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History-taking requires interaction, and skin testing requires appropriate screening
388 CORRESPONDENCE
J ALLERGY CLIN IMMUNOL AUGUST 2009
Assessment, and has provided expert witness testimony on a variety of patent issues, none related to allergy. G. du Toit has received research support from the National Peanut Board, USA, and the Immune Tolerance Network, National Institutes of Health. The other author has declared that he has no conflict of interest. REFERENCES 1. Fox AT, Sasieni P, du Toit G, Syed H, Lack G. Household peanut consumption as a risk factor for the development of peanut allergy. J Allergy Clin Immunol 2009;123: 417-23. 2. Keet C, Wood R. Risk factors for peanut allergy. J Allergy Clin Immunol 2009;124: 387. 3. Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki S, Fisher HR, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122:984-91. Available online May 28, 2009. doi:10.1016/j.jaci.2009.03.047
History-taking requires interaction, and skin testing requires appropriate screening To the Editor: Recently, Smith et al1 compared the decisions regarding allergy status made by an allergy specialist who remotely interpreted a questionnaire and skin prick test (SPT) results to the decisions made by a nurse who administered the same questionnaire and SPT while directly interacting with the patient. They concluded there was no significant difference between the two. We have several comments. First, it is difficult to interpret the study results without seeing the questionnaire used. Second, use of a rigid structured allergy history is suboptimal. A medical history involves interplay between patient and clinician, because the questions and answers often require clarification. Smith et al1 imply that patients could complete a questionnaire, have SPT performed, and then presumably receive effective treatment from either a remote allergist or a primary care clinician. We feel this promotes both the remote practice of allergy and skin testing in a primary care setting, neither of which are optimal for patient care.2 An allergist’s ability to take an astute rhinitis history through direct patient interaction is one reason allergists provide better allergy care. This was illustrated when sublingual immunotherapy prescribed by primary care physicians was ineffective.3 Third, although there was good concordance between assessments, the practice nurses were trained by the same allergist who was making the remote gold standard allergy assessment, leading to inherent bias. In addition, the use of remote allergy assessment as the gold standard is suboptimal compared with an allergen challenge.4 Finally, it appears there was little attempt to screen for asthma via questionnaire or spirometry. It is well known that fatal SPT reactions have occurred, with uncontrolled asthma a risk factor.4 Is a nurse or primary care clinician qualified to differentiate between patients with asthma who can safely undergo SPT and those who cannot? These issues must be addressed given patients with rhinitis are at least 8 times more likely to have asthma.5 Furthermore, even if a patient does not have a systemic reaction, the asthma may not be addressed, and it is clear that allergy specialist care improves multiple asthma outcomes compared with the care of primary care providers.6 In conclusion, we commend the authors for their work, but believe the medical history is a dynamic process. The remote practice of allergy should be discouraged, and safe, effective skin testing is best performed by the allergist/immunologist.
Mark La Shell, MD Chris Calabria, MD From the Department of Allergy and Immunology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Tex. E-mail: mark.lashell@ lackland.af.mil. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Smith HE, Hogger C, Lallemant C, Crook D, Frew AJ. Is structured allergy history sufficient when assessing patients with asthma and rhinitis in general practice? J Allergy Clin Immunol 2009;123:646-50. 2. Nelson HS, Areson J, Reisman R. A prospective assessment of the remote practice of allergy: comparison of the diagnosis of allergic disease and the recommendations for allergen immunotherapy by board-certified allergists and a laboratory performing in vitro assays. J Allergy Clin Immunol 1993;92:380-6. 3. Ro¨der E, Berger MY, Hop WC, Bernsen RM, de Groot H, Gerth van Wijk R. Sublingual immunotherapy with grass pollen is not effective in symptomatic youngsters in primary care. J Allergy Clin Immunol 2007;119:892-8. 4. Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, Tan R, et al. American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008;100(suppl 3):S1-148. 5. Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: an independent risk factor for asthma in nonatopic subjects: results from the European Community Respiratory Health Survey. J Allergy Clin Immunol 1999;104: 301-4. 6. Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, Stibolt TB, et al. Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis. J Allergy Clin Immunol 2005;116:1307-13. doi:10.1016/j.jaci.2009.05.043
Reply To the Editor: We thank Drs La Shell and Calabria1 for their interest in our work. It appears they have misunderstood the main thrust of our research: we are not advocating the remote practice of allergy. What we were trying to do was to assess whether skin prick testing adds significantly to the assessment of suspected allergic disease in patients who have been assessed initially by using a structured allergy history. Our data indicate that history alone tends to overestimate the importance of certain allergic triggers and underestimate others. Used in isolation, a structured history may overestimate the role of allergy: it is sensitive, but not very specific. To the best of our knowledge, there have been no fatalities from skin prick tests conducted with standardized inhalant allergen extracts in patients with allergic rhinitis or asthma. We acknowledge that adverse reactions have occurred when testing for food allergies, but that is not what we were doing or advocating. The practice parameter2 cited by La Shell and Calabria refers to problems with food allergen skin tests, but goes on to state that there were no reports of severe or near-fatal reactions to skin prick testing for inhalant allergens. In our view, skin prick testing with inhalant allergens is a safe procedure that can be performed by trained personnel in the community in patients with rhinitis or asthma. The value of input from an allergy specialist is a different matter. We agree that allergists have an important role to play in the investigation and treatment of patients with complex disease. However, given the vast number of patients that are afflicted by the allergy epidemic, we do need to take a constructive approach to considering how best to investigate and treat the large number of patients with mild to moderate allergic disease. Improving the ability of primary care
J ALLERGY CLIN IMMUNOL AUGUST 2009
Assessment, and has provided expert witness testimony on a variety of patent issues, none related to allergy. G. du Toit has received research support from the National Peanut Board, USA, and the Immune Tolerance Network, National Institutes of Health. The other author has declared that he has no conflict of interest. REFERENCES 1. Fox AT, Sasieni P, du Toit G, Syed H, Lack G. Household peanut consumption as a risk factor for the development of peanut allergy. J Allergy Clin Immunol 2009;123: 417-23. 2. Keet C, Wood R. Risk factors for peanut allergy. J Allergy Clin Immunol 2009;124: 387. 3. Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki S, Fisher HR, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122:984-91. Available online May 28, 2009. doi:10.1016/j.jaci.2009.03.047
History-taking requires interaction, and skin testing requires appropriate screening To the Editor: Recently, Smith et al1 compared the decisions regarding allergy status made by an allergy specialist who remotely interpreted a questionnaire and skin prick test (SPT) results to the decisions made by a nurse who administered the same questionnaire and SPT while directly interacting with the patient. They concluded there was no significant difference between the two. We have several comments. First, it is difficult to interpret the study results without seeing the questionnaire used. Second, use of a rigid structured allergy history is suboptimal. A medical history involves interplay between patient and clinician, because the questions and answers often require clarification. Smith et al1 imply that patients could complete a questionnaire, have SPT performed, and then presumably receive effective treatment from either a remote allergist or a primary care clinician. We feel this promotes both the remote practice of allergy and skin testing in a primary care setting, neither of which are optimal for patient care.2 An allergist’s ability to take an astute rhinitis history through direct patient interaction is one reason allergists provide better allergy care. This was illustrated when sublingual immunotherapy prescribed by primary care physicians was ineffective.3 Third, although there was good concordance between assessments, the practice nurses were trained by the same allergist who was making the remote gold standard allergy assessment, leading to inherent bias. In addition, the use of remote allergy assessment as the gold standard is suboptimal compared with an allergen challenge.4 Finally, it appears there was little attempt to screen for asthma via questionnaire or spirometry. It is well known that fatal SPT reactions have occurred, with uncontrolled asthma a risk factor.4 Is a nurse or primary care clinician qualified to differentiate between patients with asthma who can safely undergo SPT and those who cannot? These issues must be addressed given patients with rhinitis are at least 8 times more likely to have asthma.5 Furthermore, even if a patient does not have a systemic reaction, the asthma may not be addressed, and it is clear that allergy specialist care improves multiple asthma outcomes compared with the care of primary care providers.6 In conclusion, we commend the authors for their work, but believe the medical history is a dynamic process. The remote practice of allergy should be discouraged, and safe, effective skin testing is best performed by the allergist/immunologist.
Mark La Shell, MD Chris Calabria, MD From the Department of Allergy and Immunology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Tex. E-mail: mark.lashell@ lackland.af.mil. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Smith HE, Hogger C, Lallemant C, Crook D, Frew AJ. Is structured allergy history sufficient when assessing patients with asthma and rhinitis in general practice? J Allergy Clin Immunol 2009;123:646-50. 2. Nelson HS, Areson J, Reisman R. A prospective assessment of the remote practice of allergy: comparison of the diagnosis of allergic disease and the recommendations for allergen immunotherapy by board-certified allergists and a laboratory performing in vitro assays. J Allergy Clin Immunol 1993;92:380-6. 3. Ro¨der E, Berger MY, Hop WC, Bernsen RM, de Groot H, Gerth van Wijk R. Sublingual immunotherapy with grass pollen is not effective in symptomatic youngsters in primary care. J Allergy Clin Immunol 2007;119:892-8. 4. Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, Tan R, et al. American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008;100(suppl 3):S1-148. 5. Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: an independent risk factor for asthma in nonatopic subjects: results from the European Community Respiratory Health Survey. J Allergy Clin Immunol 1999;104: 301-4. 6. Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, Stibolt TB, et al. Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis. J Allergy Clin Immunol 2005;116:1307-13. doi:10.1016/j.jaci.2009.05.043
Reply To the Editor: We thank Drs La Shell and Calabria1 for their interest in our work. It appears they have misunderstood the main thrust of our research: we are not advocating the remote practice of allergy. What we were trying to do was to assess whether skin prick testing adds significantly to the assessment of suspected allergic disease in patients who have been assessed initially by using a structured allergy history. Our data indicate that history alone tends to overestimate the importance of certain allergic triggers and underestimate others. Used in isolation, a structured history may overestimate the role of allergy: it is sensitive, but not very specific. To the best of our knowledge, there have been no fatalities from skin prick tests conducted with standardized inhalant allergen extracts in patients with allergic rhinitis or asthma. We acknowledge that adverse reactions have occurred when testing for food allergies, but that is not what we were doing or advocating. The practice parameter2 cited by La Shell and Calabria refers to problems with food allergen skin tests, but goes on to state that there were no reports of severe or near-fatal reactions to skin prick testing for inhalant allergens. In our view, skin prick testing with inhalant allergens is a safe procedure that can be performed by trained personnel in the community in patients with rhinitis or asthma. The value of input from an allergy specialist is a different matter. We agree that allergists have an important role to play in the investigation and treatment of patients with complex disease. However, given the vast number of patients that are afflicted by the allergy epidemic, we do need to take a constructive approach to considering how best to investigate and treat the large number of patients with mild to moderate allergic disease. Improving the ability of primary care