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Conference Speaker: Kelly Barta, Author of “To Eczema with Love: Eczema, Topical Steroid Withdrawal, and a Life Beyond”

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Kelly Barta

Kelly Barta, who has previously appeared on this website, is a survivor of topical steroid addiction and withdrawal. We don’t use word survivor lightly. In her book, Kelly chronicles her eczema from childhood (when she was called “elephant man”) to her harrowing experience with an iatrogenic disease (caused by treatment) that took a terrible toll on her family life as an adult. As if this powerful autobiography weren’t enough, the book is also a detailed guide to the disease and to treatment. Past president of ITSAN (International Topical Steroid Addiction Network) where she still serves as a board member, Kelly currently serves as president of the Coalition of Skin Diseases, an umbrella organization comprised of more than 25 national skin-related patient groups, which exists to raise awareness of skin diseases and advocate for the 84+ million Americans living with skin conditions. She also sits on the Patient Advocacy Task Force of the American Academy of Dermatology and the Atopic Dermatitis Advisory Panel for Globalskin.

Henry Ehrlich

To register and/or make a donation click here.

Conference Speaker: Dr. William R. Reisacher, inventor of toothpaste for allergen immunotherapy

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William Reisacher, MD
Our first speaker on July 24 will be Dr. William R. Reisacher, professor of Otolaryngology of Weill-Cornell Medical Center in New York City. This website has been following Dr. Reisacher’s invention, Intrommune for years as it makes it way through the labyrinth of clinical trials as an alternative to OIT and SLIT. Like many other novel medical ideas, Intrommune sprang from a Eureka moment, which Bill described in a Q&A we conducted in 2018:

My “eureka” moment came when I was brushing my teeth one morning. I was thinking about an article I just read about the immune cells in the mouth and, as I stared into the mirror I realized that the foam was coating all the areas of the mouth where special cells, called Langerhans cells, are in highest numbers. If I could just get these extracts into a great toothpaste, then I could have a really safe and effective treatment for allergies that would also be easy to use every day from home. I almost choked on my toothpaste!

For the full Q&A,click here

8th East-West Integrative Medical Symposium for Immunology & Wellness–July 24th

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This conference will be brought to you via Zoom by New York Medical College (NYMC) and the laboratory of Dr. Xiu-Min Li, pioneer in the integration of Traditional Chinese

Dr. Xiu-Min Li

Medicine and Western Science. This year’s program will cover three broad areas: food allergies, eosinophilic esophagitis (EoE) and mast cell disorders, and eczema, including pernicious side effect, Topical Steroid Withdrawal. Several of the speakers have published on this website over the years. Institutions represented, in addition to NYMC, include Massachusetts General Hospital, Columbia, NYU, and Weill Cornell.

The program will run from 8:30am-3pm–eastern time

To register and/or make a donation click here.

 

Food Allergy Management in the Age of COVID-19

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Doylestown Community Food Cupboard

Our friend and contributor Anne F. Russell, MS, BSN, RN, AE-C , along with several collaborators, has published a new study to help nurses and doctors work with parents of food allergy patients on negotiating the challenges of feeding their families and themselves in the face of a the COVID-19 pandemic. They distributed a survey to parents, of whom 359 respondents met inclusion criteria. They found: “Concerns about COVID-19 exposure were expressed in 65.7% about accessing an emergency department and 73.6% had school reentry concerns; 66% had not discussed recommended anaphylaxis management algorithm changes with a provider; 85.8% had not discussed the temporary U.S. Food and Drug Administration food labeling policy with a provider. Most (62%) reported shortages of preferred safe food brands. 62% spent more time cooking safe foods from scratch. With regard to the recommendation by the U.S. Centers for Disease Control and Prevention (CDC) for classroom dining, 57.7% planned to request modifications. With regard to the CDC’s recommendation to use inhalers versus nebulizers, 37.7% had not discussed the topic with a provider. Ninety-two written comments were analyzed and grouped into seven themes.”-

They concluded: “New pandemic-related regulations, food supply chain disruptions, and evolving medical recommendations resulted in intensified burdens for respondents, including the increased time needed to complete food allergy management and school reentry concerns. Study results can inform clinical team members (e.g., physicians, nurses, dieticians) of effects that pandemic-related changes may have on this patient population, with subsequent consideration of patient-specific screening, education, and shared decision-making with regard to risk mitigation needs.”

The full paper “Parent perspectives on food allergy management and safety during the COVID-19 pandemic” is available free of charge from the Journal of Food Allergy. We asked Anne to share her thoughts about how this paper came about and ideas for parents.-Henry Ehrlich

AAC   How did you come to write it? How did you assemble the team of co-authors?

Anne   Shortly after WHO declared COVID-19 a pandemic, I conceptualized the study. At that time states had instituted stay-at-home orders, schools and universities ceased in-person instruction and food chain supply disruptions occurred.  Evolving medical recommendations also ensued. I wanted to investigate how these abrupt and startling changes were impacting decision-making and safety of patients managing food allergies with risk for anaphylaxis. I was interested in transposing their reported experiences into concrete recommendations for allergy/immunology clinical teams (e.g., physicians; nurses) aimed at best assisting these patients. I selected a nurse co-author with vast experience practicing in school settings as I wanted to include school-related questions in the study survey. I also included another nurse as co-author with experience in informatics to assist with practical aspects of research. Both co-authors made useful contributions to the research project.

AAC   Since the primary audience is medical professionals with a food allergy focus, how did you make decisions about what they needed to know, and how did you write the questionnaire accordingly? 

Anne   First a literature review was completed revealing sparse research on effects of the pandemic on daily food allergy management. The U.S. was only a couple of months into the pandemic at the time, so this result wasn’t surprising. Next, I thought about features of anaphylaxis prevention and preparedness, the cornerstone of daily food allergy management, to highlight in the parent study survey. Parent responses would determine how pandemic related challenges were or were not impacting these patients. Once survey responses were submitted and analyzed, I thought about subsequent recommendations to clinical teams based on study findings. The Journal of Food Allergy, which published the study, is a peer-reviewed medical journal targeting physicians, nurses and dieticians that specialize and practice in allergy/immunology with a sub-specialty in food allergy.

How do professionals utilize an article like this? Do you envision dramatic changes in the way they practice? 

A pandemic involving a novel virus constitutes a public health crisis. However, I am optimistic we will have an endpoint sooner than we may expect, and strides have been made toward that goal. Thus, this research highlights time-sensitive findings unique to a specific period during an extraordinary global event. Typically practice changes occur slowly and incrementally.  However, an abrupt public health crisis does not allow for such time and clinical teams must quickly adapt accordingly to assist patients facing unforeseen challenges. For example, I created table 5 in the article to provide clinical teams with recommendations for patient education discussion points to consider emphasizing during the pandemic based on patient needs revealed in study findings. Additionally, study findings can inform clinical teams of patient screening needs and risk mitigation discussion points unique to the pandemic to consider proactively discussing with patients.

AAC   Did any of the data surprise you? 

Anne   I expected parents would be concerned about school re-entry prior to a COVID-19 vaccine. However, I was surprised the majority reported being highly concerned. Many of these families already struggle with school-related food allergy accommodation issues and adding COVID-19 concerns on top of those baseline challenges increases their burden. I was also struck by captured data indicating the pandemic led to additional health concerns for this patient population. For example, disruptions in the food supply chain meant many families experienced shortages of their food allergy safe and familiar food brands. Several aspects of this concerned me. First, it could create risk for nutritional deficiencies if shortages are prolonged while alternative safe brands are not found. Second, it meant many families had to seek unfamiliar food brands necessitating more time spent calling manufacturers regarding ingredients and other due diligence. Such time-intensive tasks also add to their burdens. Third, having to try new food brands may heighten fears of anaphylaxis, which adds to parental stress levels.    

AAC   Again, since this is a pretty technical article directed at a professional audience, are there any takeaways that would be useful for lay readers, such as patients and families?  

The pandemic underscored the need for patients with food allergies to prepare ahead for potential emergencies. Consider having a home back-up supply of nonperishable food allergy safe foods. Cooking and baking ahead to store or freeze a supply of food allergy safe foods may be beneficial. Consider contacting food manufacturers directly to purchase preferred food allergy safe brands. Having a several month supply of prescribed medication refills ensures availability for the near future. It’s also imperative to always have accessible unexpired prescribed epinephrine auto-injectors.

I encourage parents to be proactive in preparing for appointments with physicians, nurses, and dieticians. Have questions and concerns written down beforehand prior to telehealth or in-person appointments. Do not be shy about raising topics of concern in discussions with healthcare professionals. Telehealth and in-person clinic appointments are often scheduled for specific timeframes so make the most of that limited time.

Anne F. Russell

Anne F. Russell, MS, BSN, RN, AE-C is a researcher, nurse scientist, nursing faculty and food allergy specialty nurse. She has sub-specialized in the field of food allergy for over 20 years including clinical allergy/immunology practice. Nurse Russell has published food allergy related articles including studies and has created food allergy patient educational materials for clinical use and public health education. She serves as peer-reviewer and editorial board member of the Journal of Food Allergy. Nurse Russell is also an active member of the American Academy of Allergy, Asthma & Immunology serving on several committees involved with advocacy, continuing medical/nursing education and research projects related to the food allergy patient population.

 

 

 

Portland Smoke: 500 Miles to Blue Sky

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Jessica Dabler Martin

By Jessica Dabler Martin

When I first moved to the Portland, Oregon area in 2004, I believed it “rained all the time.” Perhaps the best kept secret of the Pacific Northwest is that it only rains about eight months of the year with four months of the most perfect summer weather – dry, sunny, clear blue skies, not too hot – perfect for outdoor adventures. It made eight months of rain worth it! Air conditioning in homes was a luxury item rarely needed fifteen years ago, and in fact, most homes did not have it. Fast forward fifteen years, and I would argue air conditioning is becoming a summertime necessity due to heat and occasional smoke. Oregon summers are consistently hotter and dryer than historical averages. One scientific study after another confirms human-induced climate change. With climate change, the American west is predicted to burn longer, hotter, and bigger than before. While this year’s specific events are not definitively shown to be due to climate change, the trends in recent years fit the predictive models scientists have been warning about for years. It only takes abundant dry fuel and a spark, whatever the cause, to create an inferno.

The scale of these fires and resulting smoke feels inescapable. One friend commented about hopping in the car and “driving until finding blue sky.” On September 15, that would have involved driving over 500 miles.

Up until this year, the worst air quality I can recall in the Portland metro (confirmed here) was rated “unhealthy.” For six days now, Portland’s air quality has ranged from very unhealthy to hazardous with the amount and spread of smoke reflecting the scale of these fires. Certain communities in Oregon were ranked worst in the world for air quality – not a metric any place should aspire to. Whole town have burned to the ground, some people have died, and thousands have been evacuated (Oregon-specific summary). Fortunately, the weather improved to slow the spread of the fires, giving fire fighters a chance at containment. Even now, the southeast corner of the Portland metro remains under threat should weather conditions change for the worse. We briefly hosted good family friends, who faced evacuation orders. I am happy to report that they are home, safe, albeit still very smoky. Small towns just downwind of the fires may be a few orders of magnitude worse in air quality than what is reported for Portland. Even if these towns are currently safe from fire, the smoke is toxic and unbearable.

Fireplace sealed against the smoke

So, what does it feel like? In short, trapped in our home with nowhere to go. Going outside is like being stuck in the moment when a small campfire douses you in smoke, but with no means to move to the opposite side to get away from it. Being “trapped” was true due to COVID-19 before the fires, but we at least had an outlet to get outside daily – an option we no longer have. Unfortunately, regular cloth masks to protect against COVID-19 do not block the fine particulate smoke. We sealed off our fireplace and have not used our dryer (yes – smoke is even getting in through the laundry vent). Some people I know have sealed windows and doors. There is still a faint smell of smoke inside the house, despite recently replacing a very dirty HVAC filter. I nearly cried when the forecasted rain earlier this week never came, and air quality is now predicted to remain unhealthy for two more days. I hope the rains come on Friday.

Air filters before and after

Personally, many healthy family and friends have experienced symptoms of wildfire smoke: scratchy throats, coughing, breathing issues, headaches, and general fatigue. It is worse for individuals with asthma or other cardiorespiratory conditions. Local reports indicate increased emergency, urgent care, or telecare health visits this past week. Unfortunately, smoke exposure symptoms overlap COVID-19 symptoms overlap COVID-19 symptoms. I have personally had the thought, “is it smoke or COVID-19?” There are concerns that breathing unhealthy air will make COVID-19 more likely or worse due to inflamed lungs. On top of this, the number of families uprooted and staying with other friends or family members makes spreading COVID-19 more likely. I worry. Our family broke the rules of the pandemic disaster to help family friends facing the wildfire disaster. We would not have done it differently, though.

From a food allergy perspective, this experience only confirms that as a family we need to better prepare for natural disasters. If it were our family that got a knock on the door telling us to “get out” with minutes to spare, we would be fumbling for shelf-stable food and epinephrine autoinjectors. We also need to make sure we routinely go through our emergency kit because what could be worse than needing to use the kit and discovering rancid sunflower seed butter two years past its expiration date. I’m planning to set up a six-month cycle in our family’s shared “To do” app, reminding us to go through our kit and replace certain food items if needed. Kids With Food Allergies recently updated an excellent post on disaster preparedness with great suggestions for making and maintaining a kit.

The smoke will clear, but the damage is done. My hope is that as a nation, we will listen to our domain-specific experts to guide our path forward. We must use unpolluted science to put the health and well-being of people first. The social and political challenges are enormous. I leave with a piece of hope. At a popular campsite where nearly everything was destroyed, the American flag still stands. It is not too late to change course.

Jessica Martin earned a Ph.D. in Neuroscience from Oregon Health and Science University in 2011. She lives in the Portland, Oregon area with her husband Jason and their sons where she teaches undergraduate biology and anatomy and physiology at Portland Community College. Although not currently engaged in cutting-edge laboratory science, she continues to actively research current findings in allergy and immunology. She aspires to eventually return to the trenches of doing laboratory science in allergy and immunology.

West Coast on Fire

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By Elizabeth Muller

The world through the windshield

As I write this white ash is visible in the polluted San Francisco Bay Area air, wafting down from a smoky orange sky and into our lungs, a dangerous byproduct of wildfires burning in California, Oregon and Washington. Already this is the worst year for wildfires in California history, and the official season has barely begun. More than 3.4 million acres across the West have burned.

It’s not lost on me that this environmental disaster, a fatally perfect firestorm resulting from years of poor fire management and likely heightened by above-normal temperatures, emphasizes the need for the independent unbiased scientific research of my environmental nonprofit, Berkeley Earth. It is likely that global temperature increases were a contributing factor to these fires, but how much they contributed is largely unknown.

Web traffic to our global real-time air pollution map, which launched in 2014, has been spiking as the media and the public struggle to make sense of the particulate-sodden air that’s coating our cars with ash and seeping into our homes. My heart goes out to everyone who is affected.

Depending which way the winds are blowing — or not blowing — when the fires are at their worst it can sometimes look and smell like your neighborhood is on fire, with a haze of white smoke sitting low to the ground even though the actual flames are miles away. Air pollution can reduce visibility to distances of less than a mile and often completely obscures views of local landmarks and mountain peaks for days at a time.

Berkeley Earth offers not just real-time data, but also historical data for comparison. Do you want to know how air pollution in your city in August 2020 compares to the fire season in 2019, 2018, or 2017? You can easily look this up on our historical graphs. You can also see spikes in most years on New Year’s Eve and the Fourth of July, as fireworks temporarily cause horrific pollution, which then thankfully dissipates after a few hours. We in California have started expecting these increases in pollution levels during fire season, but others worldwide must fight dangerously high levels of pollution daily.

Fire pollution is not just affecting the West Coast. NASA satellites have tracked heavy levels of aerosols from the smoke in Minnesota and Nebraska. Our color coded air pollution map showed the tell-tale yellow, meaning “moderately unhealthy” air stretching further east. It also extends 600 miles over the Pacific Ocean.

Why does this matter? Even just slightly unhealthy air can be difficult for those with breathing problems. To help protect my asthmatic 6-year-old we have four air filters operating 24/7 and just bought a fifth one.

At least my family is well-versed in this challenge. I even blogged about it here during fire season of 2017, when our advice was the same as it is today: Stay indoors, use indoor air filters that filter particulate matter (especially PM 2.5), limit outside activities, and wear a proper face mask if you do go out.

Yet it hasn’t been that long that we’ve even measured PM 2.5, now considered the most dangerous form of air pollution. If you’ve never heard of it, you’re not alone. PM 2.5 is small particulate matter, measuring 2.5 microns in diameter or smaller. These particles are small enough to work their way deep into the lungs and into the bloodstream, where they can lead to health issues such as a heart attack, stroke, lung cancer and asthma. The main impact seems to be an increased risk of cardiovascular disease, which kills more people worldwide each year than does AIDS, malaria, diabetes or tuberculosis.

Some less serious but more immediate physical side effects of living near a burning wildfire include painfully irritated eyes, chest congestion and a slight cough or scratchy throat. For those who exercise outdoors, even a 30-minute workout on a day where the PM2.5 is at “unhealthy” levels and higher can trigger respiratory problems. Medical experts usually say people without health problems can get away with an occasional workout in smoky air but that sensitive populations should avoid it.

One way of understanding PM2.5 air pollution is to compare it to smoking a cigarette, as my Berkeley Earth co-founder Richard Muller and I did a few years ago. You divide the PM level (not to be confused with the Air Quality Index, or AQI) by 22 to get the approximate number of cigarettes equivalence.

For the United States and Europe on average, air pollution is equivalent in detrimental health effects to smoking 0.4 to 1.6 cigarettes per day. During this fire season it has gotten as bad as 5 cigarettes/day. During the 2017 fires, it got worse, as bad as 10 cigarettes/day.

Yet we have seen far worse numbers in China and India, where on bad days the health effects of air pollution are comparable to the harm done smoking several packs per day (up to 60 cigarettes). Ambient air pollution is estimated to cause 4.2 million deaths annually, which makes it arguably the greatest environmental catastrophe in the world today.

As a nonprofit organization, Berkeley Earth relies on donations to support independent air pollution and climate change research. We hope you find our data useful and are inspired to make a contribution, even a small one helps, so we can continue educating the world about these serious health issues.

Elizabeth Muller

Elizabeth Muller is Co-Founder and CEO of Deep Isolation, a company that’s disrupting the nuclear waste industry by offering an innovative, safe and permanent solution for nuclear waste disposal.She is also Co-Founder and Executive Director of Berkeley Earth, a nonprofit organization using modern statistical techniques to offer independent unbiased analyses of environmental concerns such as global warming and air pollution. Muller was recently named a Clean Energy Rising Star by Business Insider, which earlier this year listed Deep Isolation as one of its Top 30 clean tech industry startups based on data compiled by Goldman Sachs. Previously, she was Director at Gov3 (now CS Transform) and Executive Director of the Gov3 Foundation. From 2000 to 2005 she was a policy advisor at the Organization for Economic Cooperation and Development (OECD). Muller has advised governments in more than 30 countries, leading projects on improving government effectiveness, organizational change, citizen centricity, the digital divide, and developing national strategies for e-Government and ICT.

The Worse the Pandemic Gets, the Weirder It Will Get

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By Paul Ehrlich, MD

The title above is from an excellent article in The Atlantic by science writer Ed Yong entitled “Immunology Is Where Intuition Goes to Die”

Dr. Paul Ehrlich

which analyzes brilliantly the nature of the immune system and its paradoxes, which have been exposed day by day in the news. The article explicates the different stages of immunity, from innate through acquired, with the familiar cast of cytokines, chemokines, interferons and so forth, which are our friends until they are not.

There’s no bigger paradox to me than the fact that I am still alive while my friend and colleague Larry Chiaramonte is not. As we told you a couple of months ago, Larry passed away in an assisted living facility. I live in an apartment. He was older than I am by about eight or nine years. He was widowed. I am not. These are just a few items that might have relevance to a study of risk. I believe I also had Covid-19. For six weeks I had symptoms. Fatigue. Runny nose. Congestion.

I might very easily have been exposed on my commute by subway, or in my office, which was open every day right up until everything shut down. Most of my patients are children who are less vulnerable to the virus, although as we now know they are not invulnerable, and they can also be asymptomatic spreaders. As Mr. Yong puts it, children have “trigger happy immune systems.” When it comes to fighting off viruses, this is a good thing. When it comes to allergies, not so much, although it has been suggested that allergies and asthma may help resist SARS-CoV-2—another paradox. We don’t know. Weirder and weirder.

When I was feeling miserable this spring, I did a mental inventory of my own immune system. I’m 75. When I was a toddler, my father, a pediatrician, practiced in our house. His waiting room was our living room where I played while the patients came and went. His examining room was my bedroom at night. Dr. Lennie, as he was known to generations of Long Island children, decided to inoculate me to the full menu of childhood diseases by exposing me to his patients. There were no vaccines. I got them all, thankfully mild cases. He practiced until the 1990’s by which time he gave the shots instead. The only exceptions were polio cases. He would arrange for me to be away when he knew one would be coming in. Eventually, his old medical school friend Jonas Salk came up with a polio vaccine.

After I recovered from my illness this spring, I went for blood work. In addition to looking for Covid-19 antibodies, I asked the phlebotomist to test for measles, mumps, rubella, and chickenpox. To my not quite surprise, I still had powerful titers to those diseases. To my greater surprise, I had no Covid-19 antibodies. Had I had the disease? I suspect that my early exposure to a full roster of viruses all those years ago had something to do with it, a kind of suburban version of the “barnyard effect.” Maybe it’s because I have been listening to children’s hearts all these years, looking in their noses and ears. Their colds are coronaviruses, too. Maybe this gave me an advantage in confronting a novel virus. Lots of my contemporaries live the hygiene hypothesis life. Their immunity isn’t challenged day by day to renew itself. One more idea to throw into the hopper.

How then to explain what happened to Larry? He practiced in the South Bronx for many years where he confronted if anything more pathology than I did. But then he retired and he ended up living comfortably in the kind of facility that we now know to be a hotspot. He was a great doctor and a visionary immunologist. I would love to talk to him about this now. And Dr. Lennie. Both of them would have been fascinated.

Anyway, read Yong’s article. It is the clearest and liveliest exposition of the mysteries of immunology I have ever read.

Study on Food Allergies and Covid-19

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Anne F. Russell, MS, BSN, RN, AE-C

Our friend and contributor recently sent us a request to share this with our readers:

My name is Anne F. Russell, MS, BSN, RN, AE-C and I am conducting research in collaboration with Olga Kagan, PhD, RN on a study involving U.S. parents of 5 to 18 year old children with diagnosed food allergy. The aim of the study is to identify parental perceptions regarding the impact of changes during the COVID-19 pandemic on the safety of their children with food allergy. We are recruiting U.S. parents of children with diagnosed food allergy to complete the online survey which takes about 5 minutes to finish.

Parents interested in voluntarily participating in this research study can access the online survey using this link: 

https://forms.gle/Vnbq4cV9AtU31f7m9
More information about the study is provided in the informed consent section of this online Google Survey link which should be read prior to taking the survey.

 It would be greatly appreciated if you could also please consider sharing information about this study opportunity and the survey link through your social media platforms and/or by emailing it to U.S. parents of children with food allergy that you are associated with.

 If you have any questions or concerns regarding this research study, please contact:

  • Anne F. Russell, MS, BSN, RN, AE-C, Nursing faculty, Spring Arbor University at anne.russell@arbor.edu and Director, Food Allergy & Anaphylaxis Michigan Association
  • Olga Kagan, PhD, RN, Nursing faculty, Molloy College at okagan@molloy.edu
The Molloy College Institutional Review Board (IRB) reviews all research projects that involve human participants to be sure the welfare and rights of study participants are protected. If you have questions about your rights as a participant, complaints and/or suggestions about the study, you may contact the Molloy IRB office at irb@molloy.edu or call 516-323-3000.

South Dakota Allergist: Inside View from a COVID-19 Hotspot

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I recently began corresponding on Twitter with Dr. Brian A. Brennan, an allergist in Sioux Falls, South Dakota. I was curious to know how COVID 19 was affecting his practice in a location that seemed remote from the New York metropolitan area, where ambulance sirens were interrupting our sleep with much greater frequency than usual. Then, overnight, Sioux Falls became a coronavirus hotspot with a major outbreak in the Smithfield pork processing plant, which, as we now know, supplies 4-5% of the national pork supply. After some pestering, Dr. Brennan agreed to answer a few questions. –Henry Ehrlich

AAC: Thanks for taking some time for our readers, Dr. Brennan. First some background. I looked up your credentials and saw that you trained in New Jersey and Washington, DC. Why did you choose to settle in South Dakota?

Dr. Brennan: I attended Purdue University as an undergrad so I had a taste of midwestern life, returned to my birth state of New Jersey for medical school, and at that time met my future spouse who was living in Washington, D.C. but whose family was from Minnesota. So after my Peds Residency at Georgetown we both felt that we wanted to move to the Midwest and I was fortunate enough to obtain an Allergy Fellowship position at Creighton University in Omaha. Life was so much easier in Omaha than in the D.C. metro. When we lived in D.C I spent about an hour and 45 minutes in the car every day, commuting. In Omaha, we were able to live in a lovely suburban environment right in the heart of town, on a Fellows salary, and my commute to work every day was 12 minutes. Our son had just been born, so that shorter commuting time gave me 90 minutes of my life back every workday. After that we knew that we would eventually settle somewhere between Omaha and Minnesota.

AAC: What is your practice like in normal times? What are the big seasonal allergens? It’s allergy season. Is your office still open? Is it business as usual or are you doing telemedicine?

Dr. Brennan: My practice is “bread and butter” allergy. As with all community allergy practices, every once in a while something amazing will come in, but usually it’s rhinitis, asthma, itchy skin rashes, and immune work-ups. Our seasonal allergens are pretty typical. In our part of the country it’s usually a short tree pollen season. Then into grass pollen season, which can be pretty heavy, a short break with pollens in July, and then into ragweed in August. The big difference between a practice in the agricultural Midwest and coastal practices is that outdoor mold is perennial here. Alternaria, a fungus, is our most troublesome allergen in general. Of course we have dust mites and pets as indoor allergens too.

Our office is still open, but patient numbers are of course way down, as it should be. We are mainly focused on keeping our asthmatics healthy and maintaining those folks with immune deficiency. We have been doing a fair amount of telemedicine, which is great for quick rechecks when patients are doing well. We have a fair number of patients who routinely drive 3 to 4-plus hours to see us, so telemedicine can be a blessing for them. I hope reimbursement levels for telehealth services continue to be reasonable in the future, so that we can continue to provide this important service.

AAC: I haven’t been in Sioux Falls for many years. Do you see farmers and ranchers? Do you have a significant number of Native American patients?

Dr. Brennan: Farming and ranching are still a large part of the economy of South Dakota. South Dakotans speak of our state in terms of “East River” and “West River,” in relation to the Missouri. Generally speaking, East River tends to be more pastureland and row crops (corn, soybeans) similar to Minnesota and Iowa. West River tends to be more ranching and grazing land, and looks a lot more like Colorado and Wyoming. Our state is also divided into 2 time zones.

We have a significant number of Native American patients, some who live in town and others from the reservations. We also have a significant number of Hutterite patients, who tend to have a very high prevalence of atopy. Their colonies in South Dakota have been involved in published research which seems to have revealed some insights into the “hygiene hypothesis.” (1)

AAC: How are asthma levels? I know that asthma is a significant problem with farmers because of use of chemical fertilizers and pesticides. Is that something you encounter in your practice?

Dr. Brennan: Farmers are at risk for all sorts of occupational lung disease, asthma and hypersensitivity pneumonitis being the most common. We manage these issues on an almost daily basis.

AAC: Can you describe your perception of the virus as it took hold in Sioux Falls? Did your patients express concern? Were they coming to you with their symptoms? Did you take extra precautions like face masks and so on? Did they?

Dr. Brennan: Once the virus was in Italy and Washington State, I knew it would be here eventually. Everything takes a while to reach Flyover Country, whether it would be popular culture, economic troubles, or contagion. I’m surprised to see the economic hardship of 2008 being compared to the downturn caused by COVID-19. 2008-2009 were barely a blip on our radar in the Upper Midwest. COVID-19 is orders of magnitude more serious economically. In general, things are more on an even keel here. We rarely boom, and we rarely go bust, but COVID-19 will cause significant economic hardship.

Medically speaking, I was wearing a mask to the office pretty much from the time there were any cases on the continent. Overkill at that time, but I have continued to do so. I was wearing an N95 at first, once our patients had awareness and were wearing masks themselves, I felt okay backing off to a procedure mask. But unfortunately this past week to 10 days people are getting the message that someone has given the “all clear” and we see patients wanting to come to the office again without masks. Mask wearing in my community peaked about 2 weeks ago, and it has started to trail off.

AAC: The Smithfield plant has become notorious. I’d like to ask a few questions specifically about that. First, were any employees your patients prior to the outbreak? I know that these companies pay fairly well, especially for the immigrant labor that is drawn to them, but do employees have health insurance? Were they prone to any particular allergies?

Dr. Brennan: Smithfield offers their employees a health plan from one of the two large health systems in our region. Because the clinic where I work is independent, we are able to see these patients and often do for allergic disorders. I’m not aware of any specific allergens in the Smithfield plant. I’m sure there’s potential for occupational asthma there, but we haven’t seen it. Because Smithfield employees are tethered by their health plan to receive their care from only one hospital systems in town, that hospital has borne the brunt of COVID-19 hospitalizations.

AAC: As someone trained in immunology, have you been consulted on the nature of this disease? How do you explain “cytokine storm” to your patients and to others?

Dr. Brennan: I haven’t heard of this specifically in Sioux Falls and I’m not sure if tocilizumab has been used here. As you may be aware our governor, following the lead of Mr. Trump, was promoting chloroquine and hydroxychloroquine quite heavily, and arm-twisted one of the health systems (the one that doesn’t have Smithfield patients) into doing a clinical trial. I’m wondering if that health system will even have enough numbers to show statistical significance.

AAC: Has the outbreak followed the pattern we have seen elsewhere, striking nursing homes and prisons?

Dr. Brennan: Yes, it has followed that pattern, although seemingly (so far) with less virulence in nursing homes and prisons. Smithfield was the primary hotspot where close working quarters and long shifts, along with hot physical labor, seem to have been the main risk factors. The idea that the home environment in which this primarily immigrant workforce lives is the primary risk factor for transmissibility is racist nonsense. This notion, promoted recently by HHS Secretary Alex Azar seems intended to deflect responsibility from the slaughterhouse industry, in what promises to be absolute blizzard of wrongful death lawsuits that they will have to defend. The government seems to have begun promoting an idea that meat-packing plants are some sort of irreplaceable municipal utility, like electricity, clean water and sanitary sewers. My feeling is that the federal government may offer the meat-packing industry blanket immunity from lawsuits under this rationale.

AAC: What is the civic attitude towards the public health challenge presented by the outbreak? The governor has been on the let-the-chips-fall-where-they-may side of the spectrum. And has Smithfield itself behaved like good corporate citizens after receiving all this attention? I have to say I was shocked particularly by one remark early on by a company spokesperson.

Dr. Brennan: I don’t know Smithfield well. My sense is that their leadership was following our state and federal governments and not taking the entire thing very seriously until it was much too late. Since then, they seem to have tried to deflect blame and were late to act. At one point they were offering significant cash bonuses to workers to avoid absenteeism, which in this working class community was essentially an incentive to come to work ill. Eventually the United Food and Commercial Workers Union (UFCW) stepped in and more appropriate action was taken at that point to safeguard the workers. I personally was surprised to learn that there was a union at Smithfield. This part of the country and particularly South Dakota tend to have very low union participation.

The civic attitude in Sioux Falls was pretty strongly in favor of staying at home, social distancing, wearing masks, and generally doing what the CDC recommended. Healthcare is by far the largest employer in our region, and one would be hard pressed to find anyone in our community who doesn’t have a close friend or relative employed by one or both health systems. So in general we have a pretty strong awareness of what’s to be done. That’s not to say that there isn’t a small but vocal percentage of the population here as elsewhere that feel the whole thing is fake news or a Chinese plot against the President or that they have an absolute God-given right to a haircut, the rest of society be damned. But in general, most people are behaving as if they are members of civil society, which is actually pretty amazing and awesome.

AAC: Finally, do you have any particularly thoughts on the future of this pandemic in your community and for smaller cities and rural America in general?

Dr. Brennan: My sense is that we’re going to get off easy. For whatever reason, whether it’s our willingness to voluntarily shelter-in-place, the seasons changing, something about the virulence of the strain we have in our region, or just lower population density, but so far the community is feeling that it wasn’t as bad as it could have been. This also presents a problem and a challenge, as people want desperately to return to their previous “normal” lives, but it’s clearly too soon yet. It seems unlikely that we will have adequate herd immunity from this virus until we have widespread adoption of a safe and effective vaccine. We’re not going to get adequate herd immunity through natural infection.

AAC: Thanks for your time. This story isn’t going away. I expect you will hear from us again one of these days.

Dr. Brennan: You’re very welcome. I’m happy to offer my thoughts.

 

Brian A. Brennan, MD

Dr. Brennan is a Board Certified Allergy & Immunology specialist in Sioux Falls, South Dakota. In his spare time he enjoys gardening, home improvement projects, and neighborhood walks. Most winters he spends battling all manners of biblical upper midwest weather. It is his fondest hope to some day be able to retire to a warmer climate.

 

  • https://www.nejm.org/doi/full/10.1056/NEJMoa1508749

 

 

Mt. Rushmore by Christopher Lione

Confronting Covid-19 and the Face In the Mirror

By

FRANCIS V. ADAMS, MD

Dr. Frank Adams broadcasting on Doctor Radio

Covid-19 has affected every aspect of life on this planet – how we live, and in many cases, how we die. No field or profession has been impacted more than health and medicine, especially for those who practice at the bedside. According to the CDC (April 17th report) nine thousand health care professionals in the United States have been sickened by SARS-CoV-2 and to date, nineteen physicians have died. Of the nineteen, only one was under the age of 65. In a short time, I will be 74 and celebrate 50 years from graduation from medical school. In less than three years I will have been a pulmonologist for half of a century. Covid-19 has made me face what I have preferred to ignore – my aging image in the mirror and the risk to my own wellbeing.

My practice is primarily ambulatory medicine in an academic specialty group with infrequent weekend rounds. On my last weekend before the coronavirus outbreak, an elderly patient I was seeing with the assigned pulmonary fellow commented that I looked like someone who “should not be working weekends”. I was taken aback by this but attributed it to looking my age, something that also prompts longstanding patients to inquire if I am planning to retire. My answer has always been truthful – I still enjoy what I do and plan to continue as long as I am able. I am aware, however, that many of my generation of attending physicians, some younger than myself, have chosen retirement.

Covid-19 has made me confront aging and my ability to continue to practice medicine. I am not alone as thousands of retired physicians have answered the call to bolster and often enrich the medical community’s response to this pathogen. As a young pulmonologist who relished performing bronchoscopies and pleural procedures, I found that I was welcomed into my academic community. One senior physician, however, would often say to me that although he respected my abilities he wanted “some grey hair” – a more experienced physician to verify my opinion. I confess that I was irritated, even a bit insulted by this request, but as time has passed, I have come to understand its meaning.

The learning process in medicine is never ending and is fueled by the interaction between teachers and students. This process is heightened by the urgency of a healthcare crisis. Certainly, the knowledge gained from years of diagnosing and treating multiple infectious diseases such as influenza, tuberculosis, and HIV is invaluable. Yet physicians of my age must struggle with weighing the benefits of our experience at the bedside against our vulnerability.

It is also clear that PPE has failed to protect many in our profession as the number of sickened healthcare workers grows. The AMA has labelled whether senior physicians should be on the front line of patient care at this time a “complex issue” and the CDC has been silent on this matter. At the very least, physicians sixty-five and older, should be given the option to avoid exposure.

I must be truthful. If I had been asked twenty years ago if I would accept an accommodation allowing me to avoid bedside exposure, my answer would have been a firm “NO”. Now that Covid-19 has made me confront my life and whatever time remains, I answer, “YES”. The face in the mirror tells me so.

Francis V. Adams is a pulmonologist at NYU Langone Health and an Associate Professor of Clinical Medicine at NYU Grossman School of Medicine. He is also a Police Surgeon with the NYPD and hosts the pulmonology show on Doctor Radio on SiriusXM weekly.

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