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Can you order labs for a patient you haven't seen?

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  • Avatar snowcanyon 
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    State-dependent legally, but generally a bad idea.

    In my state, you are legally required to keep a medical record if you order tests or prescribe medications. I’m sure your medmal carrier would agree, regardless of the state in which you practice.

    People who can afford international travel can afford to pay cash to see an allergist in the US.

    #227134 Reply
    Avatar Panscan 
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    It’s funny to me that overprotective parents who want their kids tested for IgE are also the reason their kid has allergies to begin with.

    Roll in the mud!!!

    #227158 Reply
    Avatar trebizond 
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    Oops, liked the wrong post my own.

    I do think it’s reasonable to order labs if we know what we’re doing with them. Don’t think there’s an ethical issue, it’s in our prerogative as physicians and doing these sorts of things can help out patients quite a bit.

    I remember in residency having a terrible ear infection which my attending saw when he inspected my ear, said my ear “looked terrible” and he refused to prescribe antibiotics, so I had to go to urgent care later that evening pay a copay, then schlep over to the Rx, etc. Would have been much easier and cheaper if he had just given me a script for cefdinir.

    #227167 Reply
    legobikes legobikes 
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    Earnest refinancing bonus

    I don’t think there’s an ethical problem per se with IgE testing.

    I shy away from panels because they are overly broad. The one exception is environmental/aeroallergens, because identifying culprits on history is hard to impossible and there are many different potential sensitizations, although I have a preference for skin testing in that case anyway (yes, there is no difference between the two).

    IgE testing should be directed by detailed history taking. Only test for very specific foods for which there is a history of potential allergic reaction. This means you have to ask a lot of question about egg and dairy and soy and fish and shellfish and etc. And if it does not sound like type 1 hypersensitivity, don’t test for the GI intolerances, because the IgE level is impossible to interpret there.

    I would support 3 exceptions:

    1. Peanut testing for those with moderate-severe eczema or egg allergy or both, because the evidence supports doing this before they have ever tried peanut.

    2. Tree nuts when there is a peanut allergy and vice versa. Also sunflower seed when there is sesame allergy and vice versa.

    3. The family is deathly afraid of giving the kid specific foods, e.g. because of a family history. Then I will test more broadly – oftentimes with skin instead – to try to reassure the mother that little Johnny won’t die from trying a bit of shrimp – which he’s never tried.

    There is real harm done with panels, namely reduced quality of life by family slashing out all kinds of reasonable, wholesome, and pleasurable foods from the diet – the worst avoidances being egg, dairy, and wheat. Or, alternatively, not letting their kid visit a friend’s house because a cat or dog IgE was positive. In the worst case scenarios I’ve seen malnutrition requiring supplements because so many high calorie high protein foods were being avoided needlessly.

    Click to expand…

    Alright but when I do the (food) panel I do it with the caveat that a positive does not mean they are allergic; a negative is confirmatory. How is ‘ruling out’ problematic? (Looking at you, Peds).

     

    (And I told the parent in question that she should let her kid play in dirt.)

    #227175 Reply
    CordMcNally CordMcNally 
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    I don’t think there’s an ethical problem per se with IgE testing.

    I shy away from panels because they are overly broad. The one exception is environmental/aeroallergens, because identifying culprits on history is hard to impossible and there are many different potential sensitizations, although I have a preference for skin testing in that case anyway (yes, there is no difference between the two).

    IgE testing should be directed by detailed history taking. Only test for very specific foods for which there is a history of potential allergic reaction. This means you have to ask a lot of question about egg and dairy and soy and fish and shellfish and etc. And if it does not sound like type 1 hypersensitivity, don’t test for the GI intolerances, because the IgE level is impossible to interpret there.

    I would support 3 exceptions:

    1. Peanut testing for those with moderate-severe eczema or egg allergy or both, because the evidence supports doing this before they have ever tried peanut.

    2. Tree nuts when there is a peanut allergy and vice versa. Also sunflower seed when there is sesame allergy and vice versa.

    3. The family is deathly afraid of giving the kid specific foods, e.g. because of a family history. Then I will test more broadly – oftentimes with skin instead – to try to reassure the mother that little Johnny won’t die from trying a bit of shrimp – which he’s never tried.

    There is real harm done with panels, namely reduced quality of life by family slashing out all kinds of reasonable, wholesome, and pleasurable foods from the diet – the worst avoidances being egg, dairy, and wheat. Or, alternatively, not letting their kid visit a friend’s house because a cat or dog IgE was positive. In the worst case scenarios I’ve seen malnutrition requiring supplements because so many high calorie high protein foods were being avoided needlessly.

    Click to expand…

    Alright but when I do the (food) panel I do it with the caveat that a positive does not mean they are allergic; a negative is confirmatory. How is ‘ruling out’ problematic? (Looking at you, Peds).

     

    (And I told the parent in question that she should let her kid play in dirt.)

    Click to expand…

    I think that your questions are even more of a reason not to do it.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #227180 Reply
    Liked by Peds
    Avatar Radonlake 
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    http://www.requestatest.com

    I use them for my own labs since I know exactly how much they cost, no haggle or hassle – just pay and show up to get blood drawn. No doctors order needed, you can choose what you want.

    #227217 Reply
    Avatar trebizond 
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    I don’t think there’s an ethical problem per se with IgE testing.

    I shy away from panels because they are overly broad. The one exception is environmental/aeroallergens, because identifying culprits on history is hard to impossible and there are many different potential sensitizations, although I have a preference for skin testing in that case anyway (yes, there is no difference between the two).

    IgE testing should be directed by detailed history taking. Only test for very specific foods for which there is a history of potential allergic reaction. This means you have to ask a lot of question about egg and dairy and soy and fish and shellfish and etc. And if it does not sound like type 1 hypersensitivity, don’t test for the GI intolerances, because the IgE level is impossible to interpret there.

    I would support 3 exceptions:

    1. Peanut testing for those with moderate-severe eczema or egg allergy or both, because the evidence supports doing this before they have ever tried peanut.

    2. Tree nuts when there is a peanut allergy and vice versa. Also sunflower seed when there is sesame allergy and vice versa.

    3. The family is deathly afraid of giving the kid specific foods, e.g. because of a family history. Then I will test more broadly – oftentimes with skin instead – to try to reassure the mother that little Johnny won’t die from trying a bit of shrimp – which he’s never tried.

    There is real harm done with panels, namely reduced quality of life by family slashing out all kinds of reasonable, wholesome, and pleasurable foods from the diet – the worst avoidances being egg, dairy, and wheat. Or, alternatively, not letting their kid visit a friend’s house because a cat or dog IgE was positive. In the worst case scenarios I’ve seen malnutrition requiring supplements because so many high calorie high protein foods were being avoided needlessly.

    Click to expand…

    Alright but when I do the (food) panel I do it with the caveat that a positive does not mean they are allergic; a negative is confirmatory. How is ‘ruling out’ problematic? (Looking at you, Peds).

     

    (And I told the parent in question that she should let her kid play in dirt.)

    Click to expand…

    The reason it’s a problem is because the mother will see those labs and read “abnormal” or “positive” and then – regardless of what you say – she will subconsciously or consciously avoid giving that food to her child – even if the child consumed it before without a problem. It’s a much more sophisticated discussion that then an allergist has to have with her as to why the food is safe to continue consuming and that the lab may mean absolutely nothing clinically. With prolonged avoidance, the likelihood of true allergy developing increases, so testing someone positive to – say – dairy when they are 8 months old, without a clinical correlate, and them avoiding it for the next year before the allergist sees them – the likelihood of them developing an actual milk allergy increases compared to those who continued consumption. Especially because they were already sensitized, allergy was already evolving. By instituting avoidance prematurely you stopped the development of tolerance that may have happened (super common with wheat, egg, and dairy, and occurs in ~20% of peanut and ~10% of tree nut). That then leaves the allergist with the problem of needing to do a (graded) challenge….to prove that the food is still safe to eat. By then, because of avoidance, many kids have lost taste for the food and start refusing it anyway. See how much trouble was caused by just a measly panel?

    The reverse is also true. There are non-IgE mediated allergic reactions, as you may know, to things like alcohol, NSAIDs, vancomycin, opioids, and exercise. Specific IgE does not pick up everything. It’s not magic. It makes an assumption that a whole extract will pick up all the pertinent antibodies, whereas it’s very possible that an antigen is only released or unmasked in the course of digestion.

    For example, there is a disorder called food dependent exercise induced anaphylaxis. There are number of triggers identified, including fish, celery, and most notably wheat. In ~1/3-1/2 of patients with this disorder, who have a true allergy to wheat, if you just send a total wheat IgE you will get a negative result and miss the fact that they are allergic. You have to specifically send an IgE against omega-5-gliadin to pick up upwards of 85% of patients who are sensitized and have WDEIA.

    To give you another example, when allergists attempted to do venom immunotherapy with whole crushed extracts from wasps and bees, it didn’t work. However, fire ants crushed whole did work. For reasons we don’t understand, you have to extract the bee venom by having them activate their stingers and extract the wasp venom by removing the venom sacs, to get the required extracts for VIT. We don’t understand why the whole body crushed extract doesn’t work – because there’s definitely venom mixed into it – but it simply doesn’t work. Yet another example of “common sense” not always giving you the right answer.

    Finally, I would not presume to tell an obstetrician how they do their tests, or a cardiologist, or an endocrinologist. Best that you trust the allergists when they say that panels are NOT standard of care (except, again, environmental testing), and that any food antigen testing should be driven by the clinical history and for specific suspected allergens.

    #227349 Reply
    Lordosis Lordosis 
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    tl;dr just going to order the simple blood test 😉

    “Never let your sense of morals prevent you from doing what is right.”

    #227623 Reply
    legobikes legobikes 
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    The reason it’s a problem is because the mother will see those labs and read “abnormal” or “positive” and then – regardless of what you say – she will subconsciously or consciously avoid giving that food to her child – even if the child consumed it before without a problem. It’s a much more sophisticated discussion that then an allergist has to have with her as to why the food is safe to continue consuming and that the lab may mean absolutely nothing clinically.

    Click to expand…

    I am sure there are doctors with no actual art, only science, who can neither tailor the information they give nor the testing they do for their patients and their patient’s parents. These are, however, poor arguments to be made for simply not doing a test. For example, the reason I made this thread in the first place was because this mother was told to avoid multiple common food allergens, which she did not want to do, and the results may have provided some evidence that this is not actually necessary in order to ‘treat’ her baby’s eczema.

    Neither is it big news that the answer to food allergies is not avoidance, since the truth always seems to lie orthogonal to any scientific consensus or physician guidelines, and aligns with common practice in what remains of traditional cultures. Whenever the medical establishment does happen to return to any semblance of common sense, the truth ends up being relabeled with some idiotic nomenclature, e.g. the title of ‘baby led weaning’ for the common practice of handing the kid a chunk of bread to gum on when they develop enough awareness to indicate wanting some of your food.

    #229077 Reply
    childay childay 
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    fire ants crushed whole

    Click to expand…

    Interesting, but disturbing

    #229080 Reply
    Avatar trebizond 
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    The reason it’s a problem is because the mother will see those labs and read “abnormal” or “positive” and then – regardless of what you say – she will subconsciously or consciously avoid giving that food to her child – even if the child consumed it before without a problem. It’s a much more sophisticated discussion that then an allergist has to have with her as to why the food is safe to continue consuming and that the lab may mean absolutely nothing clinically.

    Click to expand…

    I am sure there are doctors with no actual art, only science, who can neither tailor the information they give nor the testing they do for their patients and their patient’s parents. These are, however, poor arguments to be made for simply not doing a test. For example, the reason I made this thread in the first place was because this mother was told to avoid multiple common food allergens, which she did not want to do, and the results may have provided some evidence that this is not actually necessary in order to ‘treat’ her baby’s eczema.

    Neither is it big news that the answer to food allergies is not avoidance, since the truth always seems to lie orthogonal to any scientific consensus or physician guidelines, and aligns with common practice in what remains of traditional cultures. Whenever the medical establishment does happen to return to any semblance of common sense, the truth ends up being relabeled with some idiotic nomenclature, e.g. the title of ‘baby led weaning’ for the common practice of handing the kid a chunk of bread to gum on when they develop enough awareness to indicate wanting some of your food.

    Click to expand…

    So the way I understand it is this patient wasn’t tested before and family was told to hold off of multiple foods for eczema? And some of those foods are apples and bananas?

    Really, my counseling would entirely depend on the reactions. If they have had no immediate clinical reaction to any foods, I would tell them to just resume eating them. No sIgE testing. We manage eczema with topicals and occasionally systemic medications, not broad food avoidance. The one exception, as I mentioned, is peanut in someone who has never tried it. So again, you don’t need sIgE testing to make that recommendation.

    If there are presumably local oral reactions to apples and bananas, i.e. oral allergy syndrome, again sIgE testing is not very helpful there. I just tell them it’s due to  sensitization to pollens (birch for apple, ragweed for banana, etc.), that the raw fruit is safe to eat if there is just itching or tingling (but most people will refuse anyway, which is very reasonable), but if there’s any throat tightness or hives around the mouth to abstain, and that cooked fruit (e.g. syrups, pies, banana bread) is always safe.

    Not sure what you mean by “neither is it big news that the answer to food allergies is not avoidance.” It most certainly is that. The strategy currently is early home introduction in the 1st year of life to try to avoid the development of clinical allergy, component resolved testing (e.g. Ara h 2 vs Ara h 8 for peanut), and periodic blood and/or skin testing to evaluate for a favorable trend in sensitization (reduced wheal diameter, reduced sIgE). If the trend is favorable, we evaluate for tolerance with oral challenge and either clear the allergy or recommend continued avoidance. It’s more complex with the denaturable allergens in milk and egg, where the kid may pass a graded challenge to a small amount of baked dairy or egg. We then work our way up through a home “immunotherapy” protocol (not really called that) where gradually increasing amounts of baked dairy or egg and gradually less denatured forms are given daily or most days of the week over a matter of weeks to months until tolerance is ideally achieved. Sometimes it takes months-years to enable a child to be able to consume milk or scrambled eggs; sometimes they never get there.

    You can (and probably will) do whatever you want. But again, it’s the experience with the natural history and management of these disorders that counts to reassure patients and families, not sending a test that may be meaningless in that clinical context and praying that you get a negative result, and then touting that as evidence that it’s safe to do what you’re telling them.

    #229095 Reply
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    Hank Hank 
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    local oral reactions to apples and bananas

    Click to expand…

    I’m sorry, did someone say Apples and Bananas?

    Yeah, that song is just short of Baby Shark when it comes to what the Germans call “ear worms”.

    #229205 Reply

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