E205: Dr. Julie Maamari on perioperative considerations for complex patients

Episode 205 May 07, 2024 00:34:57
E205: Dr. Julie Maamari on perioperative considerations for complex patients
The POTScast
E205: Dr. Julie Maamari on perioperative considerations for complex patients

May 07 2024 | 00:34:57


Hosted By

Cathy Pederson Jill Brook

Show Notes

Dr. Julie Hubbard Maamari is a Perioperative Clinical Pharmacy Specialist who helps patients before, during and after surgery by making sure they get the best medications for their needs.  She has helped many complex patients, including those with POTS, MCAS and other hypersensitive or allergic conditions, and she has authored peer-reviewed articles.  Dr. Maamari discusses what patients and their doctors can do to prevent mast cell reactions and have the safest, most comfortable outcomes. 

The free patient guide by The Mast Cell Disease Society, with worksheets for emergency room response plan, list of medications to favor or avoid with MCAS, and surgical medication plan can be found here.  

Dr. Hubbard Maamari's published article on perioperative consideration in patients with MCAS can be found here.

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Episode Transcript

[00:00:00] Jill Brook: Hello fellow POTS patients, and lovely people who care about POTS patients, and people who care about conditions related to POTS. Welcome all. Today we are talking about surgery. What should complex patients be mindful of when it comes to surgery? And I will be honest, when this question came in from several listeners, I thought it was a great question, but I did not think that it would ever apply to me personally. I thought that with my hypersensitivities and MCAS and POTS, I'll just avoid surgery altogether. It's not really for me. You've probably heard me say in past episodes that I think some of my issues got worse or maybe even started after wisdom teeth surgery. So I would rather just never get surgery again. But then I looked up how common it is to get surgery, and listeners, please humor me and just guess how many surgeries the average American gets in their lifetime, if they live till age 85. [00:01:00] Gotta guess? Okay. Well, according to a study published by the American College of Surgeons, the average is nine surgeries per person. So I realized that avoiding it altogether is maybe not realistic. And this topic is way more relevant than I had realized. So thank you listeners for requesting it. And a humongous thanks to our wonderful guest today, Dr. Julie Hubbard Maamari. Dr. Maamari is a perioperative clinical pharmacy specialist at Barnes Jewish Hospital in St. Louis. She takes a lead role in coordinating care for patients before, during, and after surgery. And she was first author on a 2023 peer reviewed journal article entitled Perioperative Considerations in Patients with Mast Cell Activation Syndrome. Dr. Maamari, thank you so much for being here today. Dr. Julie Hubbard Maamari: Thank you so much for having [00:02:00] me. Jill Brook: So for starters, as far as you know, is that study accurate? Is it really, like, that much surgery going on? Dr. Julie Hubbard Maamari: We do see that many surgeries for every patient that would have a life expectancy of 85, as you mentioned. So we are seeing more and more patients that are coming in with Mast Cell Activation Syndrome every day. Definitely a hot topic at our institution and something that we are continually educating all of our surgery clinicians about. Jill Brook: Wow, that is so wonderful. So, so maybe you can tell us a little more about your background. What a normal day of work looks like for you. How is it that you know about MCAS? Because we're so excited that you know about it, but I think a lot of us have experiences where we go into a hospital and nobody knows about it. So, so this is great. Yeah, we just would love to kind of like hear more about you. Dr. Julie Hubbard Maamari: Yeah, of course. So for a little bit of background about myself, as you mentioned, I'm a perioperative clinical pharmacy specialist practicing at Barnes Jewish Hospital in [00:03:00] St. Louis, Missouri. That's associated with our academic medical partners of Washington University in St. Louis. I'm actually a native of St. Louis, Missouri, so have been here for quite a while and attended St. Louis College of Pharmacy, graduating in 2020 with my doctorate of pharmacy. After completing graduation, I did a year of residency in general pharmacy practice, and then I actually went on to complete a second year of residency focusing on solid organ transplant. So, a lot about immunology. Following graduation, I stayed on at Barnes Jewish Hospital, but transitioned from that specific population of organ transplant to the general surgical population. Talking a little bit about what I do on a day to day basis, I provide pharmacy services for both our surgery groups as well as our anesthesia groups, so the groups that are putting you to sleep when you receive surgery. And I'm really helping them to guide medication therapy decisions for patients before they go to [00:04:00] surgery, what medications they should receive during the surgery, and then I also help provide some advice for medication decision making right after surgery. So some examples of that prior to surgery, my pharmacy team is going to be providing recommendations for maybe stopping blood thinners to prevent excessive bleeding. During surgery, we help our providers administer insulin therapy to help regulate blood sugars. And then my practice partner and I are also really involved in establishing drug treatment protocols to help guide surgery and anesthesia medication decisions and then facilitating introduction of new medications into our surgical space. And I feel really lucky to be practicing at my current institution because my system specifically allows our pharmacists the opportunity to focus on their individual practices and what really interests and inspires them. And for me personally, one of those interests that I've honed in on over the past couple of years is management of allergic and immunologic [00:05:00] conditions. Such as alpha-gal allergy, which is another very common allergy that we see in the Midwest, which is a tick borne illness that you develop an allergy to meat through. Kind of interesting. Local anesthetic allergies, and then of course, MCAS. And where my interest in MCAS came from was actually a consultation that we received for a patient who had MCAS, and they needed recommendations for the surgical period, and I really got to learn more and more about the condition and looking up all of the literature associated with it, and it became an interest of mine and something that I ended up publishing on after seeing many patients come in with this new condition that I educated myself on through the literature that's out there. Jill Brook: Wow. Yay. First of all, thank you so much. It's funny. We don't actually hear that often from people who took an interest in MCAS without having it themselves. So thank you for being interested and generous with your time that way. So you're actually seeing a significant number of MCAS patients? Dr. Julie Hubbard Maamari: Yes, we see MCAS patients quite a bit. [00:06:00] It might be because we're a very large institution. Barnes Jewish Hospital does hundreds of surgeries every week, so we're seeing quite a few patients on a daily basis. We have over a thousand beds at our hospital, so we're a very large hospital, so we see lots of patients and lots of specialties are taken care of at our hospital. So, through that large number and the fact that depending on what definitions you use, as well as what diagnostic criteria you use, there's some reports of up to 17 percent of the population having MCAS. I think it's something that's becoming increasingly more recognized and something that we're seeing be diagnosed more often and when it's diagnosed more often, we can address those patients in an appropriate manner and treat them better through our surgery departments. So something that is being diagnosed more often, recognized more often, and then treated more often in our surgical population. Jill Brook: Wow, that's fantastic! It seems like MCAS has a [00:07:00] good group there in St. Louis. You have Dr. Leonard Weinstock and Dr. Laurence Kinsella, and you, and wow, like, I, I wish I lived closer to St. Louis, should I ever need anything like this? Okay, so MCAS patients. Maybe we'll go into more details in a minute, but at sort of a higher level, I guess maybe for not just MCAS patients, but all patients, what kinds of things are you thinking about before, during, and after surgery? Dr. Julie Hubbard Maamari: Yeah, so for before surgery, the one thing that I'm thinking about for my MCAS patients when it comes to surgery and that time leading up to surgery which we call the preoperative period we are thinking of things that our surgery team will need to know for you. We're going to ask you to take certain medications leading up to surgery and those medications that we ask you to take leading up to surgery is going to decrease your likelihood of you having an MCAS flare up or MCAS reaction [00:08:00] during your surgery. And those medications that we have you take are all going to be oral, so medications that you take like a pill or a tablet, anti inflammatory medications. All of you have probably heard of these medications before or are already taking them yourselves, and those are medications like Benadryl, Pepcid, and Singulaire. Even if you're already taking those medications on a daily basis, one of those or all of those on a daily basis will actually have you take an additional dose both the night before and one hour prior to surgery. And the reason why we have you take these medications is because they're going to block the activity of the inflammatory molecules in your body that cause your MCAS reactions or MCAS flares. And these inflammation blockers are going to essentially lower the chance of you having an MCAS flare or blunt the severity of an MCAS flare if you encounter an MCAS trigger [00:09:00] during your surgery. So it's super important that we're not forgetting pre surgery anti inflammatory medications because there are a lot of different surgery related exposures that could trigger an MCAS reaction and we can talk a little bit more about those triggers in a bit. Shifting our focus to after surgery because where the patients are really going to be their most involved in, you know, preventing an MCAS flare is what happens before and after surgery. During surgery, you're going to be taken care of and you're going to probably be put to sleep by your anesthesia team. But before and after, you can help us out a lot by preventing MCAS flares. So we talked a little bit about before and taking those medications to prevent a flare. Shifting our focus now to after surgery. Where things are going to become tricky for an MCAS patient is really with post surgery pain management. And that's because pain itself can trigger your mast cells to go off. Of course, recovery from a major [00:10:00] surgery or even a minor surgery can be super painful. So to prevent any kind of MCAS reaction, we need to do everything we can to get the pain under control. On top of that, a lot of our common pain medications can also trigger an MCAS reaction, so making sure that getting our pain under control is sometimes difficult for MCAS patients. For example, medications like ibuprofen or Advil can trigger an MCAS reaction, as well as some of our stronger opioid pain medications that we use a lot after surgery like oxycodone. So what this means for you as an MCAS patient is that we, as your healthcare team, will need to create a special pain regimen designed specifically for you with your MCAS history in mind. You can actually help us create this regimen, too. And what I mean by that is to help us create this pain regimen for you, we'll want to know what pain medications you use at home or have received from the [00:11:00] doctor before, that have worked well to relieve your pain and have not triggered an MCAS reaction in the past. When you share that information with us, it'll help us to form a list of pain medications that focuses on what you've tolerated before and avoids giving you something that will potentially trigger an event. We'll also want you to be super honest and transparent about your pain level and pain control. Like I mentioned earlier, the sensation of pain alone is a trigger for MCAS. So to prevent any kind of reaction or flare, we'll need to make sure your pain is very well controlled with the combinations of medications, physical therapy, and other pain techniques. To help your healthcare team ensure that your pain is well controlled with these therapies, I would recommend voicing your pain level early and often so that we as your team can come up with treatments and extra treatments as needed. Jill Brook: Wow, that's so interesting. And a good reminder. I think some of us are so loathe to take extra [00:12:00] medications 'cause we're worried something in the medication's gonna be the thing that trips us off and it's easy to forget that the pain itself can do it. Wow. And you had mentioned some other triggers that somebody might be exposed to during surgery. Is this a good time to mention what some of those might be? Dr. Julie Hubbard Maamari: We can mention them now. I can mention a couple of them now and then we can get into some more later. So one that I really wanted to touch on now is that stress can be a trigger, both physical stress, which is more like pain, as well as emotional stress. So doing calming, relaxing techniques, looking into meditation, looking into factors or ways in which you can help mitigate your emotional stress prior to surgery since surgery is emotionally stressful as well, is extremely helpful to reducing your chances of having an MCAS reaction, as that's one of our known triggers. Getting a good list of your known allergies and things that have caused [00:13:00] your MCAS to flare or trigger in the past is also super helpful for us to know as a team so that we can avoid those things as well. Jill Brook: Yeah, for sure. And then I guess there are some people who are even just sensitive to like temperature changes or pressure or vibration. Dr. Julie Hubbard Maamari: And that temperature comes in very heavily when you are coming to the operating room because we like to keep our operating rooms very, very cold. So it's definitely something, a trigger that I talk to with my healthcare team about and talk to my physicians, especially my surgeons and my anesthesiologists, that temperature changes, extremes in temperature, as well as rapid temperature changes are triggers for MCAS flares. So I make sure that my team is aware of that so that they know to keep that to a minimum if possible, and if not possible, to know that my patients could have a reaction to those environmental triggers. Jill Brook: Okay. So now I know everybody's wondering what happens [00:14:00] if they have a reaction during surgery. Dr. Julie Hubbard Maamari: Yeah, that's really important. So if they have a reaction during surgery, there's a really helpful guide for our patients to be aware of that they can refer their physicians to. And it's in the Mast Cell Disease Society's Patient Resource Guide. There's a full guide to anaphylaxis treatment that I found extremely helpful as a clinician myself. It is a list of medications as well as procedures and supportive care such as oxygen and things like that that our clinicians who may not be familiar with how to treat anaphylaxis specifically in an MCAS patient can refer to to treat that patient if they were to have a flare up. What I personally do as a clinician, especially someone who, you know, works with several, several different surgeons, several, several different anesthesiologists, who might be seeing their first MCAS patient ever, is I will print off a [00:15:00] guide of how to treat anaphylaxis in an MCAS patient. And I physically hand that guide prior to surgery to those clinicians so that they have a quick reference of how to manage those patients. And I think it'll be really helpful if we can include that guide in our show notes. So all of our patients have it and they can share it with their healthcare team as well. Jill Brook: Yeah, absolutely. Okay. And so since you're seeing all of these mast cell activation syndrome patients, a lot of them must have the common comorbidities, for example, POTS or like hypermobile EDS. And those things get kind of challenging too, right? I don't know if that interfaces or changes their drug needs so much, but are you seeing that? Dr. Julie Hubbard Maamari: We are seeing a lot of patients who also have POTS as well as MCAS at the same time. It's [00:16:00] definitely one of those conditions that overlap quite a bit. We typically will focus on the MCAS portion because that's what, where you're gonna see more of that risk or potential for an anaphylaxis episode. So that's kind of where we direct our medication attention, which is where I'm involved in the care of the patient. So that's definitely, but those disease states are definitely two disease states that we see in a lot of our patients having both at the same time. Jill Brook: Yeah, in doing a little bit of research for this I found a great article by Drs. Pradeep Chopra and Linda Bluestein who are kind of friends of the community. And it sounds like for POTS, of course, a big thing is hydration. And so maybe they get saline IV beforehand, and maybe you keep an extra close eye on the heart rate and the blood pressure. And for the hypermobile EDS, maybe just be really, really careful with a more fragile body. But it did [00:17:00] seem like MCAS is kind of where, I guess, like you said, the risk seems to maybe go up a lot. So, okay. I, I imagine a lot of people listening and me, myself personally are listening and going, okay, so how afraid of surgery should I be? Can I just ask for your, like, I don't know, offhand thoughts about like, do people generally do pretty okay? How often do they not do okay? Dr. Julie Hubbard Maamari: Yeah, that's a great question. I think when we are putting in all the steps to minimize the risk associated with a patient having an MCAS reaction during surgery that we can really do surgery safely. And a lot of times you're going into surgery because you need something repaired, or you need something removed and that's just as important to have that completed as it is to potentially have an MCAS event. And it's kind of weighing the risks and the benefits of both, and we can try to control those risks of you having an MCAS event, and also safely [00:18:00] achieve the surgery that you need done. So that's really our goal is safely get you through that surgery and do everything that we can to minimize the risk associated with having an MCAS event during your surgery. So there's a lot of different things that both you as a patient and your physician can do to minimize the risk of having an MCAS flare during your surgery. Kind of walking through those steps, we'll first start with those that you do prior to surgery. First and foremost, you want to make sure that both you and your surgery and your anesthesia team, which as a reminder is that team that puts you to sleep during your surgery, you want to make sure that they're all aware that you have an MCAS diagnosis or a POTS diagnosis as soon as your surgery is scheduled. This is going to allow them the time needed to begin planning out their approach to your surgery and the adjustments that they may need to make to avoid certain MCAS triggers that you would otherwise potentially be exposed to during your surgery. So first and foremost, make sure your team is aware [00:19:00] of your MCAS diagnosis as early as possible to allow time needed to plan those adjustments. Second, if you have an MCAS emergency room response plan, make sure that plan has been given to your surgery team and a copy has been uploaded into your medical record. If you have not heard of an emergency room response plan, it's basically a treatment guide created by the Mast Cell Disease Society, which I spoke a little bit about earlier, and that's going to be used to help guide the team through the steps that they need to take if you were to have an event during your surgery or at any time when you were to go to the emergency room. A lot of times a patient and their MCAS treatment provider will go through that response plan and they're going to tailor it specifically to you. That guide should then be carried by you and uploaded into your chart to be used in emergency situations. And having access to this guide in advance to surgery is going to help us be extra [00:20:00] prepared in case you do experience a flare at some point in time during your surgery. Like I said, as a clinician myself, if you don't have that plan uploaded into your chart that's, you know, specific for you as a patient, I print that off and it's basically a general guidance that can be used for most patients. And I hand that off to my clinician. So if we have any clinicians on the line, I would recommend going to the Mast Cell Disease Society website and just printing that off and handing it to the providers that are involved in that patient's care in case they don't have an emergency response plan filled out. Jill Brook: Great. We'll link to that in the show notes. Dr. Julie Hubbard Maamari: Perfect. Thank you so much. And if you haven't completed that plan with your doctor yet you can use that link from the show notes and bring it to your next appointment and fill it out with your doctor. The last thing I want to recommend prior to your surgery to minimize the risk of having a flare during the surgery is just to remember to take those medications that we talked about earlier. As a reminder, those anti [00:21:00] inflammation medications like Benadryl, Pepcid, and Singulaire should be taken the night before and then one hour prior to surgery. And to make sure you don't miss those doses, you can set an alarm on your phone. Also, some of the medications like Singulaire are going to require a prescription. Of course, you can get Benadryl and Pepcid over the counter, but a medication like Singulaire, you would need a prescription for. So if you're not already prescribed that medication prior to surgery, you'll want to contact either your surgery team or your MCAS provider to make sure that you have access to that medication prior to surgery. Jill Brook: Fantastic. And aren't there even some anti anxiety medicines that have some good mast cell controlling properties to them? Like if you are one of those people, like I think I would be, we would probably be very anxious before surgery. Dr. Julie Hubbard Maamari: Exactly, that's a really, really great point because like we talked about earlier, emotional distress is something that can trigger MCAS. And one medication that comes to mind when you mention, [00:22:00] you know, what if I have anxiety about surgery? One medication that would work really well and is actually recommended in the treatment guideline is a medication called Hydroxyzine. It's also called Atarax, as it's known. And that's a medication that we often use for like short term anxiety because it can work really fast and it's not something that you have to be on long term to get the anxiety benefits. You can get the anxiety benefits from that quite quickly. So that is a medication that we could potentially start for you or get you on, get you a prescription access to so that you can take that prior to surgery. If you have any kind of emotional distress or anxiety related to undergoing surgery itself, it will require a prescription. So something that you'll want to let us know about prior to but that is something that you could potentially do. Jill Brook: Exciting because what I'm hearing you say is you basically just have choices and solutions, and so if your patients talk to you about what their issues are you're [00:23:00] ready. Are there more people like you around the country and around the world or are you finding that you are a rare expert in this? Dr. Julie Hubbard Maamari: So, I would say there are a lot of surgical pharmacists around the United States, so that's really exciting that we are growing as a field from the aspect of surgery pharmacy. From the side of MCAS, I am the only person at my institution that regularly sees MCAS patients from the pharmacy perspective. My partner in surgery pharmacy with me at my institution who is also on my paper is, you know, practicing for MCAS patients as well, but we are the only two pharmacists at our institution that know a lot about MCAS, but something that we're, you know, really working on educating all of our, you know, peer clinicians in our field of pharmacy about in St. Louis and hoping that the word gets out there more and how [00:24:00] to treat these patients. Jill Brook: Yeah, absolutely. Cause it's so refreshing to talk to you when I hear stories all the time of people who are having to be in hospitals where they don't even have someone who believes that MCAS is real. So I really thank you for everything you're doing to write articles and educate those around you. Dr. Julie Hubbard Maamari: And what I think is really rewarding is just meeting all of the patients that have MCAS and hearing their stories, hearing, you know, how they went through so many different physicians to finally get their MCAS diagnosis. And that's, you know, because everybody presents differently and hearing the different ways that our patients are presenting and getting more information and hearing more and learning more directly from my patients is really amazing. And I thank you all for sharing all of your stories with us. Jill Brook: Well, this is fantastic. And do you have any final advice or words of hope? I'll tell you like selfishly, anything you want to say [00:25:00] that's like optimistic for patients, I'm all ears because I'm still a little nervous about this whole idea. Is there any, anything you can say about like, Oh, it's normally fine. Don't worry. Dr. Julie Hubbard Maamari: Yeah, yeah, so I can kind of talk about what we're going to do for you during surgery to kind of relieve the anxiety that you may have, like, I'm asleep, how am I going to make sure that, like, while I'm asleep that everything is okay for me from the MCAS standpoint. So I'll kind of talk a little bit about that. There's three big points that I stress with my surgery and anesthesia team when they're taking care of a patient who has MCAS and now you're asleep. Those are awareness and avoidance of environmental triggers, medication triggers, and then how to treat an MCAS flare if it were to happen in the operating room. Since we're focusing on that prevention or minimization we'll focus on those first two points, and that's avoidance of environmental and medication triggers during surgery. There's actually quite a few environmental [00:26:00] triggers that you could come by in the operating room. We talked about those temperature changes and how our ORs are super cold. We talked about emotional stress and that's going to be super common. Some other things that can trigger are latex. So latex is considered an MCAS trigger and a lot of things in the OR can sometimes be latex, depending on what hospital you're getting your surgery at. So that's something to be aware of as a clinician ourselves is that latex is something that could trigger an MCAS reaction. Strong chemical odors, which we use a lot in the OR as well, can trigger MCAS. Chlorhexidine. Chlorhexidine is basically that cleaning solution that we use on your skin to make sure that we clean you down well prior to surgery. That can trigger MCAS. So I'm giving my clinicians a full list of the environmental triggers, even though I'm the pharmacist and I focus on medications, I'm still gonna give a list of environmental triggers 'cause not [00:27:00] everyone knows fully about all of these MCAS environmental triggers. So I make sure that everyone's aware of, you know, this could potentially cause it. Let's try to avoid it. Is there an alternative that we can choose over chlorhexidine, over latex, let's prefer those instead. So I try to make sure that they're aware of all of those triggers to minimize your exposure while you're with us. And then that second type of trigger I mentioned were the medication triggers. There are a lot of medications that we give during surgery that could trigger MCAS reactions. So, many of the Mast Cell Disease Society resources will state what medications are okay and not okay to give. And those are published especially in that patient guide. And you can find that list linked in the same patient guide that we are already linking in the show notes. Like the anaphylaxis plan or the emergency room response plan that I print off, I'm also going to print off this list. And I present it to the surgery team and I actually meet them [00:28:00] prior to them meeting you. And I go over this list with them and I say, you know, I know you traditionally use this medication to put the patient to sleep, but this patient might react to that medication, so I think that you should use this medication to put the patient to sleep. So that's kind of the conversations that I'm having with them prior, but it's really nice for them to have that list right in front of them and know which medications throughout the whole case, whole case meaning the whole surgery, they should go to and lean on in an MCAS patient and those that they should avoid. So printing off those resources is really, really helpful for my clinicians. Jill Brook: And this is something that a patient could print off for themself if they didn't have a person like you on their team. Dr. Julie Hubbard Maamari: 100%. So if you're patient, if you as a patient want to even just make sure you have that extra precaution of like, you know, I've already told them I have MCAS, I've already told them these are the things that I react to, you can print off that patient resource guide as [00:29:00] well. And just show it to your surgery team. It's towards the very back of the patient resource guide, but it's a full list of medications and a chart. And you can print off that chart as well and show your team. And, you know, maybe they haven't heard of the resource or, you know, weren't exposed to that resource before, and they'll be extremely grateful to you if you show that it to them and they haven't seen it. Jill Brook: Excellent. Okay. And your paper is also wonderful for this too, if they want to come with backup. Dr. Julie Hubbard Maamari: And then one other thing that I wanted to mention on avoiding a trigger after surgery or an MCAS reaction after surgery, it's going to relate back to what we talked a little bit about earlier and that's ensuring that we have really good post surgery pain control since pain is that trigger and creating a regimen that incorporates the pain medications you yourself have tolerated in the past and then supplementing with medications from other pain medications that we know are tolerated in the majority of patients with MCAS. And those are going to [00:30:00] be medications like Tylenol, a medication called Tramadol, and then if you have a lot of pain post operatively, we can use one of our stronger medications called Fentanyl. As a reminder, it's super important to communicate your pain level honestly and often so that we can ensure we're keeping that pain level under control and monitored as closely as possible. The last piece of advice that I have for an MCAS patient getting ready for surgery, and something that I really want to stress for my patients who have MCAS and may have surgery coming up, is the importance of communication about your health and your MCAS journey. While we as a surgery team are seeing more and more patients with MCAS every year, it's still a relatively newer condition for our surgery groups specifically. Of course, our allergy specialists know a plethora of information about this, but a lot of our surgery clinicians, this is something quite new for them. Therefore, the more we learn from you and your prior [00:31:00] experiences about your MCAS history, your response plans and what environmental or medication factors have triggered your flares in the past, we can plan with that information as a surgery team and have a better plan to avoid those specific triggers, as well as other surgery related triggers, and have the best chance at preventing a reaction on the day of surgery. Along those lines, the more information we know about your history, we can plan better and don't ever feel like you're providing too much information. Even small details about your history that you might think might be insignificant to us could make the difference in a decision we make when planning out our approach. So, when in doubt, rest assured that we would prefer excess of knowledge and information about your history over an abbreviated review. Last piece, I have found what we've talked about, that Mast Cell Disease Society Patient Resource Guide, as an extremely, extremely helpful tool to [00:32:00] use to help guide my colleagues, as I've mentioned throughout our discussion today, to avoid triggers when I'm caring for my patients. So if you haven't yet reviewed that patient resource guide, I would strongly recommend printing it off and reviewing it at home and then also with your MCAS provider or POTS provider, too. Jill Brook: Excellent. Wonderful, wonderful advice. Dr. Maamari, thank you so much. Is there anything else? Do you have a website that people can find you at or any social media handles you'd like to share or anything like that? Dr. Julie Hubbard Maamari: I do not have any social medias to share, but if you would like to review any of my other publications on allergies you can click the link when we share the article for the MCAS discussion, you can click the link and click my name and find a lot of the other allergy related topics that I've discussed. So excited for you guys to read into more of those pieces as [00:33:00] well. And really appreciate being able to share my expertise from the pharmacy side of MCAS with you all today. Jill Brook: Well, thank you so much for your care and your extra time and your researching and educating. We feel really lucky to have found you. So, hey listeners, all of those links, so Dr. Maamari's paper, the Mast Cell Disease Society resources, everything is going to be in the show notes, so check that out. And And Dr. Maamari, thanks a million. Thank you. Dr. Julie Hubbard Maamari: Thank you so much. Appreciate your time. Jill Brook: Okay, listeners, that's all for now, but thank you for listening. Remember that you're not alone, and please join us again soon.

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