Allergies | On Call with the Prairie Doc | June 1, 2017
15
October

By Adem Lewis / in , , /


FROM AN ANNOYING RUNNY NOSE TO LIFE-THREATENING REACTIONS, ALLERGIES, TONIGHT, “ON CALL WITH THE PRAIRIE DOC.”>>GOOD EVENING, AND WELCOME TO “ON CALL WITH THE PRAIRIE” DOC. DR. HOLM IS AWAY. I AM DR. JILL KRUSE WITH THE AVERA BROOKINGS MEDICAL GROUP. ALLERGIES CAN COME FROM A VARIETY OF SOURCES; CATS AND DOGS, RAGWEED, INSECT STINGS, PEANUTS, AND MORE. THE RANGE OF REACTIONS VARY WIDELY AS WELL. WE WILL EXPLORE WHY THEY HAPPEN AND WHAT WE CAN DO ABOUT THEM. FIRST, LET’S TAKE A LOOK AT THIS WEEK’S PRAIRIE DOC QUIZ QUESTION. EPINEPHRINE, AS IN AN EPI-PEN, WORKS BY… INCREASING BLOOD PRESSURE, DECREASING WHEEZING AND IMPROVING BREATHING, INCREASING HEART RATE, DECREASING HIVES AND SWELLING, ALL OF THE ABOVE. WE WILL HAVE THE ANSWER AT THE END OF THE SHOW. JOINING US TONIGHT ARE DR. TOM LUZIER WITH ABERDEEN ASTHMA AND ALLERGY, AND DR. MARK BUBAK WITH DAKOTA ALLERGY AND ASTHMA. TOM, LET’S START WITH YOU. WHAT IS THE MOST COMMON ALLERGY YOU SEE IN YOUR PRACTICE? IT’S KIND OF A TOSS-UP. RAGWEED IS THE ONE WE SEE MOST OFTEN POSITIVE. PROBABLY PEANUT COMES IN THERE AND TIMES AND Dr. BUBAK IS GOING TO TALK ABOUT THE NEW PEANUT KIND OF THING. DUST MITE IS VERY HIGH IN THIS AREA, EVEN THOUGH WE DON’T HAVE A LOT OF HUMIDITY IN THE WINTERTIME. KIND OF THE LOWER END IS DOG AND CAT, AND PROBABLY GRASS SHOULD BE THROWN IN THERE SINCE WE LIVE ON A GRASS PRAIRIE.>>SO NOT MUCH SHELLFISH IN THIS LAND-LOCKED AREA?>>NO, WE’RE NOT — JAPAN, YES, SOUTH DAKOTA, NO.>>ALL RIGHT. MARK, WHAT’S THE BIGGEST CHANGE THAT YOU’VE SEEN IN TREATMENT?>>I THINK THAT WE REALLY HAD SOME WONDERFUL ASTHMA THERAPIES, THE INHALED STEROIDS, INHALED CORTICOSTERIODS WE CALL THEM MAKE SUCH A DIFFERENCE. WHEN WE LOOK AT HOW MANY PEOPLE WERE IN THE HOSPITALS 25 YEARS AGO, ALLERGISTS HAD WARDS FULL OF ASTHMATICS IN THE BEDS GETTING ALL KINDS OF THERAPIES AND NOW IT’S RARE THAT WE EVER HAVE ANYBODY IN THE HOSPITAL IF THEY’RE ACTUALLY TAKING THEIR TREATMENTS. ITS IT’S EXCITING.>>WONDERFUL, THAT’S A BIG CHANGE. AND HAVE ALLERGY SHOTS CHANGED, AS WELL ANY REMEMBER MY OLDER BROTHER GOING IN FOR A LONG TIME.>>I THINK THE THING THAT’S CHANGED MOST WITH ALLERGY SHOTS HAS BEEN HOW SUCCESSFUL THEY ARE. BECAUSE WE’VE HAD OTHER THERAPIES, ORAL, DESENSITIZATION, THINGS LIKE THAT BUT THE ALLERGY SHOTS STILL COME OUT WAY AHEAD. WE TRY EVERYTHING TECHNICALLY THAT WE CAN DO TO MAKE THEM BETTER AND I DO THINK THEY’VE HELPED REDUCE THE KINDS OF SYMPTOMS THAT COME FROM THAT, SINUS INFECTIONS, ASTHMA, THAT KIND OF THING.>>THE BIG CHANGE THAT I’VE SEEN IS THAT WE KNOW THE CHARACTERIZATION OF WHAT’S IN THE SHOT SO MUCH BETTER THAT WE CAN TARGET MORE ACCURATELY. THAT’S THE PROBLEM WITH, SAY, SUBLINGUAL THERAPY, WE DON’T KNOW DOSES THAT WORK EXCEPT FOR TWO ALLERGENS, SO — WHEREAS WITH THE SHOTS, WE KNOW DOSES FOR MOST THINGS AND IT REALLY PAYS OFF TO GET PEOPLE BETTER AND NOT HAVE SO MANY REACTIONS. AND THAT’S NEW.>>ALL RIGHT. EXCELLENT. THE FIRST THEY THINK WE NEED TO KNOW IS TO JUST WHAT YOU ARE ALLERGIC. IT IS A SIMPLE TEST.>>THE FIRST THING WE’LL DO IS THE SKIN PRICK TEST, THE TRADITIONAL BEST WAY OF DOING THE ALLERGY TESTS. IT TELLS US IN ABOUT 15 MINUTES WHAT PERSON HAS ALLERGEN ANTIBODY TO AND WE USE IT FOR PEOPLE WITH ITCHY, SNEEZY, RUNNY NOSE, SOMETIMES HIVES. JOE WILL PUT THESE ON, WE HAVE A COMBINATION OF SOME TREE, GRASS, WEED, MOLD, DUST MITE, TYPES OF THINGS HERE, TO SEE HOW THINGS SHOW UP. A POSITIVE RESULT LOOKS LIKE A MOSQUITO BITE AND WE HAVE POSITIVE AND EFFECTIVE CONTROLS. AND WE’LL READ THAT OFF AT 15 MINUTES. AT TIMES A PERSON GETS A LITTLE NEEDLE UNDER THE SKIN, IT’S CALLED INTRA DERMAL AND KIND OF A DOUBLE CHECK, ESPECIALLY WITH WEAKER ALLERGENS TO SEARCH OUT FOR ALLERGIES. A LOT OF CONGESTION, COUGHING, I HAVE A COUGH RIGHT NOW, SO REALLY DISRUPTIVE. [Overlapping Conversation] IT TURNS RED. ALWAYS IN THE SPRING, RIGHT AWAY WHEN EVERYTHING IS BLOOMING, I REACT VERY FAST.>>AFTER THIS GETS DONE, A PERSON NEEDS TO PLAN OUT A SPECIAL TREATMENT PROGRAM FOR EACH PATIENT. IT’S WHAT KIND OF THINGS DO YOU AVOID AND WE’LL GIVE YOU AVOIDANCE TIPS, WHAT KIND OF MEDICATIONS AND SOME OF THEM NEED TO BE STARTED BEFORE THE SEASON GETS GOING AND THEN FOR QUITE A FEW FOLKS, WE END UP PUTTING THEM ON IMMUNOTHERAPY OR ALLERGY SHOTS TO MAKE YOU LESS AGEORGIC OVER THE YEARS, OR DROPS.>>15. 25.>>I HAVE SUFFERED FROM ALLERGIES EVER SINCE I’VE BEEN A CHILD SO OVER THE YEARS, OF COURSE, THE TREATMENTS HAVE BEEN DIFFERENT TYPES OF MEDS AND THEY WORK TO SOME VARIOUS DEGREES. ABOUT 25, 30 YEARS AGO, STARTED WITH ALLERGY SHOTS AND I’VE BEEN ON VARIOUS PROGRAMMING IN THE PAST AND THE ONE I’M CURRENTLY ON IS ONE OF THE BETTER ONES I HAVE BEEN ON. IT’S BEEN GOING ON FOR ROUGHLY ABOUT 15 YEARS, I BELIEVE. AND THROUGH THAT PERIOD OF TIME, IT’S BEEN A BENEFIT. NOTICE A LOT OF CHANGE IN MY LIFESTYLE, I’VE BEEN ABLE TO ENJOY LIFE A LOT MORE NOT HAVING THAT STUFFED UP NOSE OR FACE OR BEING ABLE TO GO OUT AND ENJOY GOLFING AND MOWING YARDS AND SIMPLE THINGS LIKE THAT, THAT OTHER PEOPLE TAKE FOR GRANTED. OVERALL ALL THE YEARS I’VE HAD ALLERGY SHOTS, ONLY HAD PROBLEMS WITH A SHOT ONCE MYSELF AND IT WAS A REACTION, DELAYED REACTION, HAPPENED ABOUT TWO AND A HALF HOURS AFTER THE SHOT WAS GIVEN, WHICH IS ABNORMAL. MOST OF THE REACTIONS, IF YOU NOTICE THE PLACARDS IN THE BUILDING THERE, WITHIN 30 MINUTES OF THE INJECTION. I COULD START FEELING THROAT GET — FEEL FULL AND START GETTING HOARSE AND RASPY AND SORT OF FELT FUNNY, SO IT WAS A TYPICAL REACTION THAT YOU WOULD EXPECT FROM AN ALLERGY SHOT. THE OTHER TREATMENTS I’VE BEEN ON, THEY MAKE YOU TIRED OR FEEL SLUGGISH OR SLOW AND YOU JUST DIDN’T FEEL LIKE YOURSELF AND THE THING I REALIZE WITH THE ALLERGY SHOTS, THEY ACTUALLY, YOU DON’T HAVE A LOT OF SIDE EFFECTS, OR I DON’T HAVE A LOT OF SIDE EFFECTS FROM THEM, AT ALL. THAT’S MADE IT A VERY GOOD TREATMENT FOR ME, ALONG WITH THE FAMILY — ALONG WITH THE GIRLS. YOU KNOW, THEY EXPERIENCE THE SAME THING THAT I HAVE WITH THEIR SHOTS. >>SO THE TESTING LOOKED RELATIVELY PAINLESS AND SIMPLE.>>AND QUICK, IN ABOUT 20 MINUTES, YOU GOT YOUR ANSWERS. THAT’S GREAT.>>SO HOW MANY DIFFERENT THINGS CAN YOU TEST FOR WHEN YOU’RE DOING ALLERGY TESTING?>>WELL, WE ABOVE A STANDARD SET OF TESTING AND THIS HAS BEEN NARROWED DOWN BY THE FDA WHO TOOK A LOT OF ANTIGENS THAT WE HAD CAPABILITY OF USING BECAUSE WE NEVER DESENSITIZED TO ‘EM SO THOSE DISAPPEARED. TECHNICALLY, IF IT’S A PROTEIN ANTIGEN, WE COULD MAKE SOMETHING TO TEST WITH BUT I THINK MY PANEL IS PROBABLY 90, CURRENTLY.>>IF YOU’RE GOING TO GO ON ALLERGY SHOTS, YOU HAVE ALL YEAR-ROUND SHOTS, WE TEST FOR ABOUT 54 THINGS THAT ARE POLLENS AND THE DIFFERENT MOLDS AND THINGS LIKE THAT, AND THERE ARE LOTS OF FOODS THAT WE CAN TEST FOR AND SO THE BIG THING IS PICKING WHAT TO TEST. WE HAVE CERTAIN THINGS THAT ARE AVAILABLE BUT IF YOU DON’T HAVE EXPOSURE, YOU SHOULDN’T BE TESTED FOR IT. AND IF YOU HAVE SYMPTOMS IN A CERTAIN SEASON, YOU WANT TO MAKE SURE THAT YOU TEST FOR THOSE THINGS.>>SO PATIENTS KIND OF COME IN AND SAY, THIS IS WHEN I’VE HAD PROBLEMS AND YOU CAN KINDS OF HELP CUSTOMIZE WHAT YOU’RE LOOKING FOR?>>WE HAVE A LOT OF OPTIONS BECAUSE I HAVE A LOT OF SNOWBIRDS THAT GO TO DIFFERENT PARTS OF THE COUNTRY. NOW THEY’RE GOING TO GET A DIFFERENT SET OF TESTING THAN SOMEBODY WHO’S JUST GOING TO BE AT HOME IN ABERDEEN, WHERE I DO MOST OF MY TESTING, BUT IF THEY LIVE OVER IN ROBERTS COUNTIES, THEY HAVE A LOOT MORE OAK POLLEN, WE HAVE, LIKE, TWO OAK TREES AND THEY’RE REALLY WELL-RECOGNIZED, AND THEY HAVE LITTLE FENCES AROUND THEM. NO, I’M KIDDING.>>WITH FOOD, IT’S REALLY IMPORTANT THAT YOU ONLY PICK THE ONES THAT ARE POTENTIAL FOR PROBLEMS BECAUSE THERE IS A HIGH FALSE POSITIVE RATE WITH FOOD TESTING AND WE CAN GET PEOPLE INTO REALLY BAD DIETS BECAUSE THEY AVOID THINGS THAT THEY DON’T NEED TO.>>DO PEOPLE EVER NEED TO BE RETESTED AS THEY GET OLDER, DO THE ALLERGIES CHANGE?>>CERTAINLY. [Laughter]>>YEAH, THEY REALLY CHANGE.>>YEAH, THERE’S THE ATOPIC MARCH WE TALK ABOUT WHICH MEANS SAY YOU’RE A LITTLE GUY AND YOU HAVE ECZEMA AS A ONE-YEARS OLD AND YOU GET BETTER WITH THAT BUT YOU GROW INTO YOUR HAY FEVER AS A 10-YEAR-OLD AND A LITTLE BIT OF ASTHMA AND BY THE TIME YOU’RE 40, YOU DON’T HAVE MUCH, AND YOU’RE 70 AND EVERYTHING COMES BACK, AND WHAT ALERGENS ARE IMPORTANT AT EACH OF THOSE STAGES CAN BE COMPLETELY DIFFERENT.>>YOU’VE HAD A LOT OF CHANGE IN WHAT WE TEST TO AND HOW WE DO THAT BECAUSE YOU MENTIONED THAT ECZEMA IN CHILDREN AND NOW THEY, YOU KNOW, THOSE ECZEMA KIDS HAVE ALSO HIGHER RATE OF FOOD SENSITIVITY, AND SO PEANUT IS REALLY COME FORWARD.>>SO IS THE SKIN TESTING THE MOST ACCURATE WAY? I KNOW THERE ARE SOME BLOOD TEST ATTENTION BUILT HOW GOOD ARE THEY FOR TESTING FOR ALLERGIES AND –>>WELL, THE BLOOD TEST THAT THE PERSON THAT KIND OF BROUGHT THE BLOOD TEST FORWARD BECAUSE HE WAS MY MENTOR AND WANTED TO DO SOME REMOTE ALLERGY — JUST SENDS ME YOUR BLOOD, YEP, AND SO WE DID LOTS AND LOTS OF THOSE TESTS AND THERE ARE A LOT OF ISSUES WITH THE TESTING FALSE POSITIVES AND FALSE NEGATIVES AND AS DOCS, WE HATE FALSE POSITIVES AND FALSE NEGATIVES BECAUSE IT MAKES IT VERY DIFFICULT TO READ. SO I THINK THAT THE BLOOD TEST HELPS ME WHEN I HAVE NO OTHER OPTION BUT THAT’S VERY RARE. I THINK THE SKIN TEST, WHICH A BIOLOGIC TEST, IT TELLS YOU WHERE THE RUBBER MEETS THE ROAD IS A MUCH BETTER TEST, MUCH MORE ACCURATE. STILL REQUIRES SOME ABILITY TO READ IT BECAUSE WE HAVE PEOPLE WHO HAVE A THING CALLED DERMAGRAPHISM, THEIR SKIN IS HIVES JUST WHEN YOU MARK ON IT SO THAT REQUIRES SOME SKILL IN INTERPRETING THAT — THOSE PEOPLE.>>THE SKIN TEST IS ABOUT A THIRD THE PRICE OF A BLOOD TEST, AND WHEN YOU START DOING 50 OF ‘EM, THAT STARTS ADDING UP FOR PEOPLE. SO WE TRY TO DO THE SKIN TESTING, IT’S JUST BETTER TRUE POSITIVE, TRUE NEGATIVE — >>YOU GET THE RESULT RIGHT NOW, TOO, THAT MAKES A BIG DIFFERENCE.>>SO, FAST, EFFECTIVE AND CHEAP. WHY WOULDN’T YOU START WITH THE SKIN TESTING?>>MAINLY, PEOPLE DON’T HAVE ACCESS TO IT. I LIKE TELLING FAMILY DOCS AND PEDIATRICIANS, IF YOU’RE JUST GOING TO FIND OUT IS JUNIOR ALLERGIC TO THE DOG, MIGHT AS WELL GET THE ONE DOG TEST, IF THAT’S ALL YOU’RE LOOKING FOR, THEN YOU’RE DONE AND YOU FIND OUT, ANSWER YOUR QUESTION, MOVE ALONG. BUT IF YOU’RE TRYING TO FIGURE OUT THE WHOLE SEQUENCE OF THINGS, IT’S PROBABLY BETTER TO GET A CONSULT.>>ALL RIGHT, EXCELLENT. SO ANY OTHER THINGS THAT PEOPLE SHOULD BE ASKING FOR REFERRALS OR TALKING WITH THEIR FAMILY DOCTORS ABOUT WHEN IS IT APPROPRIATE TO MOVE ON TO SEE YOU IN THE CLINIC?>>WELL, WE SEE LOTS OF — MOST OF OUR REFERRAL SOURCES ARE, OF COURSE, FROM FAMILY PRACTICE PHYSICIANS WHO RECOGNIZE WHEN ANTIHISTAMINES FAIL TO WORK FOR UPPER AIRWAY CONGESTION, WHEN TOPICAL NASAL STEROID WHICH ARE NOW OVER THE COUNTER FAIL. SO WE USUALLY SEE THE FAILURE OF ANTIHISTAMINE, FAILURE OF TOPICAL NASAL STEROIDS OR I CAN’T TAKE IT, MY NOSE BLEEDS, I HAVE AN ISSUE WITH IT, SO THOSE MOSTLY COME OUT OF FAMILY PRACTICE. WE DO GET A FAIR NUMBER OF PATIENTS THAT COME FROM ENT FOR THAT VERY REASON. THEY’VE ALREADY DEVELOPED SINUSITIS OR POLYPS OR SOMETHING OF THAT ORDER SO WE GET A STREAM FROM THAT GROUP OF PHYSICIANS. THEN THERE IS A LOT OF SELF-REFERRAL, IT IS A FAMILY THING, WE’VE COMMENTED THE LITTLE SHOW THAT WE HAD BEFORE, IT — IF YOUR MOTHER IS ALLERGIC, YOU’RE GOING TO HAVE A VERY GOOD CHANCE OF BEING ALLERGIC.>>AND I THINK THAT A LOT OF FOLKS WHO HAVE ASTHMA, THEY COUGH AND THEY WHEEZE AND, YOU KNOW, IF THE NORMAL SIMPLE PREVENTIVES AREN’T WORKING, OR YOU’RE REALLY TIRED OF TAKING THE MEDS AND THERE’S SOME AVOIDANCE, CAN WE DO IMMUNOTHERAPY TO MAKE YOU HAVE A LOT LESS ASTHMA FOR THE DECADES TO COME, THAT’S WHERE A LOT OF PEOPLE COME FROM. I THINK FOOD ALLERGY, TRYING TO FIGURE OUT, IS IT REALLY THAT I’M ALLERGIC TO THIS AND YOU NEED TO SORT THINGS OUT, MOST PEOPLE ARE PRETTY GOOD. EVERY TIME THEY EAT SOME PEANUT, BREAK OUT IN HIVES, IT DOESN’T TAKE MANY TIMES AND YOU FIGURE THAT OUT, BUT — SO WE SEE A LOT OF…>>AND WE GET A FAIR NUMBER FROM PEDIATRICIANS BECAUSE OF THE WHOLE FOOD ALLERGY, ECZEMA OR ATOPIC DERMATITIS, THE KIDS THAT HAVE THE ITCHY SKIN IN THERE AND THE CUBITAL FOSSA HERE, I THINK WE GET A PRETTY GOOD STREAM OF VERY YOUNG CHILDREN WHICH TELLS YOU THAT WE CAN TEST AS LOW AS YOU WANT TO GO.>>ANY AGE.>>ANY AGE AND WE CAN GO AS HIGH AS YOU WANT TO GO BECAUSE YOUR REACTIVITY IS STILL NORMAL UNDER THOSE CIRCUMSTANCES.>>I REALLY WANT TO ALSO POINT OUT THAT THERE’S THE WASP AND YELLOW JACKET AN ANA PHYLAXIS PROBLEMS AND ALLERGISTS CAN DESENSITIZE THOSE FOLKS AND YOU GET THE IMMUNE SYSTEM BUILT UP AND YOU WON’T GET THE AN APHYLAXIS. NICE TO GET THOSE PEOPLE SO YOU DON’T MAKE SUCH A DIFFERENCE. ESPECIALLY THE BEE KEEPERS THAT ARE MAKING OUR HONEY, WE LIKE TO KEEP THEM SAFE.>>DEFINITELY. SO I THINK WE HAVE AN ANIMATION THAT SHOWS HOW THE NASAL STEROIDS WORK, SINCE THAT SOUNDS LIKE A PLACE WHERE A LOT OF PEOPLE START, MAYBE Dr. BUBAK, YOU COULD KIND OF TALK US THROUGH HOW TO DO IT CORRECTLY SO YOU GET THE MOST BANG FOR YOUR BUCK.>>IS THERE SOME PLACE WE CLICK, THEN, TO GET THIS STARTED?>>YEP, THEY’VE GOT IT ON THE…>>OH, THERE WE GO, RUNNING THERE. WHEN WE DO A NOSE SPRAY, IT KIND OF GOES UP THE NOSTRIL. HOW DOES THIS TURN ON? OH, GOLLY, YOU WOULD THINK THAT WE WOULD REMEMBER THAT. AH. WE TRY TO HAVE THINGS GO WELL. ANYWAY, WHEN WE SPRAY UP THE NOSE, IT’S SUPPOSED TO COAT THE TURBINATES HERE SO THEY DON’T SWELL AND DRIP AND ITCHY AND SNEEZY SO MUCH SO THE CORRECT TECHNIQUE IS THE NOSTRIL, YOU TAKE THE NOZZLE BARELY PUT IT INSIDE YOUR NOSE, AIM SLIGHTLY OUTWARD AND SQUIRT A COUPLE OF TIMES AND FLIP TO THE OTHER SIDE. TAKES A FEW DAYS, THOUGH, FOR IT TO START WORKING.>>I TELL PEOPLE TO LOOK AT THEIR TOES WHEN THEY SPRAY THEIR NOSE.>>GOOD THING TO REMEMBER. I KNOW A LOT OF PEOPLE THINK THEIR NOSE MAINLY GOES UP, IT GOES BACK QUITE A WAYS.>>THE ROOF OF YOUR MOUTH IS THE FLOOR OF THE NOSE.>>GOOD THING TO REMEMBER.>>DO YOU WANT TO TALK A LITTLE BIT ABOUT PEANUT ALLERGY?>>SURE.>>SINCE IT’S CONTROVERSIAL.>>I THINK WHAT WE’RE FINDING NOWADAYS IS HOW DO YOU PREVENT PEANUT ALLERGY, AND THERE’S CERTAIN RISK GROUPS THAT ARE VERY HIGH RATES AND SO IF YOU HAVE ECZEMA, THE ATOPIC DERMATITIS, YOU AND YOUR FAMILY ARE GOING TO HAVE AN INCREASED INCIDENCE OF PEANUT ALLERGY. IF YOU HAVE EGG ALLERGY, YOU’RE MORE LIKELY TO DEVELOP A PEANUT ALLERGY, SO THERE WAS A LEAP STUDY WHERE YOU TAKE FOUR-MONTH-OLDS THAT COME FROM FAMILIES WITH ALLERGIES, ESPECIALLY THE KIDS THAT HAVE ATOPIC DERMATITIS AND/OR EGG ALLERGY, AND SHOULD YOU FEED THEM PEANUT AT AGE FOUR TO SIX MONTHS, AND CONTINUE IT ON AND DOES IT DECREASE THE RATE OF ALLERGY TO PEANUT. BECAUSE FOR YEARS, WE SAID DON’T FEED ANY OF OUR KIDS PEANUTS UNTIL THEY’RE LIKE TWO YEARS OF AGE SO THE UNITED STATES HAS THE HIGHEST RATE OF PEANUT ALLERGY. SO IF YOU DO IT EARLY, WE’RE ABLE TO CUT THE RISK DOWN A LOT, SO IT’S LIKE 2% OF THESE KIDS, IF THEY’RE FED EARLY, WOULD HAVE THE — WOULD DEVELOP A PEANUT ALLERGY VERSUS 14% IF YOU AVOID IT. THAT’S IN A GROUP OF KIDS THAT HAVE NEGATIVE ALLERGY TESTING AT THE BEGINNING OF IT. IF YOU HAVE A LITTLE TEENY POSITIVE, IT’S MORE LIKE 10% OF KIDS DEVELOP IF YOU FEED THEM VERSUS 35% IF YOU DON’T FEED THEM. SO MAKES A BIG REDUCTION BY FEEDING THOSE KIDS.>>AND CAN YOU EXPLAIN THE ATOPIC DERMATITIS A LITTLE BIT, MORE WHAT SHOULD PARENTS AND GRANDPARENTS BE WATCHING FOR, WHAT DOES THAT PRESENT US?>>IT’S ITCHY SKIN, RASH, OFTEN THE KIDS’ FACE AND HEAD, ESPECIALLY DOWN THE LOWER OUTER LEGS. LITTLE KIDS, IT’S EVEN ON THEIR TRUNK. IT’S KIND OF THE RASH THAT ITCHES AND THE MORE THEY SCRATCH, THE WORSE IT GETS.>>WE USED TO CALL IT AN ITCH THAT RASHES, BECAUSE THE ITCH COMES FIRST AND — ATOPIC DERMATITIS IS VERY INTERESTING BECAUSE WHEN THEY STUDIED THE SKIN, YOU’RE MISSING A PROTEIN CALLED FILAGGRIN AT THE SAME RATE SO WHAT HAPPENS IF THE FILAGGRIN, KEEPS YOU FROM LOSING WATER, WHICH SOUNDS WEIRD, BUT IT IS, AND WHEN YOU — WHEN THE WATER LEAVES YOUR SKIN, YOUR REGULAR LAYER KEEPS IT FROM DOING THAT, WHEN YOU DON’T HAVE THE FILAGGRIN, IT MAKES YOU ITCH. DON’T HAVE THAT FILAGGRIN, YOU’RE ITCHY. THE ITCH IS MORE IN THE FOLDS BECAUSE THEY HAPPEN TO LOSE A LITTLE MORE WATER AND SO YOU HAVE THIS DERMATITIS AND THEN THERE’S THIS ODD ASSOCIATION OF THIS FILAGGRIN AND ATOPIC DERMATITIS WITH ALLERGY, SO SOME THINK THAT THE ALLERGY OCCURS BECAUSE THE ANTIGENS GET INTO THE SKIN BECAUSE IT’S NOT PROTECTED ANYMORE FROM THE KERATIN LAYER AND THIS FILAGGRIN IS GONE AND SO THE ANTIGEN GETS INTO THE SKIN AND DOES THE SENSITIZING. SO THAT’S ONE OF THE THEORIES.>>THE DUST IN OUR KITCHENS, WHEN THE KIDS ARE JUST PLAYING AND STUFF, IT LANDS ON THEIR SKIN AND THAT’S HOW THEY BECOME SENSITIZED EARLY ON. OR IS IF YOU’RE EATING THE FOOD, YOU KNOW, WE’RE SET UP BECAUSE WE HAVE TO EAT FOOD SO WHATEVER WE PUT THROUGH OUR MOUTH, WE WANT TO BE ABLE TO TOLERATE SO WE CAN EAT IT SO TOLERANCE DEVELOPS ORALLY, WHEREAS ON THE SKIN, YOU CAN DEVELOP THE ALLERGY A LOT EASIER.>>IT’S A PRETTY COOL DEAL THAT THIS HAS BEEN DISCOVERED BECAUSE WHEN I TELL PATIENTS, THESE ARE MOSTLY YOUNG KIDS, IS THAT THE CREAMS THAT WE USE — I DON’T USE MANY LOTIONS BECAUSE THEY’RE TOO THIN. I LIKE TO USE A CREAM THAT ACTUALLY ACTS LIKE A BARRIER OR A COVER AND IF YOU RUB IT IN REAL WELL, IT ACTUALLY KIND OF SUBSTITUTES FOR THE FILAGGRIN THAT YOU’RE MISSING AND THERE IS A NUMBER OF REALLY GOOD PRODUCTS FOR THIS AND THEN IF YOU’RE REALLY FANCY, YOU CAN PUT SOMETHING OVER THE TOP OF IT LIKE AN OINTMENT LIKE AQUAFOR, OR SOMETIMES VASELINE, WE USE AQUAFOR MOSTLY. SO YOU’VE CREATED A BARRIER, SO THE STUFF THAT’S COMING IN THERE IS A BARRIER, AND THE OTHER BARRIERS ARE CLOSED, VERY IMPORTANT. I HAPPEN TO BE A SOAKER, I LIKE THEM TO SOAK IN THE TUB AND THEN WHEN THEY COME OUT, PAT THEM DRY AND PUT THE PRODUCTS ON. I THINK IT DOES A GOOD JOB OF KEEPING THE SKIN INTACT SO THESE OTHER ALLERGIES THINGS DON’T HAPPEN.>>ASIDE FROM PEANUTS, IS THERE ANYTHING ELSE THAT PEOPLE CAN DO TO TRY TO PREVENT ALLERGIES FROM DEVELOPING?>>WELL, WE THINK EARLY FEEDING IS REALLY THE ONE FOR THE FOOD SENSITIVITY.>>PICK YOU KNOW YOUR PARENTS WOULD BE ONE –>>THANK YOU VERY MUCH, WE SAY THAT A LOT IN OUR OFFICE. [Laughter] THERE IS ANOTHER SITUATION, WHEN YOU LOOK FOR INHALENT ALLERGY, GERMAN CHILDREN WHO GROW UP WITH FARM ANIMALS INSIDE OF THE HOUSE, BASICALLY, THEY’RE JUST A BARN AWAY, THOSE KIDS HAVE FEWER ALLERGY THAN DO KIDS WHO ARE NOT EXPOSED, PRIMARILY CATTLE IS WHAT WE’VE SEEN, THERE HAS BEEN ASSOCIATION WITH DOG EXPOSURE AND LESS ALLERGY IF YOU WERE EXPOSED — YOUR MOM WAS EXPOSED AND THEN YOU WERE EXPOSED AS AN INFANT HAVING LESS ALLERGY UNDER THOSE CIRCUMSTANCES. WHETHER THAT WILL, YOU KNOW, BEAR OUT BEING A GREAT THING, WHAT YOU HEARD FROM MARK WAS, WE WENT FROM 14% TO 2% SO THERE’S STILL 2% THAT’S A PROBLEM BUT –>>AND THE EXPOSURES TO DIFFERENT THE AGRICULTURAL STYLES HAS REALLY BEEN BORN OUT WITH AMISH VERSUS HUTTERITE COLONIES AND THE HUTTERITE HAVE A HIGHER ALLERGY INCIDENCE, AND THERE’S SOMETHING WITH THE HYGENE OUT THERE, WE THINK.>>EVEN TRYING TO ISOLATE THE TYPE OF BACTERIA THAT SEEMS TO EXCITE OUR IMMUNE SYSTEM THAT SUPPRESSES ALLERGY, SO THAT’S VERY COOL.>>SO TAKE YOUR KIDS TO THE FARM AND LET THEM GET DIRTY.>>EXACTLY.>>THAT’S RIGHT. EXACTLY.>>AND WITH GENETICS — I RAISED THAT BEFORE BUT WHAT EVEN SKIPPING GENERATIONS AND THINGS, IF YOU DO ALLERGY SHOTS AS A PERSON AND THEN YOUR KIDS WILL HAVE FEWER CHANCES OF HAVING ALLERGIES, THAT’S A NEW STUDY THAT CAME OUT THIS PAST YEAR, AND HOW THAT GOES, IT’S NOT WHILE YOU’RE PREGNANT, IT’S BEFOREHAND, SOMETHING CHANGES AND YOU PASS ON LESS ALLERGENIC GENETICS.>>YOU REWRITE YOUR DNA.>>WOW. THAT’S A STORY WORTH READING, THEN. [Laughter] ALL RIGHT. ANY CORRELATION WITH BREAST FEEDING HELPING REDUCE ALLERGIES AT ALL?>>PROBABLY THE BREAST FEEDING FOR FOUR MONTHS IS WHAT’S RECOMMENDED FROM AN ALLERGY STANDPOINT, IF YOU CAN DO THAT. IT SEEMS TO REDUCE IT SOMEWHAT.>>ONE OF THE THINGS THAT WE — THAT I TELL FOR MY PEDIATRIC STANDPOINT IS AS LONG AS YOU’RE BREAST FEEDING, YOU DO TEND TO REDUCE IT BECAUSE WHAT’S IN THE BREAST MILK IN REGARDS TO CELLULAR DOES TEND TO SUPPRESS, BUT, AGAIN, REMEMBER, WE’RE USING OUR G.I. TRACT WHICH IS BETTER ADAPTED TO TOLERANCE AND DESENSITIZATION THAN WHAT WE TALKED ABOUT OUR SKIN AND OUR NOSE, OUR RESPIRATORY TREE DEPENDS TO SENSITIZE A LITTLE BIT MORE. SO I THINK IT REALLY PREVENTS ALLERGY FOOD. I DON’T KNOW HOW MUCH IT PREVENT ALLERGY INHALANT, ALLERGY SKIN.>>HOW ABOUT SMOKING, DO YOU THINK THAT IF PEOPLE AVOID SMOKING, IT DECREASES ALLERGY?>>THAT’S WHAT THEY SAY, A PRETTY GOOD CORRELATION. SECONDHAND SMOKE AND ACTUAL SMOKERS. THERE IS A WHOLE PLETHORA OF THINGS THAT HAPPEN TO YOU IF YOU’RE A SMOKER. I MEAN, YOUR ALLERGIES ARE WORSE, YOUR PULMONARY DISEASE IS WORSE, YOUR IMMUNE SYSTEM IS WORSE, THERE’S NOT REALLY ANYTHING THAT DOESN’T GET WORSE IN REGARDS TO ALLERGY AND RESPIRATORY TREE.>>SO IF YOU DIDN’T HAVE ENOUGH REASONS TO STOP SMOKING, THERE’S ANOTHER.>>THERE’S ANOTHER REASON, ABSOLUTELY.>>ANOTHER REASONING.>>SO ARE FARM KIDS LESS LIKELY TO GET ALLERGIES AS THE CITY KIDS?>>YES.>>YEP.>>YEP. CLEARLY SEE THAT.>>YEP, WE SEE THE KIDS THAT ARE PEOPLE THAT HAVE MOVED FROM THE FARM AND CHILD ONE DOESN’T HAVE MUCH ALLERGY AND NOW THEY’RE IN THE CITY AND CHILD TWO DOES, AGAIN, PICKING YOUR FAMILY, THEY’RE ALLERGIC FAMILIES, ALSO. DEFINITELY RUNS IN FAMILIES.>>SO IT’S GOOD TO GET DIRTY ON THE OUTSIDE, AROUND ANIMALS BUT WHAT ABOUT INSIDE AND INDOOR ALLERGENS, LIKE DUST, DUST MITES, WHAT DO WE DO WITH THEM?>>THE DUST MITE IS JUST — YOU KNOW, WE’RE NOT ALLERGIC TO THE MITE ITSELF, WE’RE ACTUALLY ALLERGIC TO HIS WASTE PRODUCT SO I SAID IN ANOTHER SHOW, DUST MITE POOP IS OUR ENEMY, AND THE PART OF IT’S BECAUSE IT AEROSOLIZES SO EASILY AND GETS UP INTO OUR UPPER AIRWAY. AND PREVENTION THERE IS REALLY NOT HAVING MUCH CARPETING. IT DOES — CARPETING TENDS TO END HA ENHANCE THE GROWTH OF THE DUST MITE WHEREAS GIVING IT SOMEWHERE TO GROW WHEREAS HARDWOOD FLOORS NOT SO MUCH. WE DO HAVE SOME CONTROVERSY ABOUT — WE HEAR ABOUT ALLERGEN COVERS AND THAT KIND OF THING. YOU KNOW, THE DATA IS SO SOFT, YOU KNOW WE, GRADE OUR DATA LIKE A, B, C, D E, F, AND THIS IS LIKE C DATA, AT BEST.>>BUT ENCASEMENT IS RIGHT.>>ENCASEMENTS –>>IT’S REALLY HARD TO AVOID ENOUGH DUST MITES TO CLEARLY MAKE A DISTANCE UNLESS YOU GO HIGHER THAN A MILE OR DRY OUT YOUR ENVIRONMENT AND AVOIDING THE DUST MITES BEFORE YOU HAVE ALLERGY REALLY DOESN’T SEEM TO MAKE A DIFFERENCE. ACTUALLY, THE CLEANER YOU ARE, PROBABLY THE MORE ALLERGIES YOU’RE GOING TO END UP INSIDE, AVOIDANCE JUST AS WELL AS THE OUTSIDE STUFF WE WERE TALKING ABOUT.>>JUST LIKE WE SAID, YOU KNOW, YOU CAN DO SOMETHING WITH THE SKIN TO KIND OF PROTECT YOURSELF FROM HAVING IT GET SENSITIZED HERE BUT YOU CAN’T PROTECT THIS VERY WELL, SO, AGAIN, I THINK THE DATA IS PRETTY SOFT ON INHALANT SENSITIZATION.>>OKAY.>>THE EPIPEN CAN BE LIFE-SAVING WHEN USED CORRECTLY IN THE EVENT OF A SEVERE ALLERGIC REACTION. SO WE’RE GOING TO DO AN ACTUAL DEMONSTRATION. THIS IS NOT A PRACTICE PEN, A REAL PEN. I’M NOT HAVING AN ALLERGIC REACTION BUT I’M NOT AFRAID OF IT BECAUSE I KNOW I HAVE GOOD GUYS TO PROTECT ME BUT IT’S A SAFE THING TO DO, EVEN IF YOU DIDN’T NEED IT, RIGHT?>>EXACTLY. I MEAN, THIS IS A WONDERFUL DEMONSTRATION.>>SO WE SHOULD NOT BE AFRAID TO USE IT IF WE THINK WE MIGHT NEED IT. HOW WOULD YOU MIGHT NEED IT?>>IF YOUR THROAT’S SWELLING, YOU’RE ITCHING, HARD TO BREATH, FEEL LIKE YOU’RE GOING TO THROW UP, ANY OF THOSE THINGS ARE SIGNS OF AN ANAPHYLACTIC REACTION.>>PARTICULARLY IF YOU KNOW YOU’VE HAD A PREVIOUS REACTION OR YOU KNOW YOU’VE BEEN STUNG AND YOU KNOW THAT THERE’S SOMETHING — I CALL IT THE FEELING OF IMPENDING DOOM AND YOU SHOULD DO SOMETHING.>>SOMETHING TO DO. SO I’M HAVING THAT IMPENDING DOOM, I WAS JUST BITTEN BY A WASP OR, I MEAN, STUNG BY A WASP OR I JUST ATE A PEANUT AND I’M IN TROUBLE AND I KNOW IF I DO THIS, IT WON’T PUT ME AT RISK. AND IF I DON’T DO IT, IT WILL PUT ME AT GREAT RISK. SO I WANT TO DO THIS. THIS IS THE EPIPEN, THERE IS ANOTHER PRODUCT, BOTH THE SAME, RIGHT?>>RIGHT, THEY’LL DO THE SAME THING. THEY’LL SAVE YOUR LIFE.>>SO QUICKLY, WITHIN A COUPLE OF MINUTES, HELP TURN THAT ALLERGIC REACTION AROUND.>>ALL RIGHT. AND THEN YOU GET TO THE EMERGENCY ROOM.>>YES, YOU DO.>>SO THIS IS A REAL PEN, I’M GOING TO TAKE IT OFF THE TOP AND –>>TAKE IT OUT OF THE PROTECTIVE CASE, GET RID OF THAT.>>THROW THAT.>>AND THEN THE PIN COMES OUT, –>>THE COVER COMES OFF.>>THROW IT AWAY. IT’S FULLY ARMED.>>FULLY ARMED, NOW WE’RE READY.>>ON YOUR THIGH.>>ON YOUR THIGH, THROUGH MY CLOTHES AND I’LL PUSH IT IN AND HOLD IT FOR TEN SECONDS. THERE YOU GO. ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN, EIGHT, NINE, 10.>>AWESOME.>>I COULD FEEL IT.>>WAY TO GO.>>IT HURT A LITTLE, NOT BAD.>>NO, JUST A SURPRISE.>>AND IN A MINUTE OR SO HERE, YOU’RE GOING TO FEEL THAT YOUR HEART STARTS BEATING FAST, AND YOU’LL FEEL A LITTLE JITTERY, LIKE YOU JUST GOT SCARED AT THE MOVIE THEATER.>>OR HAD WAY TOO MUCH COFFEE.>>OR I WAS GOING TO GIVE A SOLO.>>THE ITCHINESS WILL START TO RECEDE AND YOU’LL BE FEELING A LOT BETTER AND YOU CAN MAKE YOUR WAY TO MEDICAL CARE NOW.>>VERY GOOD. THAT’S GREAT. THANK YOU FOR PROVIDING US A PEN AND FOR BEING HERE.>>WELL, THANK YOU.>>TWO WONDERFUL ALLERGISTS.>>THANK YOU FOR DEMONSTRATING IT. THAT WAS AWESOME. >>SO, Dr. HOLM DEFINITELY WAS THERE TO SHOW US EXACTLY WHAT IT’S LIKE. BUT COULD ANYTHING BAD HAPPEN IF YOU USE AN EPIPEN OR IF YOU USE IT AND YOU DIDN’T REALLY NEED IT?>>I THINK THE HAZARDS OF AN EPIPEN ARE GREATLY OVERBLOWN. BASICALLY, WHEN YOU GET SCARED AT A MOVIE, YOUR OWN EPIPEN GOES OFF AND YOU GET A LITTLE BIT FASTER HEART BEAT AND THINGS LIKE THAT. THE REALITY IS, EVEN IF YOU HAVE BAD HEART DISEASE, IF YOU’RE HAVING ANAPHYLAXIS AND CAN’T BREATHE AND DON’T HAVE BLOOD PRESSURE, YOU’RE GOING TO HAVE PROBLEMS BECAUSE OF THAT SO, BASICALLY, THE RISK IS SMALL AND THE BENEFITS ARE GREAT.>>AND YOU REMEMBER THAT WHEN WE USED TO BE IN THE EMERGENCY ROOM AND SOMEBODY COMES IN WITH A CARDIOVASCULAR EVENT, I.E., MY HEART STOPS, WE USED TO USE EPINEPHRINE AND WE EVEN USED IT INTRA-CARDIAC, SO IT’S THE WHOLE CARDIAC VASO CONSTRICTION THING IS REALLY NOT SOMETHING THAT IS IN PLAY BECAUSE JUST AS MARK SAID, YOU DON’T USE IT, THAT LOSS OF BLOOD PRESSURE IS VERY, VERY DANGEROUS. THAT’S THE THING THAT GETS US INTO TROUBLE AND IS DIFFICULT TO REVERSE. AND THE EPIPEN IS THE ANTIDOTE. THE SOONER YOU USE IT, THE BETTER IT WORKS. THE SOONER YOU RECOGNIZE IT AND THE HARDEST THING FOR TO US DO IS TO GET PEOPLE TO USE IT. I MEAN, I CAN’T TELL YOU HOW MANY TIMES SOMEBODY HAS COME IN, THEY’VE HAD A SYSTEMIC REACTION, NOT ANAPHYLAXIS, DROPPED THEIR BLOOD PRESSURE, THAT KIND OF THING AND.HAVE NOT USED THEIR EPIPEN AND I ALWAYS SAY, IF YOU WOULD HAVE USED YOUR EPIPEN, THIS EPISODES WOULD HAVE BEEN A LOT MILDER. IT’S JUST THE FEAR, I THINK, OF THIS MECHANISM OF THIS SELF-ADMINISTERING AND SELF-INJECTABLE PEN.>>NEEDS HE WILL INTO YA.>>EXACTLY BUT DIABETICS DO IT ALL THE TIME, WE HAVE A WHOLE LIST OF PEOPLE THAT USE NEEDLES ALL THE TIME, M.S. PATIENTS, WE HAVE A LOT OF THEM.>>THE OTHER GOOD NEWS NOW IS IT DOESN’T COST SO MUCH.>>YEAH, THAT WAS A BIG DEAL.>>IT’S $300 FOR WOULD BE SHOT. PEOPLE WERE WONDERING ABOUT IT. WITH NEW OPTIONS, EPIPEN GENERIC CAME OUT, THERE’S THE ADRENA-CLICK, WHICH IS A DIFFERENT STYLE EPINEPHERINE INJECTOR AND THERE IS AN GENERIC OF IT AND THE LVQ IS COMING BACK, SO THERE’S FIVE DIFFERENT ONES SO THERE’S MORE INTENSE COMPETITION, SO PRICES ARE COMING DOWN, SPECIAL DEALS BEING MADE SO PEOPLE CAN GET THEIR EPIPENS OR EPINEPHRINE INJECTORS AS WE PROBABLY SHOULD CALL THEM NOW.>>BUT THEY DO NO GOOD IF THEY SIT IN YOUR CAR OR YOUR PURSE AND DON’T USE THEM.>>DON’T LET THEM SIT IN THE CAR, BY THE WAY, EPINEPHRINE IS VERY SENSITIVE TO HEAT SO LEAVING IT IN YOUR PURSE IN THE CAR OR LEAVING THEM IN THE TRUCK IS A VERY BAD PLAN. IT NEEDS TO BE IN A COOLER. IT DOESN’T SURVIVE HEAT VERY WELL, AT ALL.>>LIKE THE 120, 140 IN A CAR.>>CORRECT. LIKE HOW MANY PENS SHOULD PEOPLE HAVE? SHOULD THEY’VE-LIKE STUDENTS HAVE ONE AT SCHOOL AND ONE AT HOME OR ONE AT GRANDMA AND GRANDPAS, HOW MANY OF THESE DO YOU HAVE STASHED AROUND?>>MY PATIENTS USUALLY HAVE AT LEAST TWO BECAUSE YOU HAVE TO REMEMBER THAT MANY PEOPLE IN SOUTH DAKOTA ARE AT LEAST 30 MINUTES FROM ANY TYPE OF HEALTH CARE FACILITY AND IF YOU’RE OUT WEST, IT MAY BE 45 MINUTES SO I HAVE PATIENTS WHO HAVE MULTIPLE PENS, DEPENDING UPON WHAT THEY ARE ANAPHYLACTIC TO AND THAT KIND OF THING, MY BEE STING PEOPLE BEING THE ONES THAT I REALLY ENCOURAGE GETTING DESENSITIZED SO THEY DON’T HAVE TO DEPEND ON THE EPIPEN, BECAUSE THE EPIPEN IS NOTORIOUSLY NOT ON THE PATIENT WHEN THEY GET EXPOSED.>>SO TWO THINGS HERE. ONE, WHAT YOU’RE POINTING OUT IS THAT — EPINEPHRINE INJECTION USUALLY WILL HELP SOMEBODY FOR ABOUT 15 MINUTES AND THE DRUGS METABOLIZED AND THE EFFECTS IS WEARING OFF. SO IF YOU HAVE A SECOND ONE AROUND, YOU CAN ADMINISTER THE SECOND ONE, HELP THEM OUT, BREATHE AND GET THEIR BLOOD PRESSURE UP AGAIN WHILE THEY’RE ON THEIR WAY TO THE E.R. ANOTHER QUESTION IS, HOW MANY DO YOU NEED TO HAVE AROUND AND IT’S REALLY KIND OF A FAMILY DECISION. IF YOU ALWAYS FORGET IT ON YOU, IT MIGHT BE NICE TO HAVE IT AT GRANDMA’S OR AT LEAST IT’S AVAILABLE.>>AND SHOULD IT BE STORED IN THE FRIDGE, JUST AT ROOM TEMPERATURE? AVOIDING HOT AREAS BUT OTHER THAN THAT, ANY OTHER SPECIAL –>>NO, JUST ROOM TEMPERATURE. IT’S DESIGNED TO BE AT ROOM TEMPERATURE SO THAT WOULD BE MY ADVICE WOULD BE TO HAVE IT AVAILABLE AND JUST LIKE MARK SAID, TRYING TO TRANSPORT IT TO GRANDMA’S, THE TWO GRANDMAS AND ALL OF THIS KIND OF THING IS WOEFULLY INEFFICIENT SO HAVING IT AT THE PLACES THAT THE CHILD IS, OR THE ADULT IS THE MOST IMPORTANT THING.>>ALL RIGHT. AND YOU SAID AFTER YOU USE IT, YOU SHOULD STILL GO IN TO THE EMERGENCY ROOM BECAUSE IT’S GOING TO WEAR OFF AND –>>SHOULD BE EVALUATED, ABSOLUTELY. THERE’S ALWAYS SOME — YES, IT WORKS BEAUTIFULLY AND THAT KIND OF THING BUT THERE STILL ARE ISSUES WITH VENOM EXPOSURES AND –>>HOW LONG IS THE ANAPHYLAXIS GOING TO LAST AND IF IT’S A TWO-HOUR THING SHE IT MIGHT BE NICE TO BE WHERE THEY HAVE MORE OF THE MEDICINE TO HELP YOU OUT. THAT’S THE WHOLE IDEA OF GETTING TO MEDICAL CARE.>>YEAH, ALLERGIC REACTIONS HAVE TWO PHASES, THE IMMEDIATE PHASE AND THEN THERE IS THE SECOND PHASE TO IT THAT CAN HAPPEN ANYWHERE FROM TWO TO FOUR HOURS AND CAN BE EQUALLY SEVERE SO IT’S GOOD TO HAVE SOMEBODY OBSERVING YOU AFTER YOU’VE USED THAT EPIPEN.>>SO DO YOU USE IT IF YOU JUST BREAK OUT IN A RASH OR WHEN THE LIPS HAVE TINGLING, YOU FEEL THE THROAT — AT WHAT POINT IN THE REACTION, HOW DO YOU KNOW IF IT’S GOING TO BE BAD ENOUGH TO NEED THE PEN VERSUS JUST TAKING SOME BENADRYL AND WAITING?>>WELL, AGAIN, WE’RE THE ALLERGISTS SO WE’RE VERY AGGRESSIVE WITH EPINEPHRINE. I USE IT ON PATIENTS IN MY OFFICE THAT HAVE SYSTEMIC REACTION TO THEIR SHOTS VERY EARLY BECAUSE I KNOW HOW WELL IT WORKS AND IT REALLY IS THE APPROPRIATE ANTIDOTE SO THE ANSWER TO YOUR QUESTION IS… [Overlapping Conversation]>>EXACTLY.>>IF YOU’RE HOME, PERSON, LITTLE JUNIOR HAS A LITTLE SOMETHING TO EAT AND HE GETS SIX HIVES ON HIS FACE AND IS TALKING PLAIN, THAT’S JUST GOING TO GO AWAY BY ITSELF. THE BENADRYL IS GOING TO TAKE 30 MINUTES BEFORE IT EVEN STARTS DOING ANYTHING AND SO — ALL IT HELPS IS WITH ITCH, SO I TELL PEOPLE DON’T EVEN WORRY ABOUT THAT. I WORRY THAT THE VOICE STARTS CHANGING, THEY START THROWING UP, COUGHING, WHEEZING, IF THEY’RE LOOKING LETHARGIC, ALL THOSE ARE SIGNS YOU GIVE THAT EPI.>>THE LITTLE GUYS REALLY GET KIND OF FLOPPY WHEN THIS OCCURS AND IT’S REAL OBVIOUS THAT SOMETHING SYSTEMIC IS HAPPENING. IT’S NOT SUBTLE, AT ALL, AT LEAST IT HASN’T BEEN. I HAVEN’T SEEN VERY SUBTLE ONES, AT ALL, SO I DON’T — I’M VERY AGGRESSIVE WITH IT. I LIKE THEM TO USE THEIR EPIPEN AND THEN DECIDE –>>DOESN’T REALLY HURT YOU MUCH. YOUR HEART RACES A LITTLE BIT AND NOW THE PRICE IS BETTER, SO…>>OKAY. SO USE IT IF THERE IS ANY CONCERN OR DOUBT, BETTER TO BE SAFE THAN SORRY.>>YEAH, EXACTLY.>>ALL RIGHT. AND THEN WITH FOOD ALLERGIES, DO THEY CHANGE OVER TIME? I MEAN, I KNOW MY BROTHER HAD AN ALLERGY TO CORN WHEN I WAS LITTLE AND I LEARNED THAT IF HE SAID THAT, HE DIDN’T HAVE TO EAT IT SO WHENEVER I WENT TO MY FRIENDS’S HOUSE AND THEY SERVED SOMETHING I DIDN’T LIKE, I SUDDENLY DEVELOPED AN ALLERGY TO IT SO I COULD POLITELY DECLINE.>>YOU WERE REALLY SMART AS A CHILD. THAT’S VERY CLEVER. [Laughter]>>YES, THAT’S — YES, FOOD ALLERGIES DO CHANGE. MARK ALLUDED TO IT, IS THAT WE SEE A LITTLE MORE ALLERGIC DISEASE OR A LOT MORE ALLERGIC DISEASE THAN THAT ONE-YEAR-OLD TO FIVE-YEAR-OLD GROUP, AND THEN WE SEE A LITTLE BIT LESS AND WE SEE PEOPLE THAT WE’VE TESTED TO COW’S MILK ANTIGEN AND IT’S POSITIVE AND THEY HAVE SYMPTOMS ASSOCIATED WITH IT, AND THEN THEY’RE FIVE YEARS OLD AND THOSE SYMPTOMS SEEM TO ABATE. SO THERE ARE CERTAIN ANTIGENS. I THINK EGG IS PROBABLY THE ONE THAT SHOWS THE MOST POST ACTIVITY AND GETS BETTER AS MUCH AS ANY ANTIGENS –>>SO MILK AND EGG, ALMOST EVERYBODY OUTGROWS THAT BEFORE THEY GRADUATE FROM HIGH SCHOOL. VERY FEW PEOPLE, IT’S PROBABLY 18% THAT OUTGROW NUT ALLERGY EVER IN THEIR LIFE TIME, AND, YOU KNOW, THAT’S — IT’S ANTIGEN OR ALLERGY, EAT WHAT THE FOOD STUFF IS MAKES A BIG DIFFERENCE.>>THE FISH ANTIGEN IS KIND OF INTERESTING, JUST FOR CONVERSATION IN THAT THE FISH ANTIGEN, YOU DON’T GROW OUT OF IT AND IT’S HEAT STABLE SO WHEN FISH IS COOKING AND IT’S IN THE AIR, YOU CAN HAVE AN ALLERGIC REACTION FROM THE FISH COOKING, SO WE HAVE PEOPLE — SHAME WITH SHELL FISH, THAT GO TO THAT BENIHANA THING AND THEY COOK IT IN FRONT OF THEM AND THE GUY HAS AN ASTHMA ATTACK AND CAN HAVE A SYSTEMIC REACTION JUST LIKE HE ATE IT AND HE JUST INHALED IT. VERY UNIQUE PROTEIN.>>PEOPLE WORRY ABOUT THAT WITH PEANUT AND IT’S VERY RARE THAT INHALED STUFF IS A PROBLEM, EVEN ON A PLANE NOWADAYS. IT’S BEEN SHOWN PRETTY NICELY, YOU NEED TO WIPE YOUR SEAT OFF, OR YOUR CHILD’S SEAT, DON’T TOUCH IT AND BRING IT TO YOUR MOUTH.>>RIGHT, IT’S NOT AN AEROSOLIZED ONE, IT’S MORE THE HAND-MOVING KIND OF ANTIGEN.>>I THINK WHAT’S GOOD TO SAY, TOO, IF YOU HAVE, SAY, THE PEANUT BUTTER OR STUFF ON YOUR SKIN, YOU’RE GOING TO GET SOME HIVES LOCALLY BUT YOU ACTUALLY HAVE TO EAT THE PEANUT TO HAVE ANAPHYLAXIS, SO ONCE WE UNDERSTAND THAT, IT MAKES THE ANXIETY LEVEL SO MUCH LOWER FOR NOT ONLY THE PATIENT BUT FOR THE PARENTS. GOING TO SCHOOL, A PERSON HAS A LITTLE ON THEIR HANDS, WASH IT OFF. IT’S IMPORTANT TO REALIZE THAT.>>WE DO HAVE PRACTITIONERS THAT HAVE DONE A LOT OF WORK IN THE PEANUT AND HAVE ORALLY DESENSITIZED KIDS THAT — AND MARK AND I HAVE BEEN EMBRACED THIS BY LOOKING AT IT BUT IT IS THE VERY DIFFICULT THING TO DO, YOU HAVE TO HAVE VERY LITTLE DOSES, YOU PUT THEM IN LITTLE MEDICINE CUPS AND THE BIGGEST DISADVANTAGE I THINK IS THAT YOU CAN’T — CANNOT MISS YOUR DAY WITH YOUR PEANUT BUTTER, ONCE YOU’VE BEEN DESENSITIZED BECAUSE YOUR CHANCE FOR ANAPHYLAXIS RETURNS, EACH WITH A VERY SMALL GAP SO NOT VERY PRACTICAL.>>PROBABLY 25% OF THE PATIENTS ON THEIR THREE-YEAR TREATMENT ANAPHYLAX RANDOMLY WITH THAT YOUR DOSES AND ONCE YOU QUIT EVERY DAY, MOST PEOPLE RELAPSE WITHIN JUST FOUR MONTHS. IT’S ABOUT TWO-THIRds OF PATIENTS RELAPSE AND THEY HAVE ANAPHYLAXIS AGAIN. IT’S INTERESTING AND IT’S NEAT, THOUGH, THAT SOME PEOPLE CAN BE DESENSITIZED. AND THEN THERE’S THE NEW PATCH THAT’S BEEN WORKED ON AND JUST DOESN’T MAKE YOU LESS ALLERGIC ENOUGH TO BE PRACTICAL YET.>>OKAY.>>BUT A LOT OF RESEARCH GOING INTO FOOD ALLERGY.>>IT’S LIKE ENVIRONMENTAL ALLERGIES, IS IT BEST TO TRY TO LIMIT YOUR EXPOSURE, LIKE IF YOU’RE OUT CUTTING THE GRASS OR YOU’RE DUSTING, SHOULD YOU WEAR A MASK, IS THAT GOING TO HELP LIMIT YOUR EXPOSURE AND LIMIT YOUR REACTION?>>A BARRIER IS VERY HELPFUL, SO WE HAVE A LOT OF PEOPLE THAT — I MEAN, LAWN-MOWING IS A VERY POPULAR SPORT IN SOUTH DAKOTA AND THE LARGER THE LAWN YOU MOW, THE BETTER. SO, YES, MASKING HELPS PROBABLY AS MUCH AS ANY MEDICATION YOU TAKE. AS A MATTER OF FACT, MEDICATION, BECAUSE YOU’RE GETTING SUCH A BIG EXPOSURE OVER A LONG PERIODS OF TIME USUALLY IS NOT VERY SUCCESSFUL IN CAUSING SYMPTOMS TO BE SIGNIFICANTLY REDUCED, PARTICULARLY THE SYMPTOMS THAT NIGHT AFTER YOU’VE DONE THIS LAWN MOWING SO, YES, I’M VERY BIG ON MASKS. I LIKE THE N-95 MASK BECAUSE IT HAS A BUTTON IN THE FRONT THAT WHEN YOU EXHALE, IT — IT DOESN’T STAY IN THE MASK SO THAT’S A VERY GOOD THING TO DO.>>MOST PEOPLE DON’T REALLY LIKE TO WEAR THOSE AND THEY FEEL STUPID.>>ESPECIALLY… [Overlapping Conversation]>>WEARING IT AND SO I FIND IT’S PRETTY NON-PRACTICAL TO DO THAT.>>SO — BUT DON’T LET YOUR VANITY GET IN THE WAY OF PREVENTING THE SUFFERING.>>WE SHOULDN’T LET IT GET IN THE WAY BUT WE DO.>>ACTUALLY, I’VE BEEN SURPRISED. MY FARMERS HAVE ACTUALLY DONE A PRETTY GOOD JOB BECAUSE THEY KNOW THEY GET REAL SICK IF THEY’RE IN A GRAIN BIN OR SOMETHING LIKE THAT AND WEARING SOME KINDS OF PROTECTION, THEY EVEN HAVE A HELMET, A POSITIVE PRESSURE HELMET THAT’S VERY SUCCESSFUL WHEN YOU HAVE TO BE IN IT FOR A LONG PERIOD OF TIME.>>OKAY. AND YOU SAID THE N-95 MASK, IS THAT DIFFERENT FROM THE ONES THEY CAN PICK UP AT WALMART OR WHAT SHOULD THEY BE LOOKING FOR?>>YES, RIGHT. N95 IS USUALLY AT YOUR LOCAL LIKE MENARD’S OR SOMETHING HAS A LITTLE MORE SOPHISTICATED MASKS AND THEY WORK BETTER. THE LITTLE PAPER MASKS ARE THE ONES THAT, AS MARK SAID, VERY FEW PEOPLE WEAR ‘EM BECAUSE THEY MELT ON YOUR FACE ON A HOT DAY. AND YOU CAN GET USED TO WEARING A MASK BUT, LIKE MARK AGAIN SAID, MOST PEOPLE ARE NOT BIG FANS OF WEARING MASKS WHILE THEY’RE MOWING LAWN FOR FIVE HOURS.>>ALL RIGHT. WELL, I CAN’T BLAME THEM. [CHUCKLING]>>WE WERE TALKING A LITTLE BIT ABOUT YOU CAN’T PICK YOUR PARENTS BUT IS THERE ANYTHING THE PARENTS CAN DO, MOMS CAN DO DURING PREGNANCY TO TRY TO LIMIT THEIR CHILDREN FROM GETTING ALLERGIES, YOU KNOW, TAKING FISH OIL? IS THERE ANY MERIT TO THAT OR IS THAT AN OLD WIFE’S TALE?>>JUST, JUST BEING DESENSITIZED AS A MOM WHO IS ALLERGIC WILL REDUCE THE ALLERGY IN YOUR CHILD AND YOUR SUBSEQUENT PREGNANCIES.>>ALL RIGHT.>>THAT’S WHAT YOU DO.>>TAKE CARE OF YOURSELF FIRST.>>RIGHT.>>AND DON’T WORRY ABOUT WHAT FOODS YOU’RE HAVING, YOU KNOW, EAT A HEALTHY DIET.>>WE DON’T TYPICALLY DESENSITIZE WHILE YOU’RE ACTIVELY PREGNANT BECAUSE THE SMALL RISK OF A SYSTEMIC REACTION IS KIND OF — BECAUSE YOU’VE GOT TWO PEOPLE INVOLVED AND THAT KIND OF THING, WE DON’T DO THAT AS A RULE SO WE REALLY LIKE TO DO IT OUTSIDE OF THE PREGNANT STATE.>>IF YOU’RE ALREADY BEING DESENSITIZED AND YOU’RE ON SHOTS, WE JUST STABILIZE A DOSE AND WE KEEP IT UP SO THAT’S OF VALUE IF YOU’RE PLANNING ON BEING PREGNANT.>>SO HOW LONG DOES THE DESENSITIZATION PROCESS TAKE? IS IT MONTHS, YEARS, KIND OF AN ONGOING, INDEFENDANT –>>ALLERGY SHOTS ARE TYPICALLY THOUGHT OF AS FIVE YEARS. WE KNOW YOU HAVE TO DO THREE YEARS IF YOU DO ANYTHING SHORTER, ONCE YOU STOP YOU RELAPSE AND ALL YOUR HAY FEVER-TYPE SYMPTOMS WOULD COME RIGHT BACK. SO IT STARTS OUT BUSY, A COUPLE TIMES A WEEK. ABOUT A YEAR, IT’S PRETTY CLOSE TO ONCE A MONTH THAT YOU’RE DOING IT, SO IT’S NOT SO BAD AT THAT POINT.>>OKAY. AND THAT’S SOMETHING THAT’S DONE AT A DOCTOR’S OFFICE, NOT SOMETHING YOU DO AT HOME BY YOURSELF?>>YOU DO IT AT A DOCTOR’S OFFICE, MUCH SAFER AND MOVING MOST ALL THE SHOTS TO THE DOCTOR’S OFFICE HAS REALLY MADE IT MUCH, MUCH SAFER TREATMENT FOR PEOPLE. PEOPLE DON’T DIE FROM ALLERGY SHOTS NOW SO THAT’S –>>THE OTHER THING I THINK IS CONSISTENCY IMPROVED A LOT OVER THE HOME SHOTS. THEY SHOWED THAT PEOPLE WOULD FORGET AND THEN THEY DO THEM IN A HAPHAZARD WAY AND THAT DOESN’T WORK WHETHER YOU USE ITS FOR THREE YEARS OR FIVE YEARS, THE THING THAT HE WAS ALLUDING TO IS ACTUALLY VERY NEW INFORMATION BECAUSE THEY TOOK PEOPLE THAT JUST DID SHOTS FOR ONE YEAR, ONES DID IT JUST FOR TWO YEARS, JUST FOR THREE YEARS AND WOULD STOP THEM AND SEE IF THEIR ALLERGY COMES BACK AND IT WAS A VERY GOOD STUDY, ONE THAT SHOULD HAVE BEEN DONE BEFORE AND THIS IS VERY GOOD INFORMATION. WHAT THEY’VE DEVELOPED IN THAT THIRD YEAR IS CALLED TOLERANCE AND THAT’S THE THING THAT WE’RE AIMED FOR. YOU CAN DESENSITIZE A PERSON PRETTY QUICKLY BUT FOR THEM TO DEVELOP PERMANENT TOLERANCE OR SEM-PERMANENT TOLERANCE IS THE THING WE’RE AIMING FOR.>>GREAT WAY YOU DON’T HAVE TO TAKE SO MANY MEDS AND DON’T HAVE TO TAKE THE SHOTS ANYMORE.>>ALL RIGHT. SO, I THINK THIS IS WRAPPING UP OUR TIME HERE, SO WE’LL GET THE ANSWER TO TONIGHT’S PRAIRIE DOC QUESTION. SO YOU WATCHING OUT THERE, HAVE YOU FIGURED OUT HOW EPINEPHRINE WORKS IN THE EPIPEN? DOES IT WORK BY… INCREASING BLOOD PRESSURE, DECREASING WHEEZING AND IMPROVING BREATHING, INCREASING HEART RATE, DECREASING HIVES AND SWELLING, ALL OF THE ABOVE. I THINK THESE GENTLEMEN SHOWED US THAT E, ALL OF THE ABOVE IS OUR ANSWER HERE. WE’LL BE RIGHT BACK AFTER THIS.>>ALL AROUND TOWN, FROM STORES TO PLAYGROUND, BABIES ARE ON THE MOVE. AND THERE ARE DISEASES THAT ARE ON THE MOVE, TOO, AND SOME OF THESE SPREAD EASILY. TO BEST PROTECT HIM FROM 14 SERIOUS DISEASES BY THE TIME HE TURNS TWO YEARS OLD, VACCINATE HIM ACCORDING TO THE RECOMMENDED SCHEDULE SO HE CAN GO ON ABOUT HIS BUSINESS AND YOU CAN HAVE PEACE OF MIND. FOR MORE REASONS TO VACCINATE, TALK TO YOUR CHILD’S DOCTOR OR GO TO CDC.GOV/VACCINE.>>HE HAD NO COMPLAINTS, LIKE MANY MEN WHO COME TO MY OFFICE FOR AN APPOINTMENT SCHEDULED BY THEIR WIVES, BUT AS I WAS ASKING ROUTINE QUESTIONS, HE TOLD ME THAT FOOD SOMETIMES CATCHES ON THE WAY DOWN. SINCE THIS SYMPTOM CAN BE AN EARLY SIGN OF CANCER, I SCHEDULED AN E.G.D. TO LOOK AT HIS ESOPHAGUS WITH A SCOPE. WE WERE BOTH PLEASED IT WASN’T CANCER BUT I WAS SURPRISED TO FIND ANOTHER CASE OF WHAT USED TO BE A VERY RARE DISEASE CALLED EOSINOPHILIC ESOPHAGITIS. IT WAS THE SECOND TIME I RAN INTO THIS IN THE LAST FEW YEARS, AND I WAS AWARE OF A FEW CHILDREN IN TOWN WHO ALSO HAD THE DIAGNOSIS. IT WAS ONE OF THOSE CONDITIONS YOU HEAR ABOUT AS A MED STUDENT, BUT NEVER SEE… EXCEPT NOW WE ARE FINDING MUCH MORE OF IT. EOSINOPHILIC ESOPHAGITIS, OR E.E., IS CHARACTERIZED BY AN INFLAMMATION OF THE ESOPHAGUS AND THE FINDING UNDER MICROSCOPE OF MANY OF A SPECIAL TYPE OF WHITE CELL CALLED EOSINOPHIL. WE’VE LEARNED THIS DIAGNOSIS CAN OCCUR IN YOUNG CHILDREN TO OLDER ADULTS WITH SYMPTOMS OF REFLUX, TROUBLE SWALLOWING, AND EVEN FOOD CATCHING OR GETTING STUCK. IT IS INTERESTING HOW E.E. BROUGHT SPECIALTY GROUPS TOGETHER. FIRST THE PATHOLOGISTS STARTED SEEING MORE EOSINOPHILS ON PIECES OF ESOPHAGUS BIOPSIED BY BOTH PEDIATRIC AND ADULT GASTROENTEROLOGISTS IN PATIENTS REFERRED BY PEDIATRICIANS, INTERNISTS, AND FAMILY PHYSICIANS. SINCE EOSINOPHILS ARE AN INDICATOR OF AN ALLERGIC PROCESS, THE PATIENTS WERE THEN SENT TO ALLERGISTS, WHO PUT IT TOGETHER. WE’VE DISCOVERED IT’S GENERALLY RELATED TO FOOD ALLERGY, COW’S MILK THE MOST COMMON OFFENDER, AND IS TREATED BY AVOIDANCE OF THE ALLERGENIC FOOD, BY ANTI-REFLUX MEDICINES, AND BY SWALLOWING A STEROID SPRAY THAT IS USUALLY USED FOR ASTHMA. AND WE’RE NOT SURE WHY THIS FORMERLY RARE DISEASE IS HAPPENING MORE OFTEN NOW, BUT WE HAVE OUR SUSPICION. OF COURSE, C-SECTIONS CAN SAVE LIVES, BABY FORMULA IS SOMETIMES NECESSARY, AND LESS DIRT MEANS LESS INFECTIONS, BUT WE THINK E.E. MIGHT BE SECONDARY TO OUR OVERLY CLEAN ENVIRONMENT, STERILE BABY BOTTLES, AND OUR TOO PERSNICKETY WAY WITH THE FOOD TO WHICH OUR BABIES ARE EXPOSED. IMAGINE THAT! THERE MIGHT BE AN ADVANTAGE FOR BABIES WHO COME DOWN THAT NON-STERILE BIRTH CANAL, WHO SUCKLE UP AGAINST MAMA’S BREASTS AWASH WITH NORMAL FLORA, AND WHO ARE EXPOSED, NOT PROTECTED, FROM THE DIRTY WORLD IN WHICH WE LIVE. >>A BIG THANK YOU TO OUR GUESTS, TOM AND MARK. YOU ARE BOTH GREAT FRIENDS OF THE SHOW AND ALWAYS BRING A LOT OF INTERESTING DISCUSSIONS TO US TONIGHT. AND A REMINDER TO YOU AT HOME, VACCINES ARE NOT JUST FOR KIDS. CHECK WITH YOUR MEDICAL CARE PROVIDER TO SEE IF THERE ARE ANY VACCINATIONS YOU SHOULD BE GETTING. THAT DOES IT FOR TONIGHT. FROM ALL OF US HERE AT “ON CALL WITH THE PRAIRIE DOC,” UNTIL NEXT TIME, STAY HEALTHY OUT THERE PEOPLE. CAPTIONED BY: PARADIGM REPORTING & CAPTIONING WWW.PARADIGMREPORTING.COM >>CAN’T GET ENOUGH OF THE PRAIRIE DOC? VISIT OUR WEB PAGE AND OTHER ONLINE PROGRAMMING. YOU’LL FIND EXTENDED INTERVIEWS WITH GUESTS AND MORE INFORMATION ON IMPORTANT MEDICAL SUBJECTS. VISIT PRAIRIEDOC.ORG, OR FOLLOW US ON Facebook. THE BEST WAY TO STAY HEALTHY OUT THERE.


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