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The Provider Primers Series: Introduction to Mast Cells

Mast cells : Introduction

  • Mast cells are bone marrow derived. They migrate to tissues before maturity and remain tissue bound.[i]
  • Mast cell development in tissues is regulated by a number of molecules, most significantly stem cell factor (SCF) which binds at the CKIT (CD117) receptor. A number of other molecules, including IL-3, IL-4 and IL-10, also participate in this process.[ii]
  • Mast cells are long lived, with some living for years in tissue.[ii]
  • Mast cells are versatile actors. Their functions and granule contents are tailored to the needs of the local microenvironment.[iii]
  • Mast cells perform a number of critical roles, including immune defense against microbes and larger parasites; clotting; wound repair; tissue remodeling; angiogenesis; regulation of reproductive cycle; digestion and GI motility; pain response; participation in stress response via interaction with HPA axis; inflammatory response; and regulation of sleep and some aspects of cognition.[iv]
  • Mast cells produce a multitude of mediators which are stored in granules or produced de novo. Stored mediators of consequence include histamine; tryptase; heparin; bradykinin; serotonin; and substance P. De novo mediators include prostaglandin D2; leukotrienes C4, D4, and E4; platelet activating factor; tumor necrosis factor; interferons; and a number of interleukins, including IL-1a, IL-1b and IL-6, among many others. [iii]

Mast cell involvement in disease

  • Mast cells are involved in the pathology of many conditions, including asthma[iv]; autoimmune diseases[iv]; GI dysmotility, including post-operative ileus[v]; cardiovascular events[iv], such as myocardial infarction, rupture of atherosclerotic plaques or aneurysms, and coronary syndromes, including Kounis syndrome[vi]; cardiovascular disease; malignant and neoplastic [iv]; chronic kidney disease[iv]; cutaneous conditions[iv], including many forms of urticaria; depression and anxiety; and chronic pain[vii].
  • Mast cells are effectors in all mast cell diseases.
  • Most famously, mast cells are involved in allergy and anaphylaxis.[viii]

Mechanisms of mast cell activation

  • Mast cells are primarily activated via IgE crosslinking at the FcεRI receptor. This is the mechanism for the classic allergy model in which specific IgE binds the target allergen and crosslinks at the FcεRI receptor on the surface of mast cells and basophils. In this traditional model, crosslinking causes immediate degranulation of stored mediators and late phase release of mediators produced de novo upon activation[viii].
  • There are several other mechanisms for direct mast cell activation that are independent of IgE.
  • A number of inflammatory molecules can directly activate mast cells by binding surface receptors including corticotropin releasing hormone; substance P; histamine; cysteinyl leukotrienes; adenosine; stem cell factor; IL-3; IL-4; IL-9; and IL-33, among others[ix].
  • Substances associated with immune defense and infection can directly activate mast cells. Products derived from pathogens can activate via toll like receptors (TLR2 and TLR4), Dectin-1 or CD48. Host production of β-defensins and complement C3a and C5a can also provoke mast cell activation[ix].
  • IgG can bind at FcγR receptors on mast cell surfaces. Immunoglobulin free light chains have triggered degranulation in murine models but this has not yet been demonstrated in humans[ix].

Definition of anaphylaxis

  • The definition of anaphylaxis continues to be disputed. The 2006 NIAID/FAAN criteria detailed below have been validated and are widely used.[x]
  • Anaphylaxis is likely when any one of the following three criteria is met:
  • Criterion 1: Acute onset of illness with skin and mucosal issue involvement (hives, itching, flushing, swelling of lips/tongue/uvula) with at least one of the following: compromised airway (difficulty breathing, wheezing, low blood oxygenation); or reduced blood pressure or symptoms thereof (fainting, incontinence.)
  • Criterion 2: Two or more of the following occurring after exposure to a likely allergen: skin or mucosal tissue involvement (hives, itching, flushing, swollen lips/tongue/uvula), compromised airway (difficulty breathing, wheezing, low blood oxygenation); reduced blood pressure or symptoms thereof (fainting, incontinence); or persistent GI symptoms (cramping, abdominal pain, vomiting).
  • Criterion 3: Reduced blood pressure after exposure to known allergen.  For adults, this is <90 mm Hg systolic, or at least 30% decrease from baseline.  For children under 1 year of age, this is <70 mm Hg systolic; ages 11-17, <90 mm Hg systolic.  For children 1-10 years of age, this is <(70 mm Hg + (2x age)).  So for a child who is 8 years old, this would be <(70 + (2 x 8)) = <86 mm Hg.

References:

[i] Dahlin JS, Hallgren J. (2015). Mast cell progenitors: origin, development and migration to tissues. Molecular Immunology 63, 9-17.

[ii] Amin K. (2012). The role of mast cells in allergic inflammation. Respiratory Medicine, 106, 9-14.

[iii] Theoharides TC, et al. (2012). Mast cells and inflammation. Biochimica et Biophysica Acta (BBA) – Molecular Basis of Disease, 1822(1), 21-33.

[iv] Rao KN, Brown MA. (2008). Mast cells: multifaceted immune cells with diverse roles in health and disease. Ann NY Acad Sci, 1143, 83-104.

[v] De Winter, BY. (2012). Intestinal mast cells in gut inflammation and motility disturbances. Biochimica et Biophysica Acta, 1822, 66-73.

[vi] Kounis NG. (2016). Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med, 54(10), 1545-1559.

[vii] Chatterjea D, Martinov T. (2015). Mast cells: versatile gatekeepers of pain. Mol Immunol, 63(1), 38-44.

[viii] Galli SJ, Tsai M. (2013). IgE and mast cells in allergic disease. Nat Med, 18(5), 693-704.

[ix] Yu Y, et al. (2016). Non-IgE mediated mast cell activation. European Journal of Pharmacology 778, 33-43.

[x] Sampson HA, et al. (2006). Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol, 117(2), 391-397.

Avalon

One of the benefits of growing up in Boston is that it offers a lot of places that make for decent field trips. A lot of America’s short history happened here. Boston kids know the pain of walking the Freedom Trail in the winter, memorizing Paul Revere’s Ride, and not being allowed to touch anything anywhere ever as we crammed into small rooms in historical buildings all over the city. Nothing on the Freedom Trail is going to hold the attention of elementary school kids for long.

The good news is that Boston does have some places that will hold the attention of elementary school kids. My favorite place for field trips was George’s Island. George’s Island is one of the Harbor islands and entirely occupied by Fort Warren, an active post from the late 1800’s until after WWII. I have lots of memories of wandering through the dark, damp rooms with a flashlight and a healthy dose of fear of the paranormal to keep things exciting. Like most old buildings, Ft. Warren has a ghost story. A Southern woman pretended to be a man to fight in the Confederate Army. She was captured and eventually hanged at Ft. Warren in a black dress, the only article of women’s clothing on the island. She haunts a narrow stone passageway that frankly would be creepy enough without a ghost.

This week, I went to George’s Island with my friend and her kids. Dana is one of the uncommon gifts that I got in exchange for the mast cell life, a great friend and mom to two masty kids. We caught the ferry at the wharf near the Aquarium and sat in the front in the sunshine. It was warmer than I expected but the wind is cool on the water. As the island came into view, an ominously thick fog rolled into the harbor.

I haven’t been to any of the harbor islands in years. The last time I was there, I think it was when I volunteered to chaperone for a summer camp group. But that’s not the memory the island has of me. It remembers me as 12 years old, on a field trip in seventh grade. It remembers the inherent awkwardness of middle school and of trying too hard to be liked. It remembers the boundless energy of youth and that I could be reckless with my body because it worked and it did the things I wanted it to. I never even considered that my body could fail me in the way it has in the intervening years.

Dana and the kids and I explored lots of dark rooms off the courtyard and walked the ramparts where the cannons used to be. The island isn’t big but the ground is uneven and inclines are steep. We followed the path all the way around the perimeter, stopping to investigate secret passages as the fog settled atop the water. We had a great time.

There is something very poignant about going back to places I visited before I got sick. It’s not just that it keeps this memory of before I grew up and before I made all these choices and before I got sick. It’s that I can’t not think about how different things would be if I could be twelve again and make all the right choices. And then maybe I wouldn’t lose all those years because dozens of doctors would rather think I’m crazy than believe that something awful was happening inside of me. Of all the things I struggle with, that is probably the hardest.

When we made it back to the visitor center, I was flushing and starting to feel less than stellar. I took meds before and took more while I was there. Nothing dangerous was happening, I just felt a reaction brewing. It was hot, humid and sunny. It was bound to happen and I was prepared for that eventuality.

We sat inside on the return ferry to get out of the sun. I waited for my meds to work as I watched the island grow smaller and smaller. Behind us, the mist closed around the island, my own personal Avalon where I will always be twelve.

 

At the wharf

Good times

I am not good at giving myself advice. If someone told me what symptoms they had and asked what the likely cause was, I could answer confidently. But when I have the same symptoms, it is hard to get past the anxiety to the answer. I am pretty much bracing myself for the worst possible scenario 100% of the time. These situations almost never play out the way they do in my head but that doesn’t stop my brain from populating my mind with ridiculous outcomes.

I basically live in constant fear of getting a line infection. The idea of the infection and not having a central line terrifies me. The port affords me a lot of autonomy and allows me to work, travel, and not be in the hospital once a week.

I can and do access my port if the need arises but I prefer not to do it myself. If there is anyone else who could possibly do it for me, I will aggressively pursue that option. But if I’m traveling, I do my accesses and dressing changes myself. Every time, my hands shake as soon as I put sterile gloves on. I don’t know why I’m so nervous or what I think is going to happen. If I miss, I can just do it again. I am a maniac about not contaminating things so if I think there’s even a chance something was contaminated, I just start over with new supplies. But I still get scared and you can’t reason with a fear like this.

I went to Ogunquit in July for a beach weekend with my sister, our cousin and some friends. I deaccessed my port to go swimming and reaccessed it later that day. Late that night, I caught my reflection in the bathroom mirror and realized my site was red. I flush on my chest most days so it can be hard to tell what exactly is happening. There were two curved red lines emanating from one spot about an inch from the site.

image

Before I could even think about it, I was panicked. It was 2am and everyone was asleep. I was an hour and a half from my hospital and I didn’t drive my car up.  I would have to wake up my sister, pack, and drive home to Boston in the middle of the night to get to my hospital. I went outside and paged the covering for my infusion nurse while I obsessed looked at the lines to see how fast they were moving. I was very sure that I had a staph infection that I got that day while accessing. Except infections don’t show that type of reaction in a few hours time.  The two bright red lines couldn’t be staph marching toward my heart because ports are tunneled lines and there were no blood vessels there for the staph follow.

The nurse called and told me that it could be the betadine reacting with the mineral content of the water or that I may not have gotten all the sunblock off my chest before accessing. She told me to mark the ends of the lines and I could deal with it in the morning provided I had no other serious symptoms. I woke up the following morning and the lines were gone.

I went to the dentist last week. The tooth next to the Danger Tooth that was removed in March has been hurting when I eat or drink certain things. It also has damage at the gumline from vomiting like the Danger Tooth did. At this point, I’m basically out of teeth that we can just remove. My wisdom and most of my molars have all been pulled. So I fully expected the dentist to give me a long involved spiel about a root canal or a crown or an implant or something.  I thought about the fact that I would have to stop drinking coke because the tooth was in bad shape. Being as I have no vices left, a can of coke is how I indulge. I was prepared for a several weeks long struggle to get my tooth repaired like it did in the spring. I was ready.

“Your teeth look great!” the dentist chirped. “They are so clean!” I have one tiny cavity at the gumline in the tooth next to the Danger Tooth. They can fill it normally. Otherwise my teeth were great.

I strutted out of that office like a triumphant man walking through town in a movie montage. I couldn’t believe it. I was so sure that the tooth would be crumbling and I would never be able to drink anything but water and so on. I was pretty convinced. Instead, it was a perfectly routine visit with a positive outcome.

When I went to Water Country, I used IM Benadryl. Every time I have to use IM Benadryl, I get nervous thinking about how sore and bruised my leg will be.  I have to talk myself into it every time because it gives me anxiety. For the first time ever, I somehow managed to inject the Benadryl in a way that did not result in a huge bruised knot. I don’t know how I did it and I’ll probably never be able to do it again.

We have skunks in Boston and they are out in full force this time of year. Before taking the dogs for a walk or letting them out in the yard, I go out and make sure there aren’t any skunks. Astoria already got sprayed earlier this summer and deskunking my dog at 2am in my mother’s backyard is not an activity I enjoy.

One night last week, I took Astoria out before bed. I had gone out before and checked for skunks before bringing her out. As I was reaching to unlatch the gate, I realized there was a skunk about a foot away from me. I turned to run away from it but Astoria was next to me and I tripped over her. I somehow managed to stay on my feet for about fifteen feet while running at full tilt before finally crashing to the ground on my concrete patio. I hit the ground pretty hard. I managed to open wounds on my left ankle, both knees, both hands, and left elbow. I have a spectacular bruise on my left hip extending down the bruise.

Falling down hurts a lot more than it did ten years ago so I just lay there for a minute. Astoria lay down next to me because she seemed to think this was a bonding exercise. In the split second when I landed on my elbow, my brain decided that I had broken my arm again. I have broken that arm before, twice. Without any evidence at all that anything was seriously wrong with the elbow, my mind had populated a dystopic future for me and my broken arm. I was pretty banged up but there were no serious injuries. I had foreseen the next six weeks of my life dealing with a broken elbow and I basically had a bad scrape that bled. Catastrophizing at its best.

image

In case you are wondering, Astoria did not attack the skunk (a fact that shocks me). When I sat up, the skunk was still standing in the same spot. It had sprayed a tiny bit, so little that it didn’t hit me or Astoria. After a few seconds of staring at me, it turned around and left. I cannot believe we didn’t get sprayed.

People with serious health issues spend a lot of time assuming crash positions and bracing for the pain. We are frequently met with resistance and spend a lot of time having the same conversation with ten people who still don’t rectify the issue.  I am always afraid that today will be the day that something truly awful happens.

But it usually doesn’t. I am learning how to live here, in this space where sometimes things work out.

The price of surviving anaphylaxis

Anaphylaxis is a severe, multisystem allergic event. It is a medical emergency and can be fatal. A 2015 WAO update stated that Americans have a 1.6% risk of anaphylaxis over the course of their lifetime. In the US, anaphylaxis was fatal in 186-225 patients annually, a frequency of 0.63-0.76 per million people. 30-43% of patients with a history of anaphylaxis will have a recurrence.

Epinephrine is the only drug known to decrease the incidence of death from anaphylaxis and should be administered as the first-line agent. Delay in administration of epinephrine has been shown to directly increase the risk of death from anaphylaxis. The use of epinephrine autoinjectors by patients at risk of anaphylaxis is critically important to managing patient safety. Despite this, many patients do not have or do not use their epinephrine autoinjectors.

The use of epinephrine autoinjectors in anaphylaxis has been very well studied. A 2014 paper by Wood and colleagues reported the findings from surveying 35,079 patients. They found that 60% of patients did not have an epinephrine autoinjector on their person when anaphylaxis recurred. Another study by Sanchez found 9-28% of patients carried autoinjectors.

Wood found that 52% of patients with a history of anaphylaxis were never prescribed an autoinjector. In a patient group of 261 with history of proven anaphylaxis, a mere 11% used the autoinjector for their most recent anaphylactic event. Not using epinephrine in the appropriate time frame can have grave consequences. In anaphylaxis patients who progressed to cardiac arrest, 67% did not receive epinephrine within an hour of onset. Among patients who died from anaphylaxis, none of them received epinephrine when the first symptoms presented. Only 14% of fatal anaphylaxis patients were administered epinephrine prior to cardiac arrest.

In many instances, economics is to blame for not carrying an epinephrine autoinjector. A truly stunning statistic is that 50% of anaphylaxis patients do not fill prescriptions for autoinjectors once the cost is over $300. In the previously mentioned 2014 Wood publication, 41% of anaphylaxis patients reported a household income of less than $50,000. Despite being uniformly accepted as a medication used to prevent death and severe complications resulting from anaphylaxis, epinephrine autoinjectors are often not classified by insurance companies as a preventative medication. An analysis of American insurance plans found that the two pack of Epipens was classified as a tier 1 or 2 medication in 67% plans; tier 3 or 4 in 6% plans; “approved” without any contribution to the cost of the drug in 5% of plans; and 22% plans did not cover Epipens at all.

A 2012 paper assessed how patient cost related to adherence to treatment recommended by their provider for a wide array of conditions. Eaddy reported that of the 66 studies evaluated 85% (56 studies) demonstrated that patients were less likely to adhere to the treatment plan when their costs increased.  High out-of-pocket costs were definitively shown to decrease patient use of preventative health care measures, resulting in poorer outcomes.  Increasing copays and deductibles impede access to life saving medication for anaphylaxis patients. If epinephrine autoinjectors were classified universally as preventative medications, insurance companies would be obligated to fully cover the associated costs. They would also be prevented from requiring patients to pay large out of pocket costs for autoinjectors as contribution to deductibles.

Kaplan reported that only 11% of patients with a history of anaphylaxis refill their epinephrine autoinjectors as needed. Instead, many patients rely on expired autoinjectors. Epinephrine is an inherently unstable molecule that degrades quickly when exposed to oxygen or light. A study in 2000 showed that while autoinjectors still functioned as intended up to 90 months after expiration, epinephrine concentration was significantly reduced. Still, expired epinephrine is still better than no epinephrine in the event of anaphylaxis as the benefit would outweigh the risk.

Epinephrine autoinjectors are designed to be stored at 20-25°C but tolerate occasional exposure to higher or lower temperatures in the range of 15-30°C. While heat is known to hasten degradation of epinephrine, freezing apparently is not. The 2015 WAO update mentioned that if autoinjectors are frozen, epinephrine concentration is not affected and that patients can use them as long as they are completely thawed. (I find this really wild, I had never heard of this before.)

Exorbitant costs prevent anaphylaxis patients from having ready access to epinephrine autoinjectors, the only first line medication for anaphylaxis. 50% of patients do not fill prescriptions for epinephrine autoinjectors when their cost is over $300. With the cost of autoinjectors well into the hundreds of dollars for many patients, millions of people in the US may be unable to afford this lifesaving medication for which is there is no alternative.

References:

Simons FER, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organization Journal 2015: 8(32).

Wood RA, et al. Anaphylaxis in America The prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol 2014: 133, 461-467.

Noimark L, et al. The use of adrenaline autoinjectors by children and teenagers. Clinical & Experimental Allergy 2012: 42(2), 284-292. Eaddy MT, et al. How patient cost-sharing trends affect adherence and outcomes. Pharmacy & Therapeutics 2012: 37(1), 45-55.

Simons FER, et al. Outdated EpiPen and EpiPen Jr autoinjectors: Past their prime? J Allergy Clin Immunol 2000: 105(5), 1025-1030.

Sanchez J. Anaphylaxis. How often patients carry epinephrine in real life? Rev Alerg Mex 2013: 60, 168-171.

Kaplan MS, et al. Epinephrine autoinjector refill history in an HMO. Curr Allergy Asthma Rep 2011: 11, 65-70.)

Kim JS, et al. Parental use of EpiPen for children with food allergies. J Allergy Clin Immunol 2005: 116(1), 164-168.

 

No, using the manual syringe/vial method is NOT the same as using an epinephrine autoinjector

I have a lot of inflammatory things to say about the current economic situation for patients who need epinephrine autoinjectors but for now, I’m going to stick to dispelling the most damaging myth I have seen spreading like wildfire.

No, manually drawing epinephrine from a vial or ampule into a syringe and then administering is NOT the same as using an autoinjector.

The American Academy of Allergy, Asthma & Immunology is a professional organization that regularly publishes updated practice parameters on the treatment of anaphylaxis. In their 2015 Anaphylaxis Practice Parameter Update, the AAAAI recommended that providers “prescribe two doses of auto-injectable epinephrine for patients who have experienced an anaphylactic reaction and for those at risk for severe anaphylaxis.”

This publication also addresses commonly disputed situations relating to anaphylaxis such as when and how to administer epinephrine to patients in special populations, like children under the weight range for Epipen Jr (33 pounds). The recommendation in the practice parameter was to use an Epipen Jr rather prescribe a syringe and vial of epinephrine for the parents to administer a smaller dose. The justification for this recommendation given in the 2015 Anaphylaxis Practice Parameter Update is that “…underdosing might not effectively treat anaphylaxis, giving a dose that is slightly above the ideal dose appears to be a better option than giving a dose that is below the recommended dose.”

A 2001 study by Simons et al. assessed how long it takes parents to manually draw up epinephrine from a vial. They also determined how long this took for resident physicians, general duty nurses and ER nurses. The results are in table 1 below.

Table 1: Mean time to draw up dose of epinephrine, range of time and variation in drug concentration
Group Mean time to draw up dose Range of time Variation in epinephrine content within group
Parents 142 ± 13 seconds 83-248 seconds Forty-fold variation
Resident physicians 52 ± 3 seconds 30-83 seconds 7 to 8-fold variation
General duty nurses 40 ± 2 seconds 26-71 seconds 2-fold variation
ER nurses 29 ± 0.09 seconds 27-33 seconds No variation

 

As you can see, the fastest parent drew it up in 83 seconds (about a minute and a half) while the slowest drew it up in 248 seconds (over four minutes). There was a 40-fold variation in the amount of epinephrine drawn up so both underdosing (which will not stop anaphylaxis) and overdosing (which can cause severe CV effects) would have occurred. Please note that this study does not assess how much longer it took to inject the medication for obvious reasons. It was also done in a controlled environment that assuredly was much less stressful and chaotic than one that would accompany a real life anaphylactic emergency.

Say it takes 15 seconds to find the vial and needle and open them and another 15 seconds to inject it. In a best case scenario, in which the parent is aware of anaphylaxis at the exact moment it begins, is in no way flustered, confused, or scared, and is in a situation where they can immediately respond (by which I mean, they are not driving, they are not swimming, they are not watching their child from 100 feet away), the fastest a parent would be able to draw it up and administer the med would be about two and a half minutes. Two and a half minutes with no oxygen if the child’s airway closes right away. If you are an anaphylaxis patient and are trying to do this for yourself, you would be expected to be able to function without oxygen for two and a half minutes.

About 30% of anaphylaxis patients require a redose of epinephrine to control anaphylaxis. So if you or your child is one of those people, you then have to do all of this again. If the first dose doesn’t do much, it could be another two and a half minutes.

The numbers were better for resident physicians and general duty nurses but you are still looking at 2-2.5 minutes for the slower members of these groups. There was a 7 to 8-fold difference in amount of medication drawn by resident physicians. ER nurses reliably drew up the dose in about 30 seconds and assuming that it takes 30 seconds to get the med and needle, and to inject it, they could draw and deliver in about a minute. That is the best you can hope for.

I realize that many mast cell parents and patients draw from vials/push meds/inject meds frequently and they may be practiced enough to draw the dose reliably and administer correctly. If we assume the most competent among them to be as competent as the ER nurses, it takes about a minute to administer the med. I just timed myself and it took eight seconds for me to get the epipens out of my purse, open the case, and remove the blue cap. (I used a trainer). It took less than one second to bring the injector to my leg. The entirety of the dose of epinephrine is delivered from an epipen in three seconds.  So 12 seconds for use of an epipen vs 60 seconds for the fastest, most reliable manual draw and inject.

There are currently two other autoinjectors available in the US: Adrenaclick and epinephrine autoinjector, a generic version. Both of those autoinjectors differ from epipens in two important ways: they are syringe based, whereas epipens are cartridge based; and their needles are shorter compared to epipens. In one specific comparison study by Ram et al., Epipens were found to more reliably deliver the most epinephrine (74.3% of intended dose) compared to syringe autoinjectors like Adrenaclick and epinephrine autoinjector (25.7% of intended dose). Auvi-Q was pulled off the market for similar delivery issues. (Author’s note: please note that this study did not include the specific generic epinephrine autoinjector, but its delivery mechanism is comparable to Adrenaclick).

A 2015 study reported by Umasunthar and colleagues compared how often mothers of food allergic children were able to correctly administer Anapen (a syringe based autoinjector not available in the US) vs Epipen in a simulation. Six weeks after they were shown how to use it, 42% correctly administered Anapen and 43% correctly administered Epipen. This means that over half of participants could not correctly administer epinephrine even with an autoinjector.

Alternative autoinjectors are not comparable to Epipens and neither is the manual syringe/vial method.  Delay in administration of epinephrine is a strong risk factor for poor outcome, including fatal anaphylaxis. Additionally, delay in administration of epinephrine or inadequate initial dosing is a risk factor for biphasic anaphylaxis.

Stay safe out there.

References:

Lieberman P, et al. Anaphylaxis – a practice parameter update 2015. Ann Allergy Asthma Immunol 2015: 115, 341-384.

Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol 2005: 95, 217-228.

Ram FSF, et al. Epinephrine self-administration in anaphylactic emergencies: Comparison of commonly available autoinjectors. Journal of Asthma and Allergy Educators 2012: 3(4), 178-181.

Simons FER, et al. Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: Is the ampule/syringe/needle method practical? Journal of Allergy and Clinical Immunology 2001: 108(6), 1040-1044.

Umasunthar T, et al. Patients’ ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trials. Allergy 2015: 70(7), 855-863.

Vigil

I like to be alone. It took me a long time to feel that way. When I was in grad school, I lived in a cheap apartment on the border of a neighborhood that was mostly known for gang wars and being the setting for a documentary called (I swear this is real) “Getting high on crack street.” Once while I was having a party, an episode of COPS happened on the sidewalk I traversed every day to leave my apartment. COPS was filming in Lowell and they literally caught some guy and arrested him on my sidewalk. So basically what I’m saying is my apartment was charming. And cheap. But still charming.

Not that long after the COPS incident, my roommate moved out abruptly. Shocking, I know. I was 23 and generally a person who worried a lot about money at that point because we didn’t have money growing up, I paid my way through school myself, and grad students are stereotyped as living off ramen noodles for a reason. Lowell had the cheapest housing in the state at that point, due in large part to its impressive record of violent crime and also its propensity to flood like it was the Merrimack River’s job.

Living in Lowell, you learned to view the Merrimack as an adversary. A worthy opponent. When a river can rise enough to cover four blocks beyond its banks in a foot of water, you respect that river. My little cousin wanted to see how bad the flooding was one time and we walked a few blocks down closer to the university. We identified partially submerged landmarks and then two white plastic chairs just floated by. You know, just on their way to meet up with their chair friends and all the other debris beside a shuttered ice cream place where the flood deposited all the detritus.

Anyway, my roommate moved out abruptly and I was stressed about money because I was always stressed out about about money. I didn’t sleep for two days and on the third night, I ordered the best, greasiest fake Chinese food and ate it while sitting on my living room floor, watching some crappy horror movie. I slept that night, and the following nights, and eventually decided I didn’t want to deal with roommate stress. I decided to live alone.

I worked two full time jobs while in grad school and was also in grad school so I didn’t have a lot of free time. This was helpful in the beginning. I was so tired when I got home that I usually just went to bed. I put Lord of the Rings in my Playstation 2, turned the volume down on my cathode ray tv, and fell asleep. I wasn’t really experiencing being alone. It wasn’t until later when I had a more normally structured work schedule that I had to learn how to keep myself company.

The funny thing is that once I learned how to be alone, I loved it. It alleviated so much stress. When I went to Scandinavia in 2007, I came home, walked up to my apartment, took off all my clothes in the living room and just left them in a pile while I made coffee. Living alone was fantastic. I haven’t lived with anyone who wasn’t my partner in several years and I prefer it that way. I like having the choice to not talk to anyone and to think about things and make decisions on my own.

Being confident in your ability to take care of yourself and support yourself is very empowering and liberating. But it can be isolating, too. In the years since I lived in my charming apartment in Lowell, I have become progressively sicker. It was pretty obvious to my partner at the time but not to most people, even people I was close to. I looked healthy and still worked and fundraised and volunteered and lived a fairly normal life. It became easy to not let on how unwell I was and most people didn’t know until I crashed super hard and needed major surgery and all that.

In the last few weeks, I have finally gotten my lower GI pain mostly under control. My baseline pain is lower but I am still having colitis attacks about twice a week for 2-3 hours. I don’t know what is triggering the colitis so I can’t stop it. The good news is that most of the time, my pain level is lower. The bad news is that when it’s not controlled, it is unbelievably painful. Like can’t stand up straight, think my intestines might somehow drill through my abdominal wall and enter the outside world Alien-style, painful. It is awful and unpredictable and really frustrating.

This morning after I got off the train near work, I started having bad lower GI pains. I got to work and was stuck there until the attack subsided. I took all relevant meds but these episodes seem to be self limiting and resistant to symptom interventions. I sat at my desk with my legs up and distracted myself from the pain with work.

A coworker and I were chatting and I told her about my abdominal pain which was presently terrible. I don’t know what caused this realization but I realized while we were talking that she had no idea I was in pain before I told her. That really jarred me. I have been in pain for so long that my body has adapted to a neutral affect in response. People not only can’t tell that I’m sick but they also can’t tell when I am in serious pain.

I felt suddenly this swell of loneliness. It was momentary but overwhelming. I made a choice to share my life openly. People read about my pain but something is always lost when you distill emotions and moments into words. Over time, I have developed a complicated and difficult but enriching life and this world exists solely within the confines of my body. My friends and family can visit this place but they can’t stay.

I am alone in this strange place. I know how to be alone. But being alone in this body and this pain and this struggle is a different kind of alone, a solitary vigil in an invisible space.

 

Second life

I feel very much that I have had two lives. My first life stretched from childhood to my late 20s when I became seriously ill. I lived a lot in that first life, even for a few lifetimes. I grew up in Boston and went camping in New Hampshire most weekends in warmer months. I was a good student and read a lot and journaled compulsively. I traveled, went to college and grad school, worked several jobs. I fell in love and had my heart broken and broke some hearts. I had a lot of fun in my first life, a fact for which I am very grateful.

My second life is the one I often write about here. It’s the one that started when I became too sick to work and could no longer function. It’s the life I’m still living right now. A life that started with me being so sick that I just wished it would be over, that I would just close my eyes and transcend to an oblivion where I wasn’t puking and in pain all the time. A life that saw me through those times and carried me here. A life that brought me to Hong Kong and Beijing, to a challenging job, to bright red hair.

And to Water Country.

Water Country is a New England institution, complete with an iconic and maddeningly catchy jingle that everyone from New England reading this just sang in their head. It’s a water park with slides and a wave pool and a lazy river. I went as a kid for several summers. My mom and her friends would pack coolers and beach bags and all the kids and mothers would pile into my aunt’s unbelievably large and hideous brown van. The kids mostly sat on the floor in the way back like you would do in a station wagon. No seatbelts. Very early 90’s vibe. I think I was 12 the last year we went.

I think 2013 will go down resoundingly as the worst year of my life. I was super sick, had a resection and colostomy, broke up very shortly after my ostomy placement, moved, and generally had an awful time. I had worked so hard to shape this second life into a place where I could feel happy and fulfilled. And then it was just gone. I called my best friend in the middle of the night after we broke up, sobbing. “I had this whole life,” I said in between the deep whistling hiccups of genuine despair. “I know,” Alli said. “You lost a lot.” And she was right.

Late in the summer of 2013, the two of us decided to go to Water Country. I don’t even remember the conversation that led to the decision. In the last week of August, when the NH kids were back in school, we drove up to Water Country. It was warm but not terribly hot. There was almost no one in the park. We ran up three flights of wet wooden stairs, went down the slide, and then ran back up to do it again because there was no line. It was fantastic.

We made the poor decision to try a slide that you went down on your stomach on a mat. Nothing bad happened, it was just so ridiculously difficult. I had a colostomy bag and abdominal pain and she had ulcerative colitis and a knee that had been operated on and still didn’t work well. We were on the mats on our stomachs and just could not push ourselves down the slide. It took several minutes and was not even that good of a ride. Water slide fail for two. Then we went on a bunch of other slides and drove home with the smell of chlorine and conditioned air in the car.

We go to Water Country every year. Water Country is a place that I solidly place in my second life. This was a tradition I started in my second life and that means that there was no comparing it to before I got sick. Even when things go well and I don’t react, there is an inherent discomfort in doing things in this life that I did in my old one. A lot of the time, there is an inherent discomfort in relationships with people who knew us before. It is a reminder of the differences and the space between who I used to be and who I’m not now. It isn’t something that makes me angry anymore but it is something that I don’t think will ever stop. There are some things that you hide deep in your heart you just never get over and when you are in these situations, you feel a twinge when they are hidden inside.

I don’t feel that twinge on Water Country day. It’s like a holiday for me, a testament to the fact that this second life is so much harder and scarier than my first one but that it’s still a good life. It’s hard and messy but that doesn’t mean I’m unhappy. I can be sick and happy at the same time. Every year, that day proves it.

I wish that I had never gotten sick and that my existence would never have split along this fault line, opened a chasm between who I used to be and who I am now. But it did. And most of the time, this second life isn’t really so bad.

Lucky day

The nights are getting cooler and the wind is no longer warm. Darkness descends earlier. Fall is close. I walk a lot but especially at night when it is just a little cool. I listen to music and look at the moon with a dog in tow. Life seems less antagonistic when you look at the ocean.

Last week on just such a night, I took Astoria for a walk to the water. It wasn’t late but the town was quiet. About a mile from home, as we walked down the block to the ocean, a man ran past us and almost bumped me. I turned to steady myself just in time to get coated in pesticide that was being sprayed from the back of a pickup truck.

I just stood there for several seconds because I couldn’t believe what had just happened. I was stunned. Astoria has saddlebags with her treats, water, bowl and bags on one side, and my epipen, IV meds, and emergency protocol in the other. My immediate reaction was to take benadryl but I was afraid I would contaminate the line with pesticides if I used it. We were close enough to my apartment that hurrying home would get me there faster than calling someone to pick me up and bring me to my place. I took the epipen out of the case and walked home as fast as I could with it in my hand.

I was home in under ten minutes. I took off all my clothes and threw them into the washer with Astoria’s collar, harness, leash and pack. I rinsed myself off so I could use IV meds and got benadryl and pepcid onboard. I took 50mg oral prednisone and gave Astoria a bath.

Astoria can be a lot of work sometimes but one thing that is never a problem anymore is bathing her. She loves water. She loves the hose. If I am trying to spray something with the hose, she would prefer what I’m spraying to be her face and will jump back and forth to body block whatever I am aiming at. If I wash dishes, she stands close to the sink so I can spray her with the little nozzle. She knows all about the bathtub and that the water lives there. When I get home from work and open the bathroom door, she ferries her toys from the bedroom to the bathroom one at a time, piling them on the bath mat. When she has all the toys she wants, she picks up her favorite dinosaur and gets in the tub. Just hanging out in the tub so she doesn’t miss bath time. If she is dirty (or not), she will actually get into the bathtub and look at me plaintively until I wash her. She is a ridiculous creature.

Well, it was her lucky day because after getting covered in pesticides, we had a long bath. She was pumped. I shampooed her all over and rinsed her really thoroughly while she repeatedly slapped me in the face with her tail. She shook off all over the bathroom because why not at this point and let me aggressively towel dry her, which meant she was at most 70% dry.

Since I was now covered in water, fur, dog shampoo and probably pesticides that I just washed off her, I took another shower. Fifteen minutes later, after I wiped down every last surface in the bathroom because they were somehow all coated in fur, Astoria started coughing. So she got another bath. More shampoo. More water. More shaking. More towel drying. More cleaning every single thing in my bathroom. She is having her best day ever.

As I’m changing over the laundry and loading a truly impressive amount of used towels into the washer, she is running in and out of the bathroom with her tail going so fast that she is knocking things off the coffee table. LOOK MOM THIS IS MY DINO. More wagging. More wiggling. She is at a cool 97 on the excitement scale if 100 is the point at which you actually detonate from euphoria. LET’S DO THE THING WHERE I WANT YOU TO PLAY TUG WITH A STUFFED ANIMAL THAT ISN’T BIG ENOUGH TO GET A GOOD GRIP ON. LET’S DO IT.

But I still need to shower myself again so I put some peanut butter in her kong for her to play with and I climb back into the shower. I am listening to music and trying to calm down as I scrub myself again. In the next room, Astoria finishes up with her kong and comes looking for me and then lets herself right into my shower. She is now 100% wet instead the 30% I was settling for earlier. She is slapping bottles of shampoo and body wash off the shelves with her tail. I have two towels left and it takes 1 ½ to dry her off. At this point, the dog has been washed and buffed dry three times in two hours. Her coat is so shiny, I can’t look directly at her without sunglasses. I’m bright red and developing my own cough so I take IV steroids and just plan to never sleep again.

My town was spraying for mosquitos that night, which is how all this happened. I have a landline for calls like the one I expect for spraying. I didn’t get a call. I usually do and realize that this was just an unfortunate glitch. I don’t think anyone is to blame for this situation. I didn’t make any mistakes and this still happened. You can plan and prepare but there is always an unknown element. The world is not entirely predictable and that means that there is always the chance that some unlikely thing will happen. I had my meds, I had epi if I needed it. I was responsible. I understood that I can’t always control my disease or my environment so I had to be ready to respond. A large part of learning to function with mast cell disease is understanding that you will never be able to completely control your exposure to triggers.

A completely different situation that also happened last week confronted me with a separate but related reality: that people often think that people with disabilities are just not doing it right. By which I mean being disabled and living with a disability. It is omnipresent and so frustrating and degrading. When we say that someone gave us trouble for parking in a disabled spot for which we have a placard, they say that if they were disabled, they wouldn’t park there because it’s not fair for people who have worse mobility.When we say that we are scared about not being able to get medication for chronic pain, they say that if they were disabled, they would meditate and rub themselves in [insert herbal remedy] and push through the pain by virtue of their willpower. When we say that we are worried about how changes in healthcare policy will affect disability payments, they say that if they were disabled, they would never allow themselves to need disability payments because they would continue to work fulltime. When we say that we can’t pay for our meds and copays, they say that if they were disabled, they would manage their money better. When we say that our insurance won’t pay for a medication that we absolutely need and should have, they say that if they were disabled, they would never let that happen to them, that they would just be so forceful and smart that no insurance would be able to deny them anything. (I just made a Michael Phelps face as I typed that last sentence. This point is a bit more sore than I thought.)

I realize that this response derives mostly from two things: ignorance, and to a larger extent, fear. It is terrifying to confront the fact that we live in a society where people can just refuse to provide you with things you need to function or even to stay alive. It is scary to think that you can become so sick overnight that your old life will never be manageable again and that you will need so much help to do anything. It is scary to think that providers and government agencies and pharmacies can refuse to alleviate your serious pain. It is much easier to think that disabled people are just doing it wrong than it is to realize how vulnerable we all are in so many ways. Few things are scarier than impotence. Maybe nothing is.

Hope you’re having a great summer.

 

Astoria has a bath

 

 

Astoria has a life jacket

 

 

Astoria has a bathtub

Unshakeable: An update on Kristina

On Father’s Day in 2008, my father had a massive heart attack. My mother, sister and I were passengers in the car he was driving to a restaurant for dinner when he suffered a full cardiac arrest. I know all of the facts about what happened because I have recited them so many times, but I don’t truly “remember” most of what happened. I remember performing CPR in the middle of the street and worrying that I was not being forceful enough with compressions immediately before I cracked his sternum. I also remember calling my uncle from the ambulance and thinking at the hospital that this was one of those moments that would divide my life into periods of before and after.

There have been a few other moments and I mostly recognize them when they are happening. I did not realize that the week spanning the end of September and beginning of October in 2015 would be one of those. I spend a lot of time reassuring people about their health, including myself, to the point that it is almost a reflex. I assume things will be fine until I am shown incontrovertible evidence that they will not. I trick my body into thinking it’s not scared by donning the physicality of confidence and busy my mind with other things.

I have a practiced eye and I should have been able to see the impending storm last year. On the other side of the horizon, a darkness gathered, spinning and spinning into a fury. But I didn’t. None of us did. I think about it every single day.

Last week, a friend commented that Naples is not too far from where Kristina lives. It’s lucky that she did because I had no idea. Kristina is a mast cell patient and mom of a mast cell baby. She is my friend and part of a group that included me and six other masto moms or patients who shared everything. Kristina suffered a brainstem stroke last October and suffers from locked in syndrome. She is aware and understands everything happening but is unable to control her body or speak.

I visited Kristina yesterday at home with her family. She is still Kristina. She laughed at my sarcasm and bad jokes. I asked her if I could give an update for everyone thinking of her and praying for her. She said I could.

The last ten months have been very challenging for her and her family because she lost all functionality but very limited eye movement in the stroke. Additionally, she is a mast cell patient, which complicates her management and treatment. Her team is aggressively working to teach her brain to make new pathways to control movement, especially in her face, arms and fingers. She is working on sitting upright and spent some time in a wheelchair while I was there.

She has regained some movement in her face and neck. She can turn her head from side to side. She can control her eye movement better, including blinking. She can move some other muscles in her face, including above her eyes and near her mouth. Kristina communicates currently by eye movement and answers yes/no questions or spells words by blinking when the alphabet is recited to her.

Kristina is able to breathe on her own with a tracheostomy, which allows extra assistance to help clear secretions and cough if needed. Her speech therapist tried a new valve on her trach while I was there and for the first time in ten months, I heard Kristina’s voice.

It is not in my nature to be hopeless, even when things are grim. In 2008, my father was in a coma after his heart attack long enough that we were approached about giving him a trach to keep him ventilated long term. We were given a target date for this procedure since he was not expected to wake from the coma before then. Instead, the vent was removed and he woke up on my parents’ 25th wedding anniversary. It has been eight years since that day and I am still grateful for that every day. The fact that my father survived has given me the unshakeable understanding that sometimes, even when it seems hopeless, and even when we can’t explain it, people get better.

Kristina is a tenacious, intelligent and eminently capable person. Her family is amazing. They are so dedicated to her recovery. Getting to hug Kristina, and her mom, husband and son, was easily the highlight of my year. I don’t know what will happen but I am hopeful. I told her that we love her and that so many people think about her and ask about her often. I told her that I was glad to see how well she was adapting to being home and that she was making gains and that I had an unshakeable belief that she would get better, too.

Thank you for keeping Kristina and her family in your thoughts and prayers.

An uncommon gift

Rare disease patients often have little in common but their disease.
We speak different languages.
We are of different races.
We live in different countries.
We have different families.
We have different ages
And politics
And religions.
We laugh differently
And love differently
And cry differently
But when you are in the moment, it all feels the same.
And because we are so different
We might never have been friends otherwise
But that doesn’t matter
Because we are.
And sometimes our differences make our friendships messy.
And sometimes our closeness despite our differences feels like cheating
Like getting a gift in celebration of something
We shouldn’t be celebrating.

Today I visited a dear friend
Who was a gift from this disease
And I sat with her
And rubbed her hands
And told funny stories
And reminisced
About the hard days
Before the hardest days came.
And thought to myself
That I will never be able to put this feeling into words.
To put this connection
Into words.
To describe
How one day
A long time ago
This woman told me about her son
And that she was scared
And when she did
The fear in my heart saw hers
But it saw the courage too
And hearts are always more courageous
When they don’t beat alone.
I will never be able to put into words
What happened inside me
When she lost her voice
And things seemed hopeless
And she was scared
And I was scared
But my heart mustered some courage
So that her heart would see it.
And we don’t know what will happen
But the only way to overcome these hardest days
Is by opening our eyes
Even when we don’t want to
And laughing
Even when it makes it hard to breathe
And remembering
Even when it twists your insides
To know
That none of us saw this coming
And that we are scared
That we won’t overcome this.

But we are part of this world
A world that gave us
Sunshine
And warm breezes
And the night sky.
That gave us
Swimming
And family
And friends
To remind us
That there is good here.
That gave us
Terror and pain
So that we would understand joy
Desperation
So that would know peace.
This disease
So that we could find each other.
These hardest days
So that we can overcome
And so that nothing
Will ever
Seem hard
Again.