As with many offices, we also struggle with appointments made but not kept. What happened in my practice was that this created a waiting time for new patient appointments at three months. That was too long and unacceptable. I thought long and hard about how to increase the rate of show and hopefully cut down on that prolonged wait time for an appointment.

I recalled an article  for which I was the lead author. This publication looked at asthma adherence. Part of that study included appointment keeping behavior. When a family was given an appointment by a health care office about 2/3 kept that appointment. When a family was told to make an appointment, the rate of show was 95%.

I have always wondered about our tendency to try to schedule appointments ‘office to office’ and just how well that works. It is a nice service however it may not be very effective or efficient. It may have worked for a time in the past, but I have doubts about offering that policy today. When an appointment is failed, the time of the referring physician’s office staff and our staff was wasted. I have always thought that it may be better to have families make appointments themselves. This would be a form of empowerment for a family. When a family goes home and later calls to make an appointment they have had a chance to think about a consultation and whether or not they agree with the need. They may want to consider other providers for this service. There was a chance to discuss it with other family members. Their calendars were at hand. Travel could be considered. There are many positive outcomes for doing it this way.

All too often the family is not aware of their schedule when an office makes an appointment for them. Sometimes the families don’t agree with the need for a consultation. Consider also time, transportation, cost, and even results. When a family makes their own arrangements, they are more wedded to the idea. The family is talking directly to our representatives so issues of location, time, and preparation (stopping only antihistamines) are gone over directly and not later via a third person.

So why did we do so well in January 2012 with new patient appointments (in rank order of importance)?

• Families really wanted to see me
• Families made their own appointments
• It was a quirk and it will never happen again

Regardless, I like to stay busy. I cringe when I hear that my wait time is longer than 2 weeks. Hopefully this trend will continue.

FEL (2-1-2012)

During my fellowship in allergy, I worked with family in which 7 boys were affected with X-linked agammaglobulinemis. I published a paper about their interesting presentations. One of my kids today had this condition and a number of associated problems. It was refreshing and hopefully helpful to the family who was here to see me about possible allergies.

The next was a young man of 12 years who had over the past year complaints of a scratchy throat, itchy mouth, and a garbled voice after eating watermelon. It also happened with banana, grapes, avocado, and cantelope. This is the oral allergy syndrome. I struggle with this too. My reaction to watermelon prompted one of our allergy fellows at Henry Ford Hosptial to do a research project on the problem. That work also resulted in a publication.

So two of my three patients today had clinical problems that I had written about and had published on.

It was a great day indeed.
FEL

I now have a new hip. This one is made of titanium and cobalt. My appliance and I are having a rough early time here. What has come true is that I no longer have hip pain, at least I do not think I have any more hip pain (could be the pain killers). What I do have is a left leg that is swollen, discolored, and ever so tight. I no longer use a cane- I use a walker. Dr. Pierson (Dr. Jeffery L. Pierson) said that I will love my new hip- that is true, I just hate all the muscles and soft tissue around it just now.

I am dedicated to being the perfect patient. I have been doing my exercises 3-5 times per day (been home 3 days) per instruction. I elevate the leg. I sit no more than 45 minutes. I also take two scoops of medicines a couple times a day. This is tough. I am so glad that my wife is here to help me get through this. Evn the little things-I had to have her describe the surgical scar to me before I could look at it.

The hard part is being patient, specifically a patient patient. This type of recovery has a set pace, I will not be able to change that. I have to learn to ask others for help, I need to realize that they want to help. I need to be specific about that help. I need to realize that minor routines of daily living can pose a real challenge. I have to be wary that a wrong move could result in the new joint coming out of position, I need to be careful.

So now I am a hipster!

2010 Indianapolis 'Top Doctors'

Last year I posted a notice of thanks to my colleagues who helped me achieve the honor of being listed in Indianapolis Monthly “Top Doctors”. The honor has been repeated for 2010 and again my sincere thanks to those who supported my nomination. 

This year the listing includes 194 physicians in 49 specialties. Under the section of Allergy and Immunology I share the listing with Dr. David Patterson. 

I work in the Section of Pediatric Pulmonology, Critical Care, and Allergy at Riley Hospital for Children. This year there are now four members of  our section listed:  Drs.Young-Jee Kim and Howard Eigen repeat from last year’s listing and Dr. Michael Tsangaris has been added. In one specialty section at Riley Hospital for Children we have 4 of the 194 ‘Top Doctors’ as listed in the November issue of the magazine (Indianapolis Monthly Volume 34 issue 3.).That would be 2% in one specialty section. Makes one proud indeed to work within such a group! 

Congratulations to my colleagues and my thanks once again to my colleagues for their support, 

Fred Leickly

Why House Dust Avoidance is Hard

Another way to title this is ‘Why allergists can be meanies’. How could we even think of shattering such a peaceful, tranquil, and sweet image? I wonder if this is the more commonplace reality of young children and stuffed animals.

A colleague of mine, Dr. Veda Ackerman once told me that an allergist can never give a talk without saying something about house dust mites and/or showing a picture of a house dust mite. She is probably correct on that.

The simple retort is that house dust mites are important allergens. Individuals can be sensitized and allergic to proteins in the fecal pellet of the house dust mites. Yes that is where the allergen is found in feces (also known by a number of other terms not allowed on this site). I recall the look of horror when a patient on oral drops from house dust mites realized the source of the allergen.

In the lore of allergy, it has been said that inch for inch that there are more house dust mites in stuffed animals than any other item manufactured by mankind. Given that fact, when there is sensitization to house dust mites and this is suspected as a reason for allergy symptoms, the most effective therapy is avoidance of the house dust mite. So the recommendation is the removal of the stuffed animals from the child’s environment. There are a few other options; placing the stuffed animal in the freezer over night once a week or dry cleaning the critter. I fear that in this situation, the freezer would be filled to capacity with these friends.

 This picture of my granddaughter clearly shows why advising avoidance of stuffed animals can be a problem. It is often said that more than one stuffed animal in the bed with a house dust mite sensitive/allergic individual is too many.  Fortunately Stella has no allergic conditions. This picture is precious. My daughter labels it as ‘Stella and her friends’.

Stella’s Papa

FEL

This young lady’s mother had with her an article that escaped my attention. The article was written by known experts in the field of Allergy (the lead author was Anna Nowak-Wegrzyn with Hugh Sampson, Robert Wood, and Scott Sicherer as contributing authors). The paper was a nice review of FPIES and a study of 14 special children. I think that any allergist who sees young children should review this paper. These young children can present with signs that are possibly consistent with anaphylaxis.

 The article was published in the journal Pediatrics in 2003. It is a review of 14 children who presented over a five year period at the Mount Sinai Pediatric Allergy and Immunology Clinic (New York, NY) and to the Allergy Clinic at Johns Hopkins Children’s Center (Baltimore, MD). The reactions that these children experience include severe diarrhea and vomiting which can lead to dehydration and shock. This is a clinical diagnosis; there are no specific laboratory tests that make the diagnosis. A food challenge can confirm the diagnosis.

Milk and soy have been the most commonly implicated foods causing FPIES. This article shows that other foods specifically solid foods have been shown to be associated with this syndrome; rice, oat, barley, peas, string beans, squash, sweet potato, chicken, and turkey. These children underwent food challenges to show the cause-effect relationship between the exposure and the symptoms. There were many combinations of foods causing the problem; cow’s milk alone, soy milk alone, both cow and soy milk, a single solid food, and more than one grain. The group was compared to children who were only milk/soy sensitive.

                The profile of the Solid Food FPIES population was as follows;

• Age at onset of the reaction:    5.5 months (range 3-7 months)
• Age at resolution:                      24 months (range 14-44 months)

                The Milk/Soy FPIES profile was the following;

• Age at onset of the reaction:   1.0 months (range 2 days to 12 months)
• Age at resolution:                      28 months (range 14-21 y)

This was the first published study of FPIES triggered by solid food. Oat was the most common food causing solid-food FPIES. The study also showed that breast-feeding may have a protective role in preventing/delaying the development of FPIES. The diagnosis of solid-food FPIES was not made until after two reactions. It was also noted that these reactions were severe. The delay in diagnosis was attributed to a number of possible factors; low incidence of the disorder, a presentation that looks like septic shock, and the belief that solid foods such as grains, vegetables, and poultry are of low allergenic potential. It was also noted that the time course of the reaction may delay making the correct diagnosis. The daily feeding of milk – cows and soy, leads to chronic problems. The re-introduction of the milk causes symptoms two hours after the exposure.  As mentioned previously another problem is the lack of any test (other than avoidance and a food challenge) to confirm the diagnosis.

Another point that was made was that almost half of the children in this series had multiple food sensitivities. Children who were already on a casein hydrolysate formula had a median of four solid-foods that they were sensitive to.

No infant developed FPIES with exclusive breast feeding in this series.  The authors pointed out that they were unaware of any reports of FPIES during breast feeding with absolutely no direct oral feeding of an offending food. No infant developed FPIES to milk/soy after age 1 years and the oldest child who had the solid-food FPIES was 7 months old. There were no ‘predictors’ of which child with milk/soy FPIES would go on to develop solid-food FPIES.

The Bottom Line-

The reaction of vomiting/diarrhea possibly leading to shock can be consistent with an IgE-mediated reaction and these are perhaps more common than FPIES. Such a reaction would lead to an allergy evaluation which will be negative if the diagnosis is FPIES. However, the infant is still at risk for a severe reaction with re-exposure.

Board certified allergists are credentialed in the care of allergic conditions in both pediatrics and internal medicine. Some of us went into allergy after completing training in pediatrics and others were trained in internal medicine. FPIES would not have been a clinical entity seen during internal medicine training. It may have been seen/talked about for a pediatric oriented allergist. FPIES favors infants. My point to all this is that although very rare, we need to keep this type of presentation in mind when seeing young infants with scary episodes of vomiting leading to shock with solid-food exposure. Their evaluation will show no evidence of allergic sensitization. We can help by teasing out the history of exposures and clinical course. We can offer recommendations for avoidance of the common foods that have triggered solid food-induced FPIES. This profile of young infants reacting in such a violent way needs to be considered in the evaluation especially if they have had issues with cow’s milk or soy milk.

This young lady made an impression on me. Her story was very scary. She caused me to go back to the literature and review what is known about her presentation.

Fred Leickly

We have seen many children who were evaluated for food allergy and/or who were brought by parents to be evaluated for food allergy because of redness to the cheeks that is observed after eating.

What I haven’t heard about is a syndrome called ‘Frey’s Syndrome’. 

In the January edition of Postgraduate Medicine there is a case report, pictures, and a review of this syndrome which frequently precipitates an allergy evaluation. The problem is not due to allergy. It is an allergy-pretender.

Frey’s syndrome is also called the auriculotemporal nerve syndrome.  It involves redness over the cheeks after eating or drinking. The cause is abnormal nerve regeneration which can happen with forceps delivery or after parotid-gland surgery.  The actual incidence of the syndrome is unknown and it is by this report rare in children. Sucking on a lemon brings out the facial flushing. The use of starch/iodine brings sweating which is seen more in the adult.

The facial flushing with eating, gustatory flushing, may mimic food allergy and lead to unnecessary testing and the consequence of restrictive diets.

The clinical course is benign in children. The authors point out that it is important to recognize it so unnecessary evaluations are avoided.

The treatment is explanation and reassurance.

If you can see the paper, there  pictures of this flushing. The reaction looks distinctly delineated. It follows the distribution of the nerve.  The young lady would experience the flushing after eating sweets, citrus fruit, grapes, tomato sauce, fruit-flavored ice cream, and spicy foods. She had no history of any trauma to the area of the auriculotemporal nerve. There were no other symptoms besides this flushing. There was no personal history of allergy. Her teachers thought that this was a food allergy issue. In the clinic, the flush was seen one minute after eating a citrus-flavored sweet.

 I had not heard of Frey’s syndrome before, but I have seen a good number of red-cheeked children who had no other signs/symptoms of a food allergy. In this case, the types of food that elicited the problem, the timing of the flush in relation to eating, and the specific distribution help with the diagnosis of Frey’s syndrome.

We will start stocking sweet citrus-flavored candies for test purposes only. I am soliciting suggestions. So far I think Skiddles may work. If you can think of a candy that is has more of the citrus bite, let me know.

My thanks to the authors N Hussain, M Dhanarass, and W Whithouse for this article (Postgraduate Medicine Journal January 2010 Vol 86 N0 1011 page 62.)

Fred Leickly

As with all of these courses I learned from a group of wonderful speakers and there are a few things I will add to my practice. Here are a few things to share.

First- I was under the impression that warmth would be associated with places that had the word “Mexico” associated with it. Santa Fe was colder than back home here in Indiana! There was snow as well. Surprise! Despite the weather it is a most beautiful place.

Second- the people are very warm and friendly. Here is an example-my hat has many pins from a variety of states, countries, and places that I have visited. I was with my wife and our friends having the obligatory ice cream after a dinner with a rather spicy salsa. A gentleman came up and gave me a pin that commemorates the celebration of 400 years of Santa Fe, New Mexico. He loved the hat and thought that the pin would be a welcome contribution. I offered to pay for the pin but was denied. The gentleman was the president of the Santa Fe 400 year committee and he assured me that he had a plentiful supply of those pins. I didn’t catch your name- thanks yet again.

Places and things visited- Santa Fe 400 (left lower).

Third- The speakers for this program were all top-notch.

• Dr. Veda Ackerman- Pulmonary- James Whitcomb Riley Hospital for Children, Indiana
• Dr. Meg Fisher- Infectious Diseases- Children’s Hospital at Monmouth Medical Center, New Jersey
• Dr. Ivor Hill- Gastroenterology- Wake Forest University School of Medicine, North Carolina
• Dr. Todd Mahr- Allergy & Immunology- University of Wisconsin Medical School,  LaCross, Wisconsin
• Dr. Anthony Mancini- Dermatology- Northwestern University Feinberg School of Medicine, Chicago, Illinois
• Dr. David Schonfeld- Developmental/Behavioral Pediatrics- Cincinnati Children’s Hospital Medical Center, Ohio

Fourth- Here are just a few excerpts from the program;

Pediatric Pulmonology I work with Dr. Ackerman. In fact it was at an AAP course that I first met her and she was instrumental in recruiting me to Riley Hospital. Over the years I have heard her talk on many subjects for a wide variety of audiences.

Cough suppressants have no real role in children. There are no studies to support the safety and efficacy of these agents in children. Cough suppression in children may be hazardous and contraindicated.

Infectious Disease Very few bacteria lung infections cause wheezing except for mycoplasma infections. Most of the wheezing from infection is due to respiratory viral infections.

Most viral respiratory tract infections have a gradual onset of symptoms. The exception is influenza which hits hard and fast.

Fever may be helpful- the influenza virus will not survive/replicate in a host with elevated temperature. Treating the fever may help the virus to continue to replicate which can prolong the illness and prolong the spreading of the virus. Viral shedding may be prolonged with antipyretics (acetaminophen, ibuprofen).

Gastroenterology Celiac disease is a common concern. Confirm the diagnosis before treating. Constipation is not due to a food allergy in children. In dealing with constipation, the child controls the sphincter- this makes yelling at the child quite useless as a therapy.

Allergy Air filters for house dust mite avoidance do not work due to the nature of dust mite allergens. However a HEPA filter on a vacuum cleaner helps filter the exhaust. Carpeting on concrete (finished basements) helps house dust mites grow.

Food allergens are proteins/glycoproteins they are not fats or carbohydrates (sugars).

The peanut allergy child/family needs to be aware that peanut is sometimes made to look like or substitute for tree nuts. Faux almonds in baked goods may be peanuts. READ THE LABEL AND IF YOU DON’T KNOW, THEN DON’T EAT IT.

Dermatology I could not resist asking the definition of eczema, atopic dermatitis (AD), allergic atopic dermatitis, and non-allergic dermatitis. The answer restored my faith in this area: you should work with eczema and atopic dermatitis and forget the other two terms. Thank you Dr. Mancini!

One of the shared conditions with allergy is ‘atopic dermatitis’.  The presentation debunked myths associated with this condition.

These myths were-

•             Topical steroids are unsafe and should be avoided.
•             Antihistamines don’t really help.
•             Staph Aureus is an innocent bystander
•             Food Allergy is a common culprit

The debunking

•             Topical steroids are the mainstay of treatment.
•             Antihistamines help with itch and help with sedation.
•             Treating staph infections of the skin help with healing.
•             While 30-60% have a positive test for a food, only 10-30% have worsening of the condition due to a food exposure.

The role of allergy is recognized, but it is only part of a much larger scenario. Foods seem to be part of the problem in the more moderate to severe cases. Full and strict avoidance of a food in many cases does not modify the course of the disease. All too often parents blindly eliminate foods which can lead to dietary and nutritional deprivation. Co-management of AD by dermatology and allergy is vital.

Aeroallergen issues were a concern in the teenager with AD.

Developmental/Behavioral Pediatrics The specialties of D/B and allergy rarely mix except in CME programs like this one. Behavioral issues are not secondary to allergy. Given this, we don’t have many if any consults from the specialty.

Dr. Schonfeld’s lectures were; Supporting children in times of crisis, Connecting with patients and families to conduct a behavioral/mental health interview, and How children come to understand illness and how we can learn to explain it better.

These were very interesting topics and Dr. Schonfeld did fantastic job. I am sure he is wonderful with his patients.

I have always tried to engage the child in my evaluations. After all, the child is the patient. In our practices we need to be sure the child is involved to some extent (depending on age/maturation). There should be no secrets about their condition. The child can better deal with what is going on if they understand it. Our job is to facilitate that understanding and the processing of the information. Adherence to therapy should be improved with comprehension. We should also understand that we should not try to do all this in one visit.

Dr. Schonfeld pointed out that ‘health education’ is rarely taught in medical school. In my situation, I learned about health education in my MPH curriculum. A quote that I will always keep in mind is “You don’t need to be an expert in pediatrics to explain illness to children-you need to be an expert in children.

This was a great conference and it was made great by an outstanding faculty. If you have a chance hear any of these pediatric specialists speak, do not hesitate in listening to what they have to say. If you have a chance to see them for the care of a child, then I am assured that you are in very capable hands.  

Fred Leickly

I should be receiving my copy of the journal soon. I am concerned about how food allergy will be defined in the paper: will the diagnosis of food allergy be based on a history of exposure confirmed with appropriate allergy testing or will this be based on only laboratory results and no history?

As soon as I have this in hand I will post a commentary.

Fred Leickly

Looking for a doctor? Look no further. Presenting our selection of Top Doctors, recommended by their peers and leading physicians nationwide.

Indianapolis Monthly Magazine (11/09)

It is quite an honor to be selected as one of the ‘Top-Docs’ by Indianapolis Monthly Magazine. My most sincere thanks go to those physicians who nominated me. This listing of 142 physicians from 47 specialties also included two other members members of the Pediatric Pulmonology, Critical Care and Allergy section at James Whitcomb Riley Hospital for Children; our section chief Dr. Howard Eigen and Dr. Young-Jee Kim. Congratulations to my colleagues.

Thank you!!

Fred Leickly