Practice Advice from Medical Economics

Attract New Patients by Writing a Newspaper Column

How to Hire Medical Office Staff

The Best Way to Communicate with Specialists

"Still a Privilege to be a Doctor"

Going Solo: One Doc, One Room, One Year Later. American Academy of Family Physicians, 06/2008.

To be updated as new articles become available.
Image source: OpenClipArt.org, public domain.

Updated: 06/24/2008

Video: Interpretation of Spirometry in Obstructive Lung Disease

In the Clinic - Dr. Cherry Wongtrakool, MD, Discusses the Interpretation of Spirometry Values in Obstructive Lung Disease


Video: Dr. Cherry Wongtrakool Discusses Interpretation of Spirometry Values in Obstructive Lung Disease. InsiderMedicine.

References:
Pulmonary Function Testing. Cleveland Clinic Disease Management Online Textbook.

Country Star Shares Experience with Daughter’s Food Allergy

The country star Trace Adkins participated in the NBC show The Celebrity Apprentice to win a donation of $250,000 to the Food Allergy & Anaphylaxis Network (FAAN) and raise awareness of the growing numbers of children with food allergies -- like his 6-year-old daughter, Brianna:

“She’s allergic to all nuts, all dairy and eggs,” says Adkins. “It’s something we deal with and have to be vigilant about on a daily basis. We have to keep the Benadryl, the Epi-pen, all that stuff."

There are three million school-age kids and 12 million people overall in this country today who have severe food allergies. It’s deadly. It can kill people,” Adkins says. “So I’m just trying to raise awareness of the extent of this problem.”


Trace Adkins on NBC

The 6-year-old Brianna is one of Trace’s advisers -- she suggested he release “Ladies Love Country Boys” as a single that turned into a No. 1 hit:


The official music video for Trace Adkins' "Ladies Love Country Boys" -- the little blonde girl who spots Trace in the alley at the end of the video is his daughter.


Eight top allergens account for 90 percent of all food allergies. See more Allergy and Immunology mind maps here.

Although Donald Trump ultimately "hired" his rival Piers Morgan, Trace Adkins achieved his goal by making many of the 10 million viewers of the show aware of the danger of food allergies.

References:
Amid Protest, Florida School Stands Behind Tough New Peanut Allergy Regulations http://goo.gl/joUsS - Little evidence to back this approach: http://goo.gl/59VKU

Related:
YouTube: Trace Adkins Meets The Backstreet Boys, learns what a "wheat grass juice" is and talks about the meeting in Trump's boardroom.
Interview: Trace Adkins' Family Talks About Coping with Food Allergies. AAAAI, 2009.

Interesting Journal Articles

Survey of physicians' approach to food allergy, part 2: allergens, diagnosis, treatment, and prevention. Annals of Allergy, Asthma and Immunology, 2008, vol. 100, no. 3, pp. 250 - 255, 03/2008.

Nonallergists differed from allergists in the diagnostic methods, using more leukocytotoxic tests, specific IgG4 tests, and intradermal tests, but fewer percutaneous skin tests (44.7% vs 98.9%), specific IgE tests (73.4% vs 97.8%), and challenges (61.1% vs 87.6%). Allergists were more likely to rely on elimination of proven food allergens and less likely to use conventional elimination diets, rotation diets, and sublingual or subcutaneous hyposensitization. Allergists were more likely to recommend a diet regimen during pregnancy (76.7% vs 35.3%) and lactation, breastfeeding, hydrolysate formulas (83.5% vs 64.3%), and withholding solids until the age of 6 months.

Asthma-related medication use among children in the United States. Annals of Allergy, Asthma and Immunology, 2008, vol. 100, no. 3, pp. 222 - 229, 03/2008.

Fifteen percent of all children were dispensed an asthma-related medication. Among children with an asthma diagnosis, 86% had a dispensed asthma-related medication during the 2-year study period. Among children without any asthma diagnoses, 10% had a dispensed medication. Fifty-nine percent of children with an asthma diagnosis were dispensed an anti-inflammatory medication within 90 days after a diagnosis of asthma.

Exposure to multiple indoor allergens in US homes and its relationship to asthma. JACI, Volume 121, Issue 3, Pages 678-684.e2 (March 2008).

Exposure to multiple allergens was common in US homes -- 51.5% had at least 6 detectable allergens and 45.8% had at least 3 allergens exceeding increased levels. Race, income, housing type, absence of children, and presence of smokers, pets, cockroaches, rodents, and mold/moisture-related problems were independent predictors of high allergen burden which increased the odds of having asthma symptoms.

Delayed allergic reactions to omalizumab: Are patients reporting all cases? JACI, 03/2008.

Omalizumab also successful in chronic urticaria. JACI, 03/2008.

Early clinical predictors of remission of peanut allergy in children. JACI, 03/2008.

Remission of peanut allergy can be predicted by low levels of IgE to peanut in the first 2 years of life or decreasing levels of IgE sensitization by the age of 3 years.

Does exhaled nitric oxide measurement help distinguish between wheezing phenotypes in preschool children? JACI, 03/2008.

Asthma progression: Can we and should we measure it? JACI, 03/2008.

See the picture on the JACI cover which depicts the 3 witches in Shakespeare's Macbeth conjuring up a brew of allergens, viruses, environmental pollutants, and genetics that might play a role in developing bad outcomes of asthma.

Vitamin D deficiency and asthma: Not a strong link—yet. JACI, 03/2008.

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.


Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Related:
Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education
Image source: OpenClipArt, public domain.

Delay in DPT vaccination associated with a reduced risk of asthma

Early childhood immunizations have been viewed as promoters of asthma by:

- stimulating a TH2-type immune response
- decreasing "microbial pressure," thus shifting the balance between TH1 and TH2 immunity


Th1 and Th2 subsets (mind map).

Canadian researchers found that among 11, 531 children who received at least 4 doses of diphtheria, pertussis, tetanus (DPT), the risk of asthma was reduced to ½ in children whose first dose of DPT was delayed by more than 2 months.



Mayo Clinic on Apr 8, 2011: Whooping cough. It's a bacterial infection that's risen to epidemic levels in some parts of the U.S. In adults, the symptoms can be mild, but if the infection is spread to a baby who hasn't yet received a full course of vaccinations, whooping cough can be very serious.

References:
Delay in diphtheria, pertussis, tetanus vaccination is associated with a reduced risk of childhood asthma. JACI, Volume 121, Issue 3, Pages 626-631 (March 2008).

Artist with Dermatographia Uses Her Skin as Canvas

"Using the blunt end of a knitting needle, Russell traces designs found on ancient Etruscan vases, the patterns in clothing and the wallpaper in her dad's dining room onto her skin."

Read more in Artist: 'I Use My Skin as a Canvas' by ABC News.

Related reading:

"Palmaris slapus abdominus" - more commonly known as dermatographic urticaria http://goo.gl/JMM6e
Dermatographic Urticaria (Skin Writing) http://goo.gl/5ykI8 and Flickr group
Taking dermographic urticaria and making it "art"  http://goo.gl/QEkYx
Urticaria: Brief Review. V. Dimov. Clinical Notes in Allergy and Immunology.
Mind Maps: Urticaria
Mnemonics: Urticaria
Image source: Wikipedia, public domain.

Make the Most of Annual Meetings of AAAAI and ACAAI

PalliMed offers some tips on how to make the most of a national conference -- any national conference, including the annual meetings of AAAAI and ACAAI.

References:

Make the Most of A National Conference - 4th Edition. PalliMed, 01/2008.

How to share up to 4 photos in a single Tweet buff.ly/1vTBSh1 - Great for conference posters - see example buff.ly/1vTC13L

Image source: OpenClipArt.org, public domain.

Sublingual immunotherapy (SLIT) for treatment of asthma

Sublingual immunotherapy (SLIT) is used for treatment of rhinitis but its efficacy and safety in asthma is currently not well documented.

A Chest meta-analysis included 9 studies with a total of 441 patients. There was a significant reduction in symptoms and medication use following SLIT.

The authors concluded that SLIT reduces both symptoms and rescue medication use in children with allergic asthma compared to placebo.

References:
Metaanalysis of the Efficacy of Sublingual Immunotherapy in the Treatment of Allergic Asthma in Pediatric Patients, 3 to 18 Years of Age. Chest. 2008; 133:599-609.
Editorial: Is Sublingual Immunotherapy "Ready for Prime Time"? R. G. Townley. Chest, March 1, 2008; 133(3): 589 - 590.
Sublingual immunotherapy is an extremely complex issue in the U.S. - AAAAI http://goo.gl/wVOKr

Safety of Long-acting Beta-agonists (LABA) in Asthma

A literature review published by Medscape looked at the safety of long-acting β-2 agonists (LABA) as mono- or add-on therapy to inhaled corticosteroids.

The 2 studies which showed an increased mortality with LABA allowed their use as monotherapy.

Currently, it is uncertain if the increased mortality is due to rare susceptibility to LABA or is a consequence of LABA monotherapy. The LABA monotherapy can potentially control the signs and symptoms of asthma while masking inflammation.

Hypothesis for LABAs' adverse effects:

M
Monotherapy
Masks inflammation
Mortality increase


Asthma classification and treatment for each stage. See more Allergy and Immunology mind maps here.

Update from Thorax 2012: Clearing the air: LABA/ICS reduce asthma hospitalizations, not associated with life-threatening events and deaths http://goo.gl/TesRp

References:

Safety of Long-acting Beta-agonists in Asthma: A Review. John Oppenheimer, MD; Harold S. Nelson, MD. Current Opinion in Pulmonary Medicine and Medscape, 03/2008.
In the News: Serevent-related deaths and CT scans as a cause of cancer. CasesBlog.
Risk of asthma exacerbations: Relative to SABA-only therapy, LABA use is associated with a lower risk of ED visit http://goo.gl/4sDc9
Image source: Wikipedia, public domain.
Note: The photo on the right shows a Seretide-labeled metered-dose inhaler (MDI). Seretide is the trademark for salmeterol in Europe.

Is allergy a systemic disease?

We tend to think of most allergic conditions as isolated diseases, for example rhinitis (nose), asthma (lungs) or urticaria (skin). But many patients with asthma have allergic rhinitis and vice versa. The hypothesis of "united airway" may extend beyond the airway according to the Norwegian researchers who think that allergy may be a systemic disease.

They found an association between adolescent allergic organ involvements (lung, nose and skin) and reporting of other health problems (headache, muscle pain and abdominal pain). According to the study authors, allergy may be expressed beyond organs commonly viewed as part of an allergic disease, and hence may support a hypothesis of a systemic nature of allergic diseases.

References:
Allergy: a systemic disease? The HUNT and Young-HUNT study, Norway. Elin Tollefsen, Arnulf Langhammer, Leif Bjermer, Pål Romundstad, Turid Lingaas Holmen (2008). Pediatric Allergy and Immunology.

What is the prevalence of allergic rhinitis in asthmatic children?

58.7%

In a French study of 404 asthmatic children aged 3–18 years, allergic rhinitis (AR) was diagnosed in 237 patients (58.7%).

Is AR a risk factor for the severity of asthma?
Presence of AR was not a risk factor for more severe asthma.


Allergic rhinitis mind map. See more Allergy and Immunology mind maps here.

Reference:
Allergic rhinitis in children with asthma: a questionnaire-based study. S. Hamouda, C. Karila, T. Connault, P. Scheinmann, J. de Blic (2008). Clinical & Experimental Allergy.

What is the best treatment for exercise-induced bronchoconstriction in children with asthma?

Exercise-induced bronchoconstriction occurs in many children with asthma. According to a Polish study, the best therapy for exercise-induced bronchoconstriction in children with asthma was budesonide plus montelukast or montelukast alone.

This randomized, double-blind, placebo-controlled study compared different antiasthmatic treatments to protect patients (aged 6 to 18 years) from exercise-induced bronchoconstriction.

A teadmill exercise challenge was performed before and after treatment. Exercise-induced bronchoconstriction protection improved in the budesonide + montelukast and montelukast groups compared with other therapeutic options (budesonide + formoterol, budesonide alone and placebo).

Leukotriene Receptor Antagonists (LTRA)

Antagonists of the CysLT1 receptor (LTRA) are efficacious as controller therapy in asthma and montelukast is FDA-approved for treatment of seasonal allergic rhinitis.

Mast cells quickly generate different mediators from the metabolism of arachidonic acid: leukotrienes and prostglandins (LTC4, LTB4, PGD2). These substances are produced within minutes of IgE-receptor crosslinking on the surface of mast cells.


Eicosanoids are signaling molecules made by oxygenation of 20-carbon essential fatty acids. There are 4 families of eicosanoids (PP-LT): prostaglandins (PG), prostacyclins (PGI), leukotrienes (LT) and thromboxanes (TX).


Mast cell mediators including (PP-LT): prostaglandins (PG), prostacyclins (PGI), leukotrienes (LT) and thromboxanes (TX). See more Allergy and Immunology mind maps here.

Exercise-induced bronchospasm (EIB) (click to enlarge the image):



References:
Effect of different antiasthmatic treatments on exercise-induced bronchoconstriction in children with asthma. Iwona Stelmach et al. JACI, Volume 121, Issue 2, Pages 383-389 (February 2008).
Mast Cells and Basophils. Allergy Cases.
Pathogenesis of Asthma. Allergy Cases.
49-year-old man with childhood asthma who was told he would never be able to do exercise runs a marathon every day for a year. CNN, 2011.
Image source: Wikipedia, public domain.

Food Allergy Symptom Checker by NHS

The National Health Service (NHS) in Great Britain has an interactive tool aimed to help people better understand the difference between food allergies and intolerances.

The food allergy symptom checker is available at: NHS.uk/Tools/Pages/FoodTool.aspx


Eight top allergens account for 90 percent of all food allergies. See more Allergy and Immunology mind maps here.

Related:
NHS Allergy Hub
National Health Service, from Wikipedia, the free encyclopedia.

Alcohol use may increase risk of allergic rhinitis and asthma

Many studies show a beneficial effect of moderate alcohol use on cardiovascular mortality but little is known about the alcohol effect on atopic diseases.

Alcohol consumption and risk of developing allergic rhinitis

A Danish study investigated the association between alcohol consumption and the risk of developing allergic rhinitis (AR) among 4,800 young women.

During follow-up, 14% of women developed seasonal AR and 9% developed perennial AR. Alcohol consumption (more than 14 drinks/week) was positively associated with the risk of developing perennial AR with an odds ratio of 1.78. There was no association between alcohol consumption and seasonal AR. Smoking, an activity often concurrent in people who drink, was not associated with an increased risk of developing AR.

The authors concluded that alcohol consumption was associated with an increased risk of developing perennial (but not seasonal) AR.

Alcohol consumption and risk of developing asthma

There is a U-shaped association between alcohol intake and risk of asthma, and the risk was lower for subjects with wine preference (Respir Med. 2011). The risk of new-onset asthma was related to overall alcohol intake in a U-shaped manner with the lowest risk observed in the group with a moderate weekly intake of alcohol (1-6 units/week). The highest risk of asthma was observed in rare/never drinkers (less than 1 unit/month), OR = 1.59, whereas the risk of asthma in heavy daily drinkers (more than 4 units/day) was also increased, but not statistically significant, OR = 1.13. The risk of new-onset asthma was lower for subjects with wine preference (3.3%) compared with beer preference (4.3%) or no preference (4.4%).

References:

Alcohol consumption and the risk of self-reported perennial and seasonal allergic rhinitis in young adult women in a population-based cohort study. P. Bendtsen, M. Grønbæk, S. K. Kjær, C. Munk, A. Linneberg, J. S. Tolstrup (2008). Clinical and Experimental Allergy.
Alcohol literally kills: Gary Moore had 380mg/dL in his blood, Winehouse 416mg/dL when she died surrounded by 3 empty vodka bottles. Telegraph UK, 2012
Intake of alcohol and risk of adult-onset asthma. Lieberoth S, Backer V, Kyvik KO, Skadhauge LR, Tolstrup JS, Grønbæk M, Linneberg A, Thomsen SF. Respir Med. 2011 Nov 28. [Epub ahead of print]
Alcohol Allergy - Medscape blog post, 2011.
Alcohol allergy? 1. Prick-prick tests with suspected drinks. 2. If negative, oral challenge test with increasing doses of the drinks should be performed. http://buff.ly/16uHYbi
Image source: OpenClipArt.org, public domain.

Google Gadget: Pollen Levels


Pollen Levels is a gadget for Google Desktop or iGoogle personalized page. It shows the 1-day and 4-day pollen levels for your zip code as given by Pollen.com.

Below are some of the user reviews:

"The pollen forecast really helped me prepare for my seasonal allergies. I was able to plan for when to take medication before my symptoms acted up. I can also check the pollen levels for when I'm traveling."

"Great tool! I have it set up on both my home and work computers, with each set to their local zip codes. It’s interesting to see the difference in the Pollen 4-day forecast between these 2 areas."

References:
Featured Gadget: Pollen.com - Pollen Levels. Inside Google Desktop, 02/2008.
Interactive Allergy Map by Greer Labs. Click your state to find region-specific, common airborne allergens there.