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Volume 91 No. 6 June 2008 Asthma & Allergy UNDER THE JOINT VOLUME 91 NO. 6 June 2008 EDITORIAL SPONSORSHIP OF: Medicine Health The Warren Alpert Medical School of Brown University HODE SLAND Edward J. Wing, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND M EDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director COMMENTARIES Quality Partners of Rhode Island Richard W. Besdine, MD, Chief 158 Neuroprotective Trials: No Longer a Cautious Optimism Medical Officer Joseph H. Friedman, MD Rhode Island Medical Society 159 An Alien Legend With a Bite Nick Tsiongas, MD, MPH, President Stanley M. Aronson, MD EDITORIAL STAFF Joseph H. Friedman, MD CONTRIBUTIONS Editor-in-Chief SPECIAL ISSUE: Asthma and Allergy Joan M. Retsinas, PhD Guest Editor: Russell A. Settipane, MD, FAAAAI Managing Editor Stanley M. Aronson, MD, MPH 160 Special Focus: Allergy & Asthma – Introduction Editor Emeritus Russell A. Settipane, MD, FAAAAI EDITORIAL BOARD 161 Childhood Asthma and Obesity Stanley M. Aronson, MD, MPH Sheryl J. Kopel, MSc, and Robert B. Klein, MD Jay S. Buechner, PhD 164 Inner City Asthma John J. Cronan, MD Stanley Hoyt Block, MD, FAAAAI James P. Crowley, MD Edward R. Feller, MD 166 The National Asthma Education and Prevention Program (NAEPP) John P. Fulton, PhD Guidelines: Will They Improve the Quality of Care in America? Peter A. Hollmann, MD Sidney S. Braman, MD, FCCP, and Arul Viggs, MBBS Sharon L. Marable, MD, MPH Anthony E. Mega, MD 171 Update On Stinging Insect Allergy Marguerite A. Neill, MD Alan Gaines, MD, FAAAAI Frank J. Schaberg, Jr., MD 174 The Role of Pollens In Allergy Lawrence W. Vernaglia, JD, MPH Henry B. Freye, MD, FAAAAI Newell E. Warde, PhD 184 Latex Allergy OFFICERS Anthony R. Ricci, MD Nick Tsiongas, MD, MPH President 187 Advances In Therapeutic Immunomodulation of IgE-mediated Diane R. Siedlecki, MD Respiratory Disease President-Elect Russell A. Settipane, MD, FAAAAI Vera A. DePalo, MD Vice President COLUMNS Margaret A. Sun, MD 196 IMAGES IN MEDICINE – MR Imaging of Acute Appendicitis in Pregnancy Secretary Jill A. Steinkeler, MD, and Courtney A. Woodfield, MD Mark S. Ridlen, MD Treasurer 197 GERIATRICS FOR THE PRACTICING PHYSICIAN – Case Presentation: Mr. J, Barry Wall, MD an 88 year-old man found on the floor, complaining of Immediate Past President generalized weakness Rebecca Starr, MD, and Ana Tuya Fulton, MD DISTRICT & COUNTY PRESIDENTS Geoffrey R. Hamilton, MD 199 HEALTH BY NUMBERS – Hospitalizations and Associated Costs for Bristol County Medical Society Principal versus Additional Diagnoses of Asthma: Implications Herbert J. Brennan, DO for Monitoring Children’s Health Kent County Medical Society Deborah N. Pearlman, PhD, Nancy Sutton, RD, MS, Sze Liu, MPH, Rafael E. Padilla, MD Janice Fontes, MS, and Jay S. Buechner, PhD Pawtucket Medical Association Patrick J. Sweeney, MD, MPH, PhD 202 PUBLIC HEALTH BRIEFING – Department of Health Promotes e-Licensing Providence Medical Association for Physicians Nitin S. Damle, MD Michael Simoli and Robert Crausman, MD Washington County Medical Society 203 PHYSICIAN’S LEXICON – A Planetary Vocabulary Jacques L. Bonnet-Eymard, MD Stanley M. Aronson, MD Woonsocket District Medical Society 203 Vital Statistics Cover: Image from a series entitled “The Escape Artist,” Acrylic and Collage, by Evan 204 June Heritage Larson. Evan Larson is an award-winning illustrator and graduate of the Rhode Island School of Design. His work has appeared in Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 Nickelodeon Magazine, American Illustra- Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. 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Production/Layout Design: John Teehan, e-mail: [email protected]. www.postmodernfrog.blogspot.com. 157 VOLUME 91 NO. 6 JUNE 2008 Commentaries Neuroprotective Trials: No Longer a Cautious Optimism You can’t win a race if you can’t find the with active drug and the other with pla- tee supported the project because it found starting line. Yet that is exactly where we cebo and following both, has seized on a the “old” theory just as persuasive as the are in the development of drugs to slow clever idea: the “delayed treatment” para- newer ones, and wasn’t persuaded that down Parkinson’s disease (PD). The drive digm. One group is treated at entry, and newer meant better. We all thought that it to find these drugs has produced trials that the other arm is treated initially with a pla- was worth a shot, even if the odds of suc- assess an intervention despite not knowing cebo, then after a predetermined period cess were slim. I don’t think that any longer. what the disease process is. Let’s take the both groups are treated equally with the There’s a problem basing large trials case of PD. In the 1950s there were de- active drug. If the treatment produces only on theories, when the theories, unsup- bates about where the pathological process a symptomatic benefit then the two groups ported by much data, wax and wane with was. That was definitively answered that de- should end up looking the same, whereas the season. Theories are tremendously cade, until the 1990s when it changed, and if the group treated early does better than important so long as the hypotheses gen- continues to change. In the 1980s there the group treated late, one might hypoth- erate research, but not so good when the were debates about the importance of the esize that early treatment either produces research has to be a lengthy, expensive, Lewy body. That was settled when the Lewy increasing benefits, or that the treatment difficult clinical trial that may siphon off body became a requirement for diagnosis. may slow disease progression. Either in- money from better uses. Ten years ago we figured out what the Lewy terpretation still implies that treating early Like my colleagues, I have thought body is composed of, but we still don’t know produces a better outcome. Pain treat- for many years that it’s better to do some- whether it’s “good” or “bad.” Either this ment, for example, is more effective if be- thing than nothing and either put the ball of condensed protein is gumming up gun early and maintained, so that pain theory to rest, or show that it works. I have the cells, or, by forming a glob, is taking patients can be treated with less medicine come to see things differently. I think that bad proteins out of circulation, keeping the if they are started early and given doses on $10,000,000 is better spent on the basics cells from gumming up. Not only that, but a regular basis, whether needed or not. and not on a single trial that is unlikely to after the 30-year debate, and after the Lewy This doesn’t alter disease progression (e.g., produce benefit. Ten million spent on a body was finally accepted as a requirement cancer pain) but does result in better out- poorly supported clinical trial is ten mil- for the pathological definition of PD, we comes. In PD one will derive the plausible lion stolen from basic research. But the are now probably about to classify two types conclusion that the drug slows the pro- problem, of course, is less simple. It is un- of idiopathic PD, one with and one with- gression, and it will not be disprovable. likely that the $10,000,000 saved would out the Lewy body although no one knows However, it will not be proof and, at the go to PD basic research. More likely it what other differences there are. least, we will know that early treatment, as would go to something unrelated, prob- For many years we’ve focused on the with pain, results in better outcomes (not ably not even to medical research. dopamine deficiency in PD, but, as a re- including side effects). Is the PD community better served cent editorial in Neurology [“The dopam- The federal government has spon- by a large clinical trial or nothing? For this ine hypothesis, beating a dead horse,”] sored expensive trials looking at a variety of question I don’t have an answer. We can pointed out, the dopamine deficiency con- drugs to slow disease progression in PD. talk about how to spend money better, but tributes to many, but not all, of the motor These trials are based on theories of disease too often when government money isn’t deficits in PD, but has little to do with some progression having to do with apoptosis spent on one unrewarding thing, it’s spent motor problems such as dysarthria or freez- (programmed cell death), biochemical on something less useful. ing, and has nothing to do with the demen- death from oxidation and “free radical scav- tia, depression, anxiety, apathy, sleep disor- engers,” abnormal cell protein folding, ab- – JOSEPH H.