Abstract
My current main areas of clinical research include the retrospective evaluation of patients with pediatric asthma in the Emergency Department for asthma triggers, co-morbidities, obesity, and vitamin D levels, as well as the evaluation of adult African American and Hispanic patients with asthma. I am conducting the former study together with the Chief of Pediatric Emergency Medicine at Nassau University Medical Center and a pediatric resident. It is a chart review study that will likely continue for 2 years. The adult research project is a 2-year prospective study funded by a grant from the New York State Department of Health and performed with my Empire Clinical Research Investigator Program (ECRIP) fellow.
The goals of the pediatric study are to evaluate pediatric patients seen in the emergency department for asthma and asthma triggers. We are studying how many of these children are obese and have triggers identified, how many return, and how many have vitamin D levels determined. I have written two articles on this topic, a review on Vitamin D in children and a study in adults on Vitamin D deficiency for allergic disorders and immune mechanisms.1,2 We also recently reported on a child in the Pediatric Emergency Department with bloody tears. 3
Another main clinical research project focuses on the role of cardiovascular disease in adult patients with systemic lupus erythematosus, which I presented as a symposium at the American Federation for Medical Research (AFMR) in April 2011. Another paper from this meeting in review centers on accelerated atherosclerosis in systemic lupus erthematosus and role of pro-inflammatory cytokines. 4
I also have some in vitro basic science research studies in development related to the role of combined asthma agents in human airway cells involving the measurement of various cytokines. Other published articles were related to asthma and bronchopulmonary dysplasia in infants and a review on asthma pathogenesis.5,6 Another current study involves the evaluation of human conjunctival and nasal epithelial cells in the presence of agents targeting various cytokines.
I have edited a textbook and published several chapters on food allergy and multiple articles on this topic, and it has been an area of interest for quite some time.7–11 I treat both adult and pediatric patients with food allergy. Areas of particular interest have been the role of eosinophilic esophagitis, 12 probiotics in atopic dermatitis, and oral allergy syndrome (OAS) especially in pediatric patients related to food allergy.
Among the recent advances in the field are newly published guidelines on food allergy related to when children may outgrow allergy to certain foods and when those foods can safely be reintroduced. There are also new molecular diagnostic studies that have led to Food and Drug Administration–approved methods for identifying epitopes—of peanut allergens and other components—to help define subsets of children with peanut allergy and other food allergens that might not be identified using other testing methods such as skin test or specific IgE tests. These new diagnostic tests may not yet be accessible to everyone because of their cost. They will be used primarily for patients in whom it is not clear whether a particular epitope is inducing an immune response.
During my career, I have seen a rise in food allergy, in part due to better detection, and I have also seen the emergence of the concept of OAS, which describes the cross-reactivity between pollen and food, especially birch and ragweed. I have a large number of pediatric patients with OAS, and it is something of which primary care physicians and parents are too often unaware.
Food allergy in general is often misdiagnosed. For example, it is not uncommon for non-physicians and nonspecialists to measure IgG4 levels, which are not pertinent. There are also new treatments available, such as anti-IgE. The role of immunotherapy in food allergy is being studied at several medical centers, and its safe use in severely allergic children is being explored.
Over the years, both of these societies have furnished us with important new and updated information in our field. One of the most significant changes has been the development of a very academic focus—including both clinical and basic science topics—with the continuous development of new information updated annually. I joined both the AAAAI and ACAAI in the early 1980s, and the ACAAI was very clinically oriented, whereas it is now much more basic science oriented.
Other important changes and advances have been the increased identification of patients who might not previously have been recognized by primary care or other physicians, and the publication of joint guidelines by both the ACAAI and the AAAAI that are available online and developed by our expert leaders to help guide physicians and strengthen the standards of care.
The pediatric and adult asthma epidemic represents a major challenge. We now know more about the genetic basis of asthma and are more attuned to recognizing the risk in families. We are also beginning to understand the differences in risk with exposure to the common cold rhinovirus; the role of interferon-beta, which can enhance allergen exposure and exacerbate asthma; and the role of respiratory syncytial virus, irritants, and stress.
Another important area is the recognition of factors that may affect the progression of asthma. For example, many physicians may prescribe steroids, which do not always interfere with disease progression and loss of function. The guidelines that have been available since 2007 emphasize 2 main factors with regard to treatment goals: risk and impairment. Ongoing trials with anti-IgE in children with asthma in the inner city are producing new information. We are also gaining a better understanding of the role of vitamin D deficiency in asthma and other immune diseases and how it can affect the ability of steroids to improve asthma.1,2 Controversial issues involve care of allergic and immune disorders practiced by nonmedical staff and unapproved diagnostic testing and treatments as listed in our practice parameters.
The main challenge has been the closure of hospitals that provide care to indigent populations. Presently, I evaluate only adults at Nassau University Medical Center, but I evaluate children in 2 other private sites. When I treated children at Nassau University Medical Center from 1983 to 2006, the main issues were lack of insurance and transportation, poor recognition of patients' conditions, challenges related to treating a variety of ethnic groups, and the need for translation of clinical and educational information related to asthma care. Public hospitals in particular tend to care for more underserved patients and, often, groups that need more care and education. We have conducted many asthma screenings for both children and adults through the ACAAI programs.
I was honored to receive a Distinguished Fellow award from the ACAAI in 2006, as well as a Distinguished Service award in 2008. I received the Women in Allergy award from both societies, in 2002 from the ACAAI and in 2003 from the AAAAI. I was an Allergy Immunology Training Program Director for Nassau University Medical Center from 1986 to 2006 and have trained more than 50 Fellows. I served on the ACAAI Board of Regents from 1994 to 1997 and on the Joint Council of Allergy, Asthma and Immunology Board of Directors from 2001 to 2005. I am also a past-president of the Long Island Allergy and Asthma Society, and I currently serve as co-CME Chair and am on the Board of Directors of the Society.
Women's health issues are not always recognized in practice—including asthma, osteoporosis, and the hormonal link between fracture risk and asthma. Osteoporosis is especially under-recognized as we recently reported. 13
In terms of being a woman physician, I believe that recognizing women's accomplishments is important, especially in academic centers. It is not always easy for women in an academic environment. I work in a medical center where women receive good opportunities to excel; however, in some other academic medical centers, women may not be given as much recognition or receive academic advancement. In private practice, women typically do very well, and I believe that they may offer a different (not necessarily better, but perhaps more communicative and compassionate) approach to interacting with patients.
I have conducted several leadership conferences for women during national ACAAI and AAAAI meetings to help promote the leadership role of women in the field.
I have a Ph.D. in Microbiology–Immunology, and my most influential mentor during my Ph.D. training was Dr. Nancy Bigley. She is at Wright State University and is still lecturing and mentoring students. My Ph.D. focus area was in the immunology of rheumatoid arthritis. I am trained in autoimmune disorders and diagnostic laboratory immunology, in addition to allergy. Because of Dr. Bigley, I really enjoyed developing my science background before entering medical school. I strongly considered becoming a rheumatologist. In medical school, at Loyola University Stritch School of Medicine, a mentor who allowed me to perform basic science as a student was another rheumatologist, Dr. John A. Robinson, Professor of Medicine, Allergy/Immunology/Rheumatology, who selected me to receive the Alpha Omega award in 2004.
During my fellowship training at the National Institutes of Health (NIH), my main first-year mentor was Dr. Anthony Fauci, Director, National Institute of Allergy and Infectious Diseases (NIAID), and Chief, NIAID Laboratory of Immunoregulation, at the NIH. My interest was initially in human immunodeficiency virus (HIV) and I was also trained in areas related to infectious diseases during my fellowship. My first ECRIP fellow award for a young physician I mentored was related to work in HIV done from 2007 to 2009. He presented at the AFMR on apoptosis and tumor necrosis factor α (TNF-α) by the V3 loop fragment of gp120 in human alveolar pulmonary epithelial cells. 14 I also mentored a young pathology resident on a basic science project related to vascular endothelial growth factor and TNF-α in brain tissue from HIV-positive patients with/without central nervous system lesions, 15 which was presented at the Federation of Clinical Immunology Societies meeting, in Boston, June 2010, and a paper with a second-year ECRIP fellow. 16
An influential mentor during my second and third years of fellowship at the NIH was Dr. Dean Metcalfe, a past-president of the AAAAI. He was head of the Mast Cell Section of the NIAID and his research focused on mast cells and food allergy. He was my mentor for 2 years when I evaluated patients with food allergy and mastocytosis. 17 I also worked on several clinical and basic science projects on lymphocytes and mast cells. Other influential mentors during my early and current career are Dr. Dianne Schuller at Hershey Medical Center and Dr. Joseph A Bellanti at the International Center for Interdisciplinary Studies at Georgetown University Medical Center when I presented a case at one of his pediatric meetings. 18 Also, my uncle, Dr. Anthony Frieri, who trained at Georgetown University Medical School, greatly influenced me.
I am currently mentoring a young female physician who just finished a pediatric residency, presented a poster in June 2011 on contact dermatitis at our local allergy society and has submitted an abstract for the AAAAI in March 2012. Overall, I encourage young physicians to present posters at regional and national meetings and write articles for publication. I am also mentoring a male resident who has an abstract accepted for the ACAAI related to lupus nephritis and eosinopilia in November 2011. I advise these young physicians to pursue their love of the field and not to get discouraged about the challenges of being successful in practice. I also encourage them to participate in educational programs in the field of allergy and immunology and to learn from the experts.