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Mast Cell Disorders

August 20, 2023 by

Mast Cell Disorders

by Allergy Partners
August 20, 2023

Eczema

This post was updated on January 06, 2020.

A mast cell is a type of white blood cell that is part of the immune system, and it contains many granules that are rich in histamine and several other chemicals. Mast cells are best known for their role in allergic reactions which are initiated by allergens cross-linking high-affinity IgE receptors on their surface. This leads to the release of histamine which typically leads to hives, swelling, hypotension (low blood pressure), bronchospasm with symptom of cough, wheeze and chest tightness, and digestive problems such as diarrhea and vomiting. However, mast cells can cause problems outside of classic allergic reactions as well.

One of the mast cell diseases is mastocytosis, which is characterized by the overproduction of mast cells and CD34+ mast cell precursors. People affected by mastocytosis are susceptible to itching, hives, and anaphylactic shock, caused by the release of histamine from the abundant mast cells. Most cases of mastocytosis are localized to skin, or cutaneous. The most common form of this cutaneous mastocytosis is called urticaria pigmentosa. Urticaria pigmentosa can be diagnosed by identifying dark brown and fixed lesions that forms a hive (or urticates) when scratched. However, urticaria pigmentosa can evolve into systemic mastocytosis which involves the bone marrow and other rare mast cell diseases, such as mast cell leukemia and mast cell sarcoma.

A blood test called a serum tryptase level is the initial screening test for suspected systemic mastocytosis. To confirm the diagnosis a biopsy of the bone marrow or the affected organ to identify an increased numbers of mast cells is needed. There is currently no cure for mastocytosis, but the symptoms are alleviated by a number of medications, such as antihistamines, leukotriene blockers, mast cell stablilizers, corticosteroids, and epinephrine. Other medications that have been used in mastocytosis include proton pump inhibitors to reduce the increased gastric acid production, bronchodilators like Albuterol to reverse bronchoconstriction, calcium channel blockers to reduce mast cell degranulation, and chemotherapy or Gleevec in severe systemic disease.

Another mast cell disorder is mast cell activation syndrome (MCAS) which is characterized by the same symptoms as mastocytosis. In MCAS, however, there is a normal number of mast cells which are defined as “hyperresponsive.” Named as a new diagnosis as recently as 2007, MCAS is often found in patients with Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome, and idiopathic anaphylaxis. Symptoms can be caused or worsened by triggers such as specific foods and drinks (especially alcohol), temperature extremes, exercise, and emotional stress. Diagnosis of MCAS is often difficult, but laboratory evidence of elevated mast cell mediators such as N-methyl histamine and prostaglandin D2 is helpful, as is a good response to the same drugs used in mastocytosis.

Although rare, mast cell disorders mimic the symptoms of severe allergic reactions and anaphylaxis. Allergy Partners’ board certified Allergist-Immunologists are specialty trained in the diagnosis and treatment of both anaphylaxis and mast cell disorders. Our physicians work collaboratively with area specialists (such as hematologists) as well as tertiary care centers to ensure that patients with mast cell disorders receive the best care possible. Additionally, some of our physicians have particular interest in mast cell disorders. To learn more, visits www.allergypartners.com or contact your trusted Allergy Partners physician.

Dr. Sol Drapkin,

Allergy Partners of Chicago

Curriculum Vitae: Your Career on Paper

August 20, 2023 by

Curriculum Vitae: Your Career on Paper

by Allergy Partners
August 20, 2023

two people holding on to a clipboard

A well-constructed CV displays your attention to detail and lays plain your professional accomplishments.

Whether it’s your first one out of school, or needs to be refreshed for a new job search, your CV is a potential employer’s first look at your qualifications. Keeping it clear and organized will not only make a great first impression, it will also assist other departments in their work once you’re hired.

There’s a lot more to your CV than a list of training, employment and publications. During a job search, it will be referenced by a number of in-house teams that will focus on different information along the way. From recruiters, to hiring committees and credentialing teams, your CV is the go-to document as you move through the stages of hiring so it’s important that it is accurate and up-to-date.

Title and Contact Info

List your full name and credentials as you would have them appear on a business card or employment contract
Include your home address and cell phone number
Use your personal email address (and remember to check it often)

Training

List your medical training in reverse date order, beginning with Fellowship
Include the institution, location and degree received
If you are an international medical graduate, indicate if you have obtained ECFMG Certification
Format dates as MM/YY (the credentialing department will thank you for it!)
If you are still in Fellowship training, include start date and expected graduation date

Certifications

Include all board certifications (i.e. pediatrics or internal medicine) and active dates
If you are not yet board-certified in allergy/immunology, indicate if you are board-eligible

Employment

List your related employment in reverse date order, beginning with the most recent
Include name of institution, location and title if applicable (i.e. Department Head)
This is an appropriate section to include military service as well

Awards and Honors

Grants and awards
Special military recognition

Memberships and Affiliations

Memberships in local, state or national professional associations (including AAAAI and ACAAI)
Include committee participation or offices held

Languages Spoken

If you speak languages other than the one in which you are interviewing, be sure to include that as well. Speaking additional languages can be very attractive to employers in many regions of the country (and may even be required for some positions.)

Publications and Research

For some, this section can be quite lengthy! One option is to only include the last ten years of items, with a “full list of publications available on request.”

A good CV can provide a solid foundation document for years to come, and needs only to be updated annually or as necessary. There are a number of free templates online for a good head start. Remember to keep it clear, concise, and under four pages if possible. Run it through spell check, and pay special attention to email addresses and phone numbers that might be transposed. It will save recruiters and on-boarding teams major delays if your CV is accurate and up-to-date when you apply for a new position.

Penicillin Allergy

August 1, 2023 by

Penicillin Allergy

by Allergy Partners
August 1, 2023

medicines

Allergy to penicillin is very commonly documented in patient charts, but is much less common than perceived by the general population. The reported prevalence of penicillin allergy is about 10%, however, more than 90% of patients are found not to be allergic. In patients found to have true penicillin allergy, the frequency of positive skin test results decreases over time. Clinical evaluation of these patients is important to help decease drug resistance, decrease healthcare costs and improve patient outcomes.

Appropriate evaluation of patients with a history of penicillin allergy can be accomplished by gathering historical information regarding reaction in addition to skin testing. Most drug reactions are either type I IgE-mediated reaction (immediate) or type IV (delayed) reaction. Immediate reactions generally occur within the first hour after initial dosing, but can take up to two hours particularly if medication was taken orally and with food. Symptoms can include hives, itching, swelling, wheezing, shortness of breath, low blood pressure and loss of consciousness. Delayed type responses generally occur days into treatment. Symptoms can include various skin reactions, anemias, kidney dysfunction, and other types of systemic illness. The most common reaction is a skin rash or hives. Positive response to epinephrine and antihistamines within a few hours of a reaction may indicate an immediate hypersensitivity reaction. Many skin reactions are a result of viral or bacterial infections. Also important to ascertain is whether a patient has tolerated other similar antibiotics (beta – lactams). This could indicate that the patient is not or no longer allergic to penicillin.

Even though skin testing can only identify a type I allergic response, it is this response that can lead to an anaphylactic reaction so it is important to be able to identify or rule out this type allergic issue. Risk factors for a hypersensitivity reaction include frequent or repeat courses of penicillin and high dose IV penicillin. Age and history of other allergic disease are not risk factors. Most patients lose allergic sensitivity to penicillin over time. Nearly 50% of patients are no longer allergic within 5 years of a reaction, and 80% or more by 10 years.

Penicillin allergy is the most commonly reported a drug allergy in the United States. Ninety percent of patients labeled as penicillin allergic are able to tolerate the drug. Adequate evaluation for true penicillin allergy with thorough history, skin testing and graded oral challenge can improve overall healthcare by decreasing cost and improving patient outcomes.

An Allergist-Immunologist is specialty trained in the diagnosis and treatment of allergic reactions, including penicillin allergies. If you would like to learn more about Penicillin allergy, contact your trusted Allergy Partners physician or visit allergypartners.com.

References:

Gonzalez-Estrada A, Radojicic C. Penicillin allergy: A practical guide for clinicians. Cleve Clin J Med. 2015 May:82(5):295-300
Nadarajah K, Green GR, Naglak M. Clinical outcomes of penicillin allergy testing. Ann Allergy Asthma immunol 2005;95:95:541-545.

Cow’s Milk Allergic Children | Understanding Formulas & Alternative Milks

July 23, 2023 by

Cow’s Milk Allergic Children | Understanding Formulas & Alternative Milks

by Allergy Partners
July 23, 2023

Mother and daughter drinking milk

Being a mom can be challenging sometimes, but being a mom to a milk allergic child can be frightening and frustrating. You asked, and Dr. Catherine Cranford answered a lot of your questions on Cow’s Milk Allergic Children and how to help your child.

Exercise Induced Asthma

July 21, 2023 by

Exercise Induced Asthma

by Allergy Partners
July 21, 2023

woman running by the sunset

Like the name suggests, exercise induced asthma or exercise induced bronchospasm (EIB) is asthma that is triggered by vigorous or prolonged exercise or physical exertion. Most people with chronic asthma experience symptoms with exercise; however there are some people without asthma who can experience symptoms only with exercise.

Symptoms

Symptoms usually start within 5-20 minutes of starting exercise or can start 5-10 minutes after completing exercise and include:

Chest tightness
Cough
Shortness of breath
Wheezing
Excessive fatigue with exercise

Mechanism/ Pathophysiology of EIB

There may be more than one biological mechanism that causes EIB. A change in the temperature and moisture content of inhaled air is the primary change that causes symptoms in these individuals.

During normal breathing, we inhale air through the nose which is first warmed and moistened through the nasal passages. During strenuous exercise, we breathe through the mouth and the air tends to be cooler and drier; strenuous exercise sets in motion molecular events that trigger inflammatory changes which cause narrowing of the airways and mucous production.

EIB can also be made worse when the patient is sick with a cold or when the allergens ( pollen, mold) counts are really high during the allergy seasons or when the person exercises in very cold weather.

Diagnosis

Exercise induced asthma is diagnosed on the basis of a reliable history and supportive tests like Spirometry and sometimes an Exercise challenge test.

A Spirometry is a breathing test that is done in the office to measure a patients lung capacity at baseline and to see the effect of a bronchodilator on lung function.

An Exercise challenge test is sometimes necessary in patients who have exercise induced symptoms but don’t seem to be getting better with treatment. Such patients may have other conditions which mimic EIB and may need to be treated differently.

An Exercise Challenge test is usually done in our office using a treadmill – the patient is made to undergo vigorous exercise in order to provoke the patients symptoms; Spirometry is done pre -exercise and again post exercise every few minutes to determine if the patient is showing evidence of bronchospasm.

Conditions that can mimic exercise induced asthma include:

Vocal cord dysfunction
Gastroesophageal reflux disease
Other lung disorders
Cardiac arrhythmia or other conditions

Should exercise be avoided by patients who have EIB?

No, asthma should not be used as an excuse to avoid exercise. Exercise induced symptoms can be both prevented and treated with medications as well as taking certain precautionary measures during exercise.

Treatment

Pre-exercise inhalers:

Short acting Beta2 agonists (SABA’s) like albuterol help to relieve bronchial spasm and are the most commonly prescribed inhalers for EIB -the inhaler is usually taken 10 minutes before exercise as a preventive measure and can be used additionally if a patient experiences symptoms. However, if pre-exercise treatment alone is not enough and the patient needs this inhaler regularly even after exercise, then he/ she may need a daily controller medication.

Daily controller medications:

For those patients with chronic asthma and those requiring SABA’s daily for EIB ,there are other inhalers ( such as inhaled corticosteroids and LABA’s ) and leukotriene modifiers (Singulair) which are often prescribed as controller medications. These medications help to control inflammation and can also help to prevent exercise induced symptoms.

In addition, the patient may want to take certain extra precautions like trying to avoid exercising outdoors in very cold weather and using a face mask if exercising during high pollen count days which would also help to minimize symptoms. A gradual warm up routine prior to vigorous exercise and a cooling down routine post exercise also helps.

Certain exercises like swimming are better tolerated by these individuals because it is usually done in a warm moist air environment.

Activities that involve short intermittent periods of exertion like volleyball, walking and wresting are generally better tolerated than other strenuous exercises like soccer, ice hockey and basketball but most patients with exercise induced asthma should be able to actively participate in sports and activities.

The board certified and eligible physicians at Allergy Partners offer extensive training, knowledge and experience in diagnosing and treating patients with exercise induced asthma. As the leaders in allergy and asthma care, our physicians take a detailed history, perform careful physical examination and create a patient centered treatment plan to ensure all needs are addressed thoroughly.

Mona Hirani, MD

Allergy Partners of Chicago

Credentialing 101 for New Physicians

July 13, 2023 by

Credentialing 101 for New Physicians

by Allergy Partners
July 13, 2023

Physician Planning

Having the necessary documents ready puts you in the best position for a timely career move.

Many physicians are surprised to learn that credentialing with payors for a new position can take 90-120 days.

Unlike most other professions, doctors are subject to several timelines that determine when they can begin seeing patients in a new job. Licensing and credentialing processes are determined by states and payors and can add months of lead time to starting a new position.

The credentialing process can often feel like getting a mortgage in that there’s always just one more piece of information that you’re asked for. Having all the necessary documents ready to go will put you on the best track to a target start date.

Know the Timelines

Application for and receipt of a state medical license can take 4-6 weeks.
Credentialing with commercial payors can take 90-120 days and cannot commence until state licensure is received.
Credentialing for physicians coming out of fellowship cannot start until July 1, following completion of their training, and may be contingent upon the receipt of board results. That means new fellows will likely not be able to start new positions until the fall.

That last point comes as a big surprise to many new fellows when they learn they will be benched for a few months following graduation. This is a good stretch of time that can be best used to make geographical moves and get families settled.

Gather Passwords

Depending on the size of the practice you’re joining, you may be working with an in-house credentialing team or an outside vendor to walk through the process. They will request access to some of your dashboards, so have your credentials ready to go when they ask.

NPPES/PECOS (NPI/Medicare) ID, Login, and Password
CAQH Provider ID, Login, and Password

Update your CV

It may seem like a fine point, but payors prefer to have CVs formatted in a specific fashion. You can save time by updating your CV to list the dates of employment and education in MM/YYYY format. If you’ve signed a contract with an employer, they may ask you to add your new position as well.

Scan Your Documents

Payors will require a variety of documents that confirm educational accomplishments and citizenship. Make sure they are scanned in color and that the file names include your name and a reference to the document type so they are easy for the credentialing team to reference.

Driver’s license or passport
Social security card
Proof of citizenship if born outside the United States
State medical licenses (current and former)
Federal DEA certificate
State CDS certificate
Malpractice insurance certificate for last 10 years (current/former employers)
Medical school diploma
Residency diploma
Fellowship diploma
American Board of Allergy & Immunology certificate
Educational Commission for Foreign Medical Graduates certificate, if applicable
Other Documents and Applications

You will also likely be asked to complete applications specific to the practice you are joining, which may include supplying additional information for background checks and medical malpractice coverage.

MedPro application
Hospital privileges application

Whether you are joining a practice as a new physician or aligning your practice with a larger company through acquisition, the credentialing team will need every item on their checklist in order to proceed. Having all documents and passwords pulled together will put you in the best position to be fully credentialed by your start date.

Does Summer Signal the End of Allergies?

July 3, 2023 by

Does Summer Signal the End of Allergies?

by Allergy Partners
July 3, 2023

tree leaves

Yes and no. Sure, spring allergies to trees pollens may be winding down but that does not mean you are in the clear. Summertime brings a new list of possible triggers. Symptoms such as sneezing and runny nose or congestion as well as dark eyes, swelling of the eyes and itching of the mouth and/or eyes can signal the beginning of exposure to mold, grasses or ragweed. Mold thrives in damp areas including basements and bathrooms in addition to outdoor areas such as woods and water sources (lakes, streams, rivers, etc.). Ragweed starts early to mid-August and affects more than 23 million Americans. Treatment is best effective when started at least 2 weeks prior to the expected onset of symptoms. A proactive approach with medications or immunotherapy will alleviate the height of symptoms and suffering.

Oral allergy syndrome, also known as pollen-food syndrome, can become more prevalent during summer when fresh fruits and veggies are consumed more frequently. This is caused when cross-reacting allergens found in both pollen and raw fruits or veggies is present, making the immune system react with an allergic response. It is common to begin experiencing issues even if the same foods have been consumed previously without issue. Symptoms can include itchy mouth, scratchy throat or swelling of the lips, mouth, tongue and throat. Symptoms typically will subside quickly once the food is swallowed or removed from the mouth.

Insect stings are also a common problem in the summer months. Bees, wasps, yellow jackets, hornets, fire ants and other insects can cause allergic reactions when they sting. A severe allergy could lead to a life-threatening situation. Typically these insects cause mild symptoms such as itching or swelling around the sting site. However, if symptoms such as tongue or throat swelling, dizziness, or nausea present, medical help should be sought immediately.

As in most cases, avoidance is key yet not always ideal. Although there are measures you can take to reduce exposure, a trip to your board-certified allergist should be first on the list. The trusted allergists at Allergy Partners have a wealth of training and experience in diagnosing and treating asthma and allergic disease such as those mentioned above. Locations and physicians can be found by visiting www.allergypartners.com/locations.

By Dr. Bill McCann

Allergy Partners of Western North Carolina

New Treatment for Atopic Dermatitis

July 1, 2023 by

New Treatment for Atopic Dermatitis

by Allergy Partners
July 1, 2023

Atopic dermatitis, also known as atopic eczema, is an inflammatory skin condition leading to itchy, red, swollen and cracked skin. It typically starts in childhood, but up to 40% of patients will continue to have eczema into adulthood. This skin condition can greatly affect patients with itchy skin interfering with sleep and focus on daily activities such as school, sports and work. Breakdown in the skin due to scratching can also lead to secondary skin infections. The reddened and thickened areas, known as lichenification, can also be embarrassing for patients in public.

Atopic dermatitis is a chronic condition that requires daily treatment. Typical treatments include daily hydration and multiple applications of lubrication, as much as 4-5 times a day. Topical steroids, beneficial to help control the inflammation, are also applied but can cause side effects such as thinning of the skin and decreased pigment leading to whitish areas where the steroids were applied. Oral antihistamines, like Benadryl or Claritin, can also be added to help with itching. Atopic dermatitis is a condition that is difficult for many patients to fully control.

Recently, two new treatments have been approved for atopic dermatitis and have shown significant improvement in control of this condition.

1. Eucrisa (crisaborole 2% ointment) has been approved for ages 2 and older for mild to moderate atopic dermatitis. It acts as a phosphodiesterase inhibitor that most likely affects cytokine signals in the inflammatory cascade, although exact mechanisms have not been clearly defined in atopic dermatitis. This medication is applied to involved areas of skin twice a day. Two studies have shown improvement in atopic dermatitis scoring, which resulted in clear to almost clear skin or improvement of 2 categories from baseline.

2. Dupixent (dupilmab) has been approved for patients 18 years and older with moderate to severe atopic dermatitis. This medicine is given as a subcutaneous injection and acts as an interleukin 4 receptor alpha antagonist that blocks the actions of interleukin 4 and 13 which are implicated in allergic diseases such as atopic dermatitis. Three studies showed improvement in atopic dermatitis symptoms ranging from 40 to 60% for patients who were already on typical medical treatment. Studies are currently being done in patients < 18 years old.

These are two new treatments for atopic dermatitis that address the underlying immune mechanisms and hold hope for better control of this disease for patients affected by them.

To learn more about eczema and how best to manage it, visit your trusted Allergy Partners physician.

How Effective Is Immunotherapy (Allergy Shots or Drops)?

July 1, 2023 by

How Effective Is Immunotherapy (Allergy Shots or Drops)?

by Allergy Partners
July 1, 2023

immunotherapy

Dr. Sussman from Allergy Partners of New Mexico explains how effective immunotherapy is.

Early Food Introduction For Infants

June 29, 2023 by

Early Food Introduction For Infants

by Allergy Partners
June 29, 2023

healthy food

Food allergies have been a hot topic in the news over recent years. With the increasing rates of food allergies, it seems that all of us know someone whose life is impacted. While most of the recent news has focused on kids, a recent article by Dr Ruchi Gupta from Northwestern University suggests that rates of food allergies are likely increasing among adults as well.

Fortunately, there has also been a great deal of good news regarding food allergies. Over the last few years, several studies have suggested that early introduction of highly allergenic foods such as peanut and eggs may lead to a lower rate of food allergies later in life. In the past, allergists and pediatricians recommended delaying the introduction of these foods until at least 1 year of age to reduce the risk of developing food allergies. However, the tide has shifted and based on research studies such as the Learning Early About Peanut Allergy (LEAP) trial these recommendations have changed. The LEAP trial demonstrated that for infants at high risk of developing a peanut allergy, introducing regular peanut consumption during infancy lead to a dramatic reduction of peanut allergy at age 5. Based on this and other promising studies, the American Academy of Pediatrics recently published an updated report on the role of early infant diet on the prevention of allergic disease.

According to this report “there is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs and fish, beyond 4 to 6 months prevents atopic disease.” The report goes on to state that “there is now evidence that early introduction of peanut may prevent peanut allergy.” In other words, allergists and pediatricians now believe that adding these foods once an infant reaches 4 to 6 months of age may actually reduce the rate of food allergy. These exciting findings offer hope that we will be able to reverse the trend and actually see lower rates of food allergies in the future.

Changing recommendations and guidelines can be confusing for patients and families. Your local Allergy Partners providers can help you with up to date recommendations about food introduction for your children and discuss any concerns you have about current food allergies.

By Dr. Chris Copenhaver
Allergy Partners of Western North Carolina