Risk Of Anaphylaxis Research Articles

Exploring Beekeepers' Experiences and Perceptions of Anaphylaxis Risks: A Qualitative Study to Inform Targeted Health Education Programs.

Beekeeping plays crucial natural and economic roles but also poses health risks, as bee stings can cause severe allergic reactions like anaphylaxis, a potentially life-threatening condition that requires timely intervention. Understanding symptoms and the proper use of adrenaline autoinjectors is essential to minimize risks. This study aimed to assess the need for education on anaphylaxis and to develop a health education program to enhance beekeepers' preparedness and safety. A qualitative descriptive interpretative method was employed. Two focus groups were conducted, one with eight health care professionals specializing in allergy and clinical immunology and the other with six active beekeepers. The data were analyzed via content analysis using QDA Miner® Lite v3.0.5 software. The analysis structure comprises five thematic areas: (1) the management of anaphylaxis; (2) the prevention of anaphylaxis; (3) health education approaches; (4) systemic approaches in prevention; and (5) adrenaline autoinjectors. The results highlight key challenges, including the need for better strategies to manage anaphylaxis, improve prevention, and provide practical educational programs for beekeepers. There is also a need for better collaboration between health care professionals and beekeepers, as well as improved access to and knowledge of adrenaline autoinjectors. Targeted education for beekeepers on recognizing anaphylaxis symptoms and using adrenaline autoinjectors is essential for timely intervention and preventing severe outcomes. Given their exposure to bee stings, beekeepers require proper training and regular practice to improve preparedness and safety. This research underscores the need for a comprehensive educational program to reduce anaphylaxis risk and enhance safety in beekeeping.

Allergen immunotherapy.

Allergen immunotherapy (AIT) is a potentially disease-modifying therapy that is effective for the treatment of allergic rhinitis/conjunctivitis, allergic asthma and stinging insect hypersensitivity. The decision to proceed with AIT should be made on a case-by-case basis, based on a comprehensive evaluation of the patient, allergy testing and a thorough discussion with the patient about treatment goals, risks vs. benefits, and long-term commitment to the treatment plan. For those with allergic rhinitis and/or asthma, it is also important to consider individual patient factors, such as the degree to which symptoms can be reduced by avoidance measures and pharmacological therapy, the amount and type of medication required to control symptoms, the adverse effects of pharmacological treatment, and patient preferences.Since AIT is associated with a risk of anaphylaxis, it should only be prescribed by physicians who are adequately trained in the treatment of allergic conditions. Furthermore, for subcutaneous therapy, injections must be given under medical supervision in clinics that are equipped to manage anaphylaxis. In this article, we review the indications and contraindications, patient selection criteria, and details regarding the administration, safety and efficacy of AIT for allergens other than foods. Immunotherapy for food allergy will be discussed in the Oral Immunotherapy article in this supplement.

National trends in the prevalence and recurrence of anaphylaxis across all ages: The role of neighborhood deprivation and comorbidity (2002–2019)

BackgroundUnderstanding the trends of anaphylaxis and risk factors associated with its recurrence is essential for the effective management and prevention of this condition. ObjectiveThis study aimed to analyze the prevalence trends of anaphylaxis and identify risk factors for recurrence, with a focus on the influence of neighborhood deprivation and comorbidities, across all age groups. MethodsWe conducted a retrospective administrative cohort study on anaphylaxis utilizing the National Health Insurance-National Sample Cohort (NHIS-NSC) database in Korea (2002–2019). Anaphylaxis was defined with ICD-10 codes for the diagnosis combined with prescription codes. The Neighborhood Deprivation Index was used to identify the risk of recurrent anaphylaxis. Trends in the annual prevalence and recurrence of anaphylaxis were assessed through joinpoint regression and Cox proportional hazard models. ResultsOut of the 1,137,861 individuals studied, 37,012 (3.25%) cases of anaphylaxis were identified. Among these, 5783 individuals (15.6%) experienced a recurrence, half of them experiencing it within the first year after the initial episode. The highest incidence of anaphylaxis was observed in children and adolescents, followed by middle-aged adults. A rapid increase in anaphylaxis cases was observed from 2002 to 2006 (Annual Percentage Change [APC], 33.2), followed by a more gradual increase until 2013 (APC, 12.8), and a stable trend from 2013 to 2019 (APC, 0.61). Males and adult age groups exhibited an increased risk of recurrence. Living in an area with neighborhood deprivation and the presence of comorbid conditions were associated with increased recurrence risk. ConclusionsThe increasing prevalence of anaphylaxis and its association with certain risk factors calls for targeted intervention. Addressing neighborhood deprivation and comorbid conditions may aid in reducing the recurrence and overall burden of anaphylaxis.

Tree Nut Allergy in Children-What Do We Know? -A Review.

Food allergy represents a significant public health concern, with its prevalence increasing in recent decades. Tree nuts are among major allergenic foods, and allergies to them are frequently linked to severe and potentially life-threatening reactions. Data on the prevalence and natural history of tree nut allergy are limited. Primary nut allergy typically presents with rapid-onset IgE-mediated symptoms. Diagnosis can be confirmed by demonstrating a positive skin prick test (SPT), specific IgE (sIgE), or through an oral food challenge. Component-resolved diagnostics (CRD) can identify those with a high risk of anaphylaxis. The main management strategy involves avoiding the culprit allergen and treating symptoms after accidental exposure. New therapeutic options, such as sublingual immunotherapy, oral food immunotherapy, with or without omalizumab, and other monoclonal antibodies, are being investigated to modify tree nut allergy. Tree nut allergy is a lifelong disease with a low likelihood of resolution. The aim of this paper is to present the current data on the prevalence, diagnosis, natural history, and management options for tree nut allergy.

Uricase-Expressing Engineered Macrophages Alleviate Murine Hyperuricemia.

Background: Uricase, or urate oxidase (Uox) is a key enzyme in uric acid (UA) metabolism and has been applied in clinical treatment of human hyperuricemia (HUA). However, the current clinically applied uricases, despite their potent urate-lowering capacity, tend to form anti-drug antibodies because of their immunogenicity, leading to increased risk of anaphylaxis, faster drug clearance and reduced or even complete loss of therapeutic effect, limiting their clinical application. In this study, we constructed engineered macrophages that stably expressed uricase, which might serve as a promising alternative to the direct injection of uricases. Materials and Methods: Engineered macrophages RAW264.7 cells were injected intravenously to treat hyperuricemic KM mice. Serum uric acid and bio-indicators for renal and hepatic functions were detected by an automatic biochemical analyzer; inflammatory cytokines were determined by ELISA; the livers and kidneys of the mice were sectioned for histological examination. Results: The uricase-expressing macrophages reduced UA levels from 300 ± 1.5 μmol/L to 101 ± 8.3 μmol/L in vitro. And in an HUA mouse model established by gavage with yeast extract, intravenous injection of the engineered macrophages could reduce the serum uric acid (sUA) of mice to normal level on the 14th day of modeling, with a decrease of 48.6%, and the urate-lowering effect was comparable to that of the first-line clinical drug allopurinol. In terms of safety, engineered macrophages did not cause liver or kidney dysfunction in mice, nor did they induce systemic immune response. Conclusions: Using macrophages as a chassis to deliver uricase might be a new, safe and effective strategy for the treatment and control of hyperuricemia.

Hereditary alpha tryptasemia: elevated tryptase, female sex, thyroid disorders, and anaphylaxis.

The clinical significance of elevated baseline serum tryptase (BST) in the absence of mast cell disorders or allergic reactions has long been unclear. Recently, a genetic variation of the TPSAB1 gene, which among others encodes for alpha tryptase, has been reported and named hereditary alpha tryptasemia (HaT). HaT has been linked to various manifestations, including severe allergic reactions. However, clinical studies are limited. In this study, we aimed to determine HaT prevalence and characterize its clinical manifestations in patients at a specialized allergy center. From January 2022 to December 2023, patients with elevated BST at least once were screened for HaT at the outpatient clinic. A control group included patients with a history of anaphylaxis undergoing specific Hymenoptera immunotherapy. TPSAB1 copy numbers, BST levels, and clinical parameters were assessed and analyzed. Of 47 patients with elevated BST (≥11.4 µg/L), 93% showed increased TPSAB1 copy numbers. Individuals diagnosed with HaT displayed a BST range between 12.3 and 28.4 µg/L, with 84.1% associated with TPSAB1 duplication and 15.9% with triplication. HaT predominated in women (86.4%) and was associated with thyroid disease (27.3%). Over half had a history of anaphylaxis (54.5%), which was mainly low-grade. In patients with elevated BST but no mastocytosis, the most likely cause of elevated BST was an increase in the copy number of the TPSAB1 gene. A heightened risk of anaphylaxis should be considered. Further research is needed to explore the predominance of women and the emerging link with thyroid disease.

Adverse effects of monoclonal antibodies in the treatment of moderate-to-severe asthma: a narrative review

Introduction and purpose: Over the past two decades, the management of severe asthma shifted from high doses of inhaled and oral corticosteroids to targeted biologic agents. Adverse effects of treatment with monoclonal antibodies are not yet fully characterised. The aim of this paper is to provide a comprehensive review of the adverse effects of the FDA-approved monoclonal antibodies in the treatment of moderate-to-severe asthma, including omalizumab, benralizumab, dupilumab, mepolizumab, reslizumab, tezepelumab. Material and methods of research: A thorough literature review was performed using PubMed Web of Science and Embase, employing key words related to monoclonal antibodies, asthma and adverse effects. Description of the state of knowledge: Omalizumab and mepolizumab have black box warning on the risk of anaphylaxis. Due to scarcity of data, no causal association between the use of monoclonal antibodies and risk of malignancy can be established. The most common adverse effects of biologic agents in severe asthma include upper respiratory tract infections, nasopharyngitis and asthma worsening. Conclusions: Overall, monoclonal antibodies have a favourable safety profile, with certain risk of side effects remains present, and is variable for the different molecules. More studies of asthmatic patients treated with monoclonal antibodies are needed to spot rare adverse events and those developing over longer time.

Safety and Low Incidence of Anaphylaxis in Performing Oral Drug and Food Challenges in Mastocytosis

BackgroundPatients with mastocytosis (MC) have an increased risk of severe anaphylaxis. They report hypersensitivity reactions to drugs and food, but causality often remains questionable. Most allergy centers avoid oral challenge tests (OCT) in MC patients. ObjectiveTo determine the safety of food and drug OCT in patients with MC. MethodsTo retrospectively evaluate the safety and outcome of challenges to drugs and food including food additives, out of 126 adult MC inpatients, 83 patients had a suspicion of food or drug hypersensitivity and 445 OCTs were performed. History, clinical data and allergy test results highlighting OCTs were analyzed. ResultsOnly 10 of 445 OCTs (2.2%) in 9 patients resulted in anaphylaxis. Drugs elicited reactions in 4/170 (2.4 %) patients: two patients to acetylsalicylic acid (2/39 tested patients, 5.1%), one to tramadol (1/12, 8.3%) and one to flurbiprofen (1/1). Anaphylaxis to food was recorded in 6/275 OCTs (2.2%); two out of 48 (4.1%) to α-gal, two to other foods and two to sulfites. Flushing or diarrhea occurred to histamine in 5/48 (10.4%), but also in 5/50 (10.0%) placebo challenges strongly questioning its relevance. Patients with proven anaphylaxis had more bone marrow MC and higher basal serum tryptase (71.3 vs. 44.3ug/l; p<0.05). ConclusionsChallenge-confirmed food and drug anaphylaxis was rare in MC patients. Results have to be interpreted cautiously as placebo reactions did occur. Severe anaphylaxis was seldom, but may occur and should be met by emergency preparedness.

Demographics, Types of Patient-Reported Allergic Diseases, and Anaphylaxis in Mastocytosis: A Single-Center US Experience

BackgroundPatients with mastocytosis are at increased risk of anaphylaxis. Idiopathic anaphylaxis and venom induced allergy are commonly reported in mastocytosis, however the incidence of other allergies has been less well studied. ObjectiveWe sought to characterize the true prevalence of allergic disease including food, venom, contrast, and drug allergy compared to the number of patients that simply avoid potential triggers. We also gathered demographic information. MethodsWe performed a retrospective study of 259 consecutive pediatric and adult patients with a confirmed diagnosis of either cutaneous or systemic mastocytosis who received care through the University of Michigan Health system from 1/1/2018 to 3/17/2021. ResultsMastocytosis was more prevalent in non-Hispanic white population. As compared to the general population, patients had similar rates of atopy and allergies with a slight increase in reported asthma prevalence. Overall prevalence of anaphylaxis was 28% and the great majority occurred in SM, with most common trigger being hymenoptera venoms. Most patients reported drug allergies preemptively in order to avoid exposure, particularly to NSAIDs. We also saw an increase in contrast-induced anaphylaxis compared to prior literature, and a lower prevalence of venom allergy as compared to European cohorts. ConclusionOur study characterizes the rate of common atopic conditions as well as allergies in a large cohort of patients with mastocytosis in the US. Anaphylaxis in CM is rare. Hymenoptera venoms were the most common trigger for anaphylaxis while drug allergies were overreported preemptively in order to avoid potential exposures due to concern for having a reaction.

When Home Cooking Turns Hazardous: Two Botulism Cases

Introduction: Botulism is a rare, potentially life-threatening neurotoxin-mediated disease caused by the anaerobic, grampositive bacterium Clostridium botulinum, and occasionally by related species such as C. baratii and C. butyricum. The diagnosis of botulism relies on clinical suspicion and a comprehensive neurologic examination. Timely diagnosis is crucial. Case Report: A 62-year-old woman presented to our department with diplopia, dysarthria, dysphagia, and hoarseness, which had developed over the past four days. She had a recent history of vomiting 48 hours after consuming homemade pumpkin preserves, followed by the onset of dysphagia, diplopia, dysarthria, and hoarseness 48 hours later. Neurological examination revealed dysphonia with a “hoarse” voice and an asymmetry of the pharyngeal reflex, more pronounced on the right. Laboratory tests showed no significant abnormalities. Brain CT scan results were unremarkable. Botulinum toxins were detected in her blood, and botulinum toxin-producing clostridia were found in rectal swabs. A diagnosis of foodborne botulism was established, and botulinum antitoxin was administered. The patient’s symptoms improved rapidly, with diplopia being the only persisting symptom. She was discharged after 7 days with indications for orthoptic rehabilitation. Several days later, the patient’s husband, who had also consumed the homemade preserve, was admitted to the emergency room with similar symptoms, including constipation, dysphagia, dysarthria, diplopia, and eyelid ptosis. Botulinum toxins were not detected in his blood, but botulinum toxin-producing clostridia were found in rectal swabs. He received antibotulinum serum, leading to symptom improvement. He was discharged after five days with mild eyelid ptosis, and orthoptic rehabilitation was recommended. Discussion: Foodborne botulism is diagnosed based on neuromuscular symptoms and a history of ingesting potentially contaminated food. Simultaneous symptom onset in individuals who consumed the same food supports the diagnosis, which can be confirmed through the detection of C. botulinum toxin in serum or feces. Botulinum toxins are highly resistant to degradation and can be found in various types of food, particularly in homemade canned goods with low acidity and occasionally in commercially prepared foods. Symptoms of foodborne botulism typically begin 18-36 hours after toxin ingestion, with an incubation period ranging from 4 hours to 8 days. Treatment primarily consists of supportive care and botulinum antitoxin administration. Administering antitoxin early in the illness course improves outcomes, while delays can be less effective. It’s important to report all patients receiving antitoxin to health authorities. The heptavalent antitoxin, derived from horse serum, carries a risk of anaphylaxis or serum disease [1-7]. Immunity does not develop after infection, and new recombinant vaccines are under investigation. The administration of botulinum antitoxin reduces mortality, duration of intensive care unit treatment, and hospitalization duration.

Anaphylaxis after Treatment with an Endodontic Material Containing Polyethylene Glycol

Polyethylene glycol (PEG) is sometimes included in temporary endodontic filling materials to modify viscosity. PEG is considered a low hazard chemical, but parenteral PEG exposure is associated with a risk of anaphylaxis. We report 2 cases of anaphylaxis after treatment with an endodontic temporary filling material containing PEG. One patient survived after hospital treatment, but the second case was fatal. Extensive investigations were needed to find the culprit. Allergic reactions to PEG are increasingly reported and have significant implications for the patient. Precautionary measures are discussed.

Pearls for practice from the 2023 joint task force anaphylaxis practice parameter.

To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter. The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis. The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.

Introducing NASN's School Nursing Evidence-Based Clinical Practice Guideline: Allergy and Anaphylaxis CPG and Implementation Toolkit.

Clinical Practice Guidelines (CPGs) are statements informed by a systematic review of research/evidence and provide recommendations for clinical practice to improve healthcare quality and patient outcomes. The National Association of School Nurses (NASN) released School Nursing Evidence-Based Clinical Practice Guideline: Students with Allergies and Risk for Anaphylaxis, in 2023, to provide evidence-based recommendations specific to school nursing practice and support the role of the school nurse in providing high-quality care for school-age children with allergies and risk for anaphylaxis. This article will provide an overview of the CPG and Implementation Toolkit. The implementation toolkit is designed to provide school nurses with tools and resources to implement the recommendations into practice. These tools and resources include school policies; nursing assessments and intake; planning, training, implementing, and evaluating care; and data collection. Examples are discussed, including how to customize the toolkit resources to your current practice needs.

Utility of rest magnetocardiography in patients presenting to the emergency department with chest pain: A case series on the CardioFlux MCG

BackgroundMagnetocardiography (MCG) may provide a rapid diagnostic option for patients presenting with chest pain in the emergency department (ED). Case summariesThis case series presents two instances from a multicenter study, where MCG could have served as a rapid, non-invasive diagnostic tool for chest pain patients. In both cases, multiple high-sensitivity troponin (hsTn) tests yielded incorrect evidence of ischemia. In the first case, multiple positive hsTn tests led to the patient requiring 23 h of observation care, while MCG rapidly ruled out acute coronary syndrome (ACS). In the second case, MCG revealed findings indicative of cardiac ischemia where serial ECGs did not indicate ischemia and serial hsTns were normal. Subsequent cardiac catheterization confirmed 99 % stenosis in the patient's left main and left anterior descending arteries, necessitating coronary artery bypass grafting (CABG). ConclusionMCG offers a rapid, painless, non-invasive, radiation free assessment for patients presenting with acute chest pain. Integrating MCG into ED workflows has the potential to improve throughput, reduce the need for subsequent patient observation or inpatient admission, and minimize or eliminate the need for other more expensive non-invasive cardiac testing. MCG avoids some of the problems associated with other methods for diagnosing ischemia. MCG does not involve radiation or the use of pharmacologic agents which have a risk for allergic reactions and anaphylaxis, or the need for an intravenous line. Stress tests are frequently contraindicated or unable to be performed in patients on various medications, may require patient cooperation and in the case of exercise stress tests, the patient's capability to exercise. MCG requires no special patient preparation.

The risk of anaphylaxis on holidays.

The goal of this review is to summarize the potential causes of anaphylaxis in the different holiday contexts, providing practical suggestions aimed to mitigate the stress challenged by allergic patients because of unfamiliar situations. A regard was reserved to potential food triggers, particularly uncommon ones and typical of certain destinations, and to arthropods responsible for anaphylaxis. This review highlights the potential risk of anaphylaxis due to the unusual contexts more experienced during holidays (i.e., travels, outdoor activities and eating out). Moreover, it underlines the need for a further allergological education in these cases, in order to prepare allergic patients to avoid and manage undesired situations.

Co-sensitizations to Gibberellin Regulated Proteins (GRPs) in Italy: results of a polycentric study.

Background. Gibberellin Regulated Proteins (GRPs) are small glycoproteins that induce allergy to various types of fruit. This study aimed to evaluate co-sensitization to cypress pollen and other molecules responsible for fruit allergy, such as nsLTP (Pru p 3), PR-10 (Bet v1), and Profilin (Bet v2). Methods. Sixty subjects sensitized to peach GRP (Pru p 7) were consecutively recruited from four Italian centers: 28 males and 32 females (mean age 37.9 years; range 11-79). Specific IgE for Pru p 7, Pru p 3, Bet v 1, Bet v 2, cypress pollen extract (Cup s), and Cup a 1 were determined in all subjects. Results. Sensitization rates to Cup s, Cup a 1, Pru p 3, Bet v 1, and Bet v 2 in the entire studied population were 90.0%, 83.3%, 45.8%, 40.0%, and 30.0%, respectively. In subjects residing in Northern Italy, the respective sensitization rates were 96.4%, 80.0%, 50.0%, 73.3%, and 40.0%, while in those residing in Southern Italy, they were 83.3%, 86.7%, 40.0%, 6.7%, and 20.0%. The only significant difference was observed for PR-10 (p less than 0.0001) Co-sensitization to PR-10 was found to be associated with a reduced risk of anaphylaxis (OR: 0.125). Allergic reactions were most commonly triggered by peach (26/40), followed by orange (12/40), with other foods being less frequently implicated. Conclusions. This study confirms a high association between sensitization to Pru p 7 and cypress pollen and highlights a high percentage of co-sensitization to nsLTP, PR-10, and profilin. PR-10 emerged as a protective factor against anaphylaxis.

Is Component-Specific Antibody Testing Sufficient to Replace the Oral Food Challenge in the Diagnostics of Peanut-Sensitized Children? A Proof-of-Concept Study.

(1) Peanut allergy is associated with high risk of anaphylaxis which could be prevented by oral immunotherapy. Patients eligible for immunotherapy are selected on the basis of a food challenge, although currently the assessment of antibodies against main peanut molecules (Ara h 1, 2, 3 and 6) is thought to be another option. (2) The current study assessed the relationship between the mentioned antibodies, challenge outcomes, skin tests and some other parameters in peanut-sensitized children. It involved 74 children, divided into two groups, based on their response to a food challenge. (3) Both groups differed in results of skin tests, levels of component-specific antibodies and peanut exposure history. The antibody levels were then used to calculate thresholds for prediction of challenge results or symptom severity. While the antibody-based challenge prediction revealed statistical significance, it failed in cases of severe symptoms. Furthermore, no significant correlation was observed between antibody levels, symptom-eliciting doses and the risk of severe anaphylaxis. Although in some patients it could result from interference with IgG4, the latter would not be a universal explanation of this phenomenon. (4) Despite some limitations, antibody-based screening may be an alternative to the food challenge, although its clinical relevance still requires further studies.

Epinephrine autoinjectors for individuals with food allergy: Who, how many, and when to use.

Anaphylaxis is a serious allergic reaction that is effectively treated with epinephrine. Epinephrine autoinjectors are devices that contain fixed doses of medication that can be carried by patients at risk for anaphylaxis so that ready access to first line medication is available outside the medical setting. This review will discuss recent studies evaluating patient characteristics to consider when prescribing epinephrine autoinjectors. Decisions regarding who should be prescribed epinephrine autoinjectors will depend on the type of allergy, as well as co-morbidities and other risk factors that can increase a patient's risk for poor outcomes. Shared decision-making is essential when developing guidance regarding post-epinephrine management. Regular education during routine follow-up visits can reinforce knowledge and skills for managing food allergy reactions.

Anaphylaxis: Definition and criteria.

Anaphylaxis is a systemic allergic reaction that may be severe and life-threatening. With more than a dozen anaphylaxis definitions proposed over the past several decades and several diagnostic criteria in circulation, there is a need for a multinational consensus definition to simplify management across specialties. Anaphylaxis diagnostic criteria are more alike than they are different, and approaches of the National Institute of Allergy and Infectious Disease, World Allergy Organization, and Brighton Collaborative help to add granularity and perspective to patient management. Anaphylaxis occurs across a spectrum of severity within populations, although, among individual patients, there is some evidence to suggest more consistency for an individual allergen. Still, severity is influenced by a number of factors that demonstrate variability: factors that relate to allergen triggers, patient characteristics, and treatments received. Severity of anaphylaxis impacts management, and recent guidelines provide approaches that consider individual factors to inform both strong and conditional recommendations. Conditional recommendations serve as navigational signals for shared decision-making when patient expertise is leveraged to inform individual preferences and values together with clinician expertise in anaphylaxis management to provide patient care bespoke to each patient. As novel approaches to both prevention and treatment of anaphylaxis emerge, an understanding of the significance of strong and conditional recommendations becomes critical to providing individualized and appropriate care for patients at risk for anaphylaxis.

Identifying thresholds of reaction for different foods.

Current food allergy management universally treats all patients with food allergy as being at risk for anaphylaxis (with the exception perhaps of pollen food allergy syndrome). Thus, patients are told to avoid the allergenic food in all potentially allergic forms and amounts. However, research over the past 2 decades has shown that many patients will tolerate small amounts of the allergen without any allergic reaction. Thus, if one were able to identify the threshold of reactivity, this could change management. At the population level, establishing levels at which the vast majority of patients (e.g., 95%) do not react could have public health ramifications, such as altering labeling laws. At the individual patient level, personal threshold levels could determine avoidance strategies, affect quality of life, and alter treatment decisions, e.g., oral immunotherapy starting doses. In this review, threshold data for various allergens and their potential effect on the management of the patient with food allergy are examined.