Not Everybody's Body Reads the Book

Medical textbooks have descriptions of classical ways that conditions and diseases present. Wheezing, coughing, chest tightness, shortness of breath are all attributes of asthma, but not all people with asthma experience these symptoms or recognize them as such.

Feelings of fatigue or lack of energy are relatively common (although not everyone with fatigue has asthma).

Often, people will limit what they do to avoid feeling out of breath. They don't describe this as "limitation of daily activities due to bronchospasm or uncontrolled asthma". They say: "I don't like to exercise." If asked why, they may explain: "I'm just not good at it...I get out of breath; I must be out of shape." Now it's true that being "out of shape" can cause such feelings as can many other medical conditions, but careful discussion , validated questionnaires (such as the Asthma Control Test) and objective lung function testing can help pick up asthma that may not have been suspected.

Why is diagnosing asthma important if the person experiencing it hadn't noticed anything wrong? Because people with asthma can suffer from decreased quality of life and health whether or not the asthma is recognized. Moreover, with recognition and proper management, these same people can (mostly) achieve a good quality of life with few or no limitations in activity and decreased risk of serious asthma attacks.

Time, reflection and history

Time and the importance of stories have been on my mind lately. As students, we were told: 85% of your diagnosis comes from the history --the patient's account of his symptoms and experiences. Although I have no journal citation for this pearl, it reflects the centrality of the history to the practice of medicine. The telling and exploration of the patient's story not only gives information which may lead to a diagnosis (although this is certainly important), but serves as a source of connection, understanding and healing. (N.B. I owe a good deal of what I know about Thomas and Percy, several WWII battles and the Raffles Hotel to these histories.) A good story takes time: to tell; to listen; to respond; and to reflect upon its meaning. When all goes well, the patient's narration and our subsequent discussion tell me her experiences, priorities, situation, environment and goals. I am then able to facilitate her understanding of the possible explanations of her experiences (a differential diagnosis) and together we work out of plan to move forward towards those goals. For me, this is not the work of 15 minutes.

Happy World Asthma Day 2009!

May 5, 2009 is World Asthma Day and this year's theme is "you can control your asthma".  May is asthma awareness month.  

Many folks with asthma put up with symptoms and decreased quality of life--including avoiding activities. All too many folks with asthma miss school/work or spend time in ERs or hospitals. About 4000-5000 people die from asthma every year. This is tragic, especially since most of this is preventable.

As an allergist and asthma specialist, I see quite a disconnect between my daily experiences and the grim statistics.  Most of the patients I see do pretty well once we figure out the right treatment approach. They lead active lives including--for some--extreme athletic events; we adjust our approach as needed and occasionally there are office visits for flaring symptoms. ER visits and hospital stays are things we discuss and (mostly) avoid.

I recently received an email with some interesting statistics excerpted from ACAAI Asthma Management--Better Outcomes at Lower Costs  regarding asthma specialists' care including:

45% decrease in "sick care" office visits:

77% reduction is amount of work/school missed;

77% reduction in asthma hospitalizations;

Reduction in costs (77% for ER costs, 95% for inpatient costs--is anyone in Washington listening...).

As I've said and written on a number of occasions, it IS possible to lead a full, healthy active life with asthma and I hope that this month more people living with asthma are empowered to do so.

Thinking about Swine Flu in the Peanut Gallery

A few thoughts about our most recent emerging infection with apologies for anthropomorphism and speculation to follow... Influenza viruses evolve/mutate pretty quickly and practice a type of "free love" exchanging genetic material (RNA in this case) usually when 2 strains are in an (usually non-human) individual at the same time. These may have been part of the back-story of the strain (or strains) of influenza currently dominating the news cycle. At least some of the recent ancestral strains seem to have come from pigs, hence the Swine Flu moniker. As with any emerging infection, there are many unknowns. It seems to me that 2 particularly relevant matters are immunity (or lack thereof) and virulence. It may be that this virus's genes and the resulting proteins are sufficiently different from previous strains as to render them unrecognizable to out immune systems. Then there is "original antigenic sin"; I don't know if this is a factor in this case, but I couldn't resist mentioning it. Virulence--how likely this flu is to cause serious illness or death--is still an open question although the preliminary reports from outside of Mexico are not alarming. (Even in Mexico, since we don't actually know the denominator...) Which Influenza A are you anyway? The current swine flu is an Influenza A H1N1, a quite different virus (immunologically speaking) from the seasonal human Influenza A which is still around as well. The classification and naming of influenza viruses can be confusing. I found a really nice easy-to-read article at arstechnica.com. Is it time to panic yet? In a word, no. (Although all those exhortations to remain calm may not be helping...) The new swine flu is sensitive to several anti-viral medications. Hand-washing, respiratory hygiene and other avoidance measures have significant roles to play in preventing the spread of infection. Interim guidelines have been posted by the CDC (cdc.gov--the link is on the home page) and are updated regularly. This is my preferred source of information and I highly recommend it.

Allergy and the First Pet

Like many of our fellow Americans, I have been avidly following the stories of the Obama family’s search for a dog. As an Allergist who often fields questions about “hypoallergenic” dogs, these reports have been of particular interest. Generally speaking, having a dog when allergic to dogs is a good news-bad news (bad news-good news?) situation. The bad news is that a hypoallergenic breed has not yet been found (more about this later). The good news is that dog allergy doesn’t necessarily bar one from having a dog. People who are allergic to dogs react to proteins found in the skin flakes and saliva. There are several known proteins from dogs that cause allergies (allergens) and others probably exist. The amount of protein (allergen) varies among individual dogs. A person with allergies to dogs may have more symptoms with one dog and fewer symptoms with another but this cannot be predicted based on the breed alone. I have not seen any studies of allergen levels of Portuguese Water Dogs. One study I do know of looked at levels of one of the major dog allergens across a number of breeds—including German Shepherds, Poodles, Cocker Spaniels, Labradors and a few others—and found that only the Labradors had an average allergen level that was statistically significantly lower than the others. But, before everyone runs out to get a Lab, it’s important to realize that the range of even the Labs overlapped quite a bit with the other breeds. (Ramadour et al. 2005. Allergy (60)8:1060-4—a link to the full text article can be found at pubmed.gov). In summary, there is more variation between individual dogs than between breeds. So, what to do if you’re allergic to dogs and really want one as a pet? In part the answer lies in how affected the person in question is (e.g. mildly itchy eyes vs. being hospitalized for asthma). For some people choosing another type of pet is probably the best way to go. Also, spending time with an individual dog prior to deciding to adopt it may give you an idea if that dog triggers allergy symptoms (although the environment in which these visits take place can be a confounding factor). For dogs that are already part of the family, there are measures to decrease exposure to the allergen (environmental controls): hand washing after petting; washing the dog weekly; washing the dog’s bedding in hot water weekly; using a vacuum cleaner with a HEPA filter and wearing an appropriate mask; and having a “dog-free” zone at home that includes bedrooms, carpeted areas and upholstered furniture (especially the bedroom). (ACAAI.ORG has tips for many environmental controls; look for the Allergy HOME link under patient education.) Nasal saline washes (for nasal and sinus symptoms), medications and allergen immunotherapy are some of the therapy options for the allergic dog lover. (AAAAI.ORG has drug guides for allergy and asthma medications; decisions about which medications are right for you are best made with your doctor.) One of the most important steps is to get a correct diagnosis, which isn’t always possible from history alone. Allergist-Immunologists (or Allergists for short) are physicians specifically trained to diagnose (including choosing the right tests and interpreting the results) and treat allergies including allergic asthma. (Find out more about Allergists at AAAAI.ORG and ACAAI.ORG). Many people with allergies can lead healthy active lives with symptoms controlled by the right combination of strategies and treatments. As for the Obama family and the new First Dog, may they have many good years together and may Malia’s allergies be well controlled. (Note: I have no first hand information about Malia’s allergies, just what I’ve seen on the news.) Although this is a post about dogs, it is spring and I wish everyone a happy, healthy (symptom-free) season. (Disclaimer: this blog is for informational purposes only and should not be used in place of a physician’s evaluation and care.) Copyright 2009 Rebecca G. Piltch, M.D.