now it had morphed until an ugly specter that swamped his thinking about each patient.  So he began to study it, asked his most knowledgeable colleagues for a concrete answer to it, and even called in so-called "experts in The Question" to help him answer it better.  But it was always the same. 

 

The Question was sometimes hard.  

The Question was sometimes impossible to answer.

And everytime he answered The Question, a haunting voice in the back of his mind would whisper, "Have you truly answered The Question correctly?

Sometimes he really didn't know if he had...

Everyone wanted to know the answer to The Question.  He thought again of Mrs. Shelby.  It would affect her.  In fact, it would affect people that he hadn't even seen.  People miles away.  Was this what he had studied medicine for?  To become a specialist in Allergy, and have to face The Question?  

And he had to face The Question.  Everytime he walked into a room with a new patient.  Everyone was affected by The Question.  All were influenced.  No exceptions.  

He even found he was beginning to think about The Question as he would examine a patient.  He always tried to push it from his mind.  Some people thought if you could answer The Question correctly, then you were a "good doctor". But he knew better.  It was a lie.  


It seemed that more and more time was being devoted by people--people he never knew or met--who criticized his answer to The Question.  Sometimes his answer to the question was deemed "wrong" and he was left puzzled, frustrated, and occasionally just plain angry. And impotent.   

So as he left the room, the image of Mrs. Shelby gradually faded from his mind.  Her concerns seemed less important, the distress she was in seemed almost immaterial.  She wasn't important--at least not compared to The Question: 

     Should he code her as a 99203 or 99204?

Later, Dude

 

Posted on Saturday, March 26, 2011 at 04:10PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment