Allergy Clinic Research Articles

The efficacy of omalizumab treatment in patients with nonatopic severe asthma.

Nonatopic asthmatic patients generally have more severe clinical manifestations, frequently accompanied by chronic sinusitis and nasal polyps, with more limited therapeutic options as compared to atopic asthmatic patients. This has led to a search for novel therapeutic approaches, including omalizumab, for nonatopic asthmatic patients who are not adequately controlled with current therapies. In this retrospective study undertaken between August 1, 2020, and December 31, 2021, at a tertiary allergy clinic, data from 61 patients with nonatopic asthma inadequately controlled with optimum therapy was examined. A total of 61 patients with severe asthma were included in the study [Female: 48 (78.7%), male: 13 (21.3%, mean age: 49 (18-71) years]. The mean duration of asthma was 60 (18-160) months. A statistically significant increase in Forced expiratory volume (FEV1per second), forced vital capacity (FVC), and asthma control test (ACT) scores were found after 1 year of omalizumab treatment (p ˂ 0.001, for all parameters). Omalizumab treatment was associated with a significant decrease in the number of asthma exacerbations, asthma-related hospitalizations, duration of hospitalizations, and several unplanned emergency room visits after 1 year (p ˂ 0.001, for all parameters). A 1-year treatment with omalizumab led to significant changes in eosinophil counts and serum IgE levels (p ˂ 0.001 and ˂ 0.001, respectively). In the severe atopic asthma patient group, omalizumab treatment provided similar clinical benefits to those observed in patients with severe atopic asthma, suggesting that it may be a useful therapeutic option in patients with nonatopic asthma who failed to benefit from treatments with steps 4 and 5.

Positive drug provocation with beta-lactam antibiotics in children: A single test may not be enough.

Drug provocation tests (DPTs) are considered the gold standard for diagnosing beta-lactam allergy. However, positive results tend to be mild and difficult to interpret. This study aimed to describe pediatric patients with a presumedly positive or inconclusive DPT, assess the decision to repeat the DPT, and describe its outcome. Retrospective review of all presumedly positive or inconclusive DPTs performed in six pediatric allergy clinics from 2017 to 2019. We describe the interpretation of results, focusing on the decision to repeat the DPT and its outcome. Of 439 children challenged with a beta-lactam, 26 (5.9%) with a presumedly positive or inconclusive result were included in this study. Most were girls (n = 16, 61.5%), and the median age was 5 years (range 1-13). The initial DPT used amoxicillin (n = 13, 50.0%), amoxicillin-clavulanic acid (n = 12, 46.2%), or cefadroxil (n = 1, 3.8%). Reactions were early (n = 11, 42.3 %), delayed (n = 14, 53.8 %), or not registered (n = 1, 3.8 %), but mild in all cases. A second confirmatory DPT was proposed in 19 patients (73.1%) and performed in 17 patients (65.4%). Nine DPTs were performed from 1 day to 4 months after the first DPT, and the remaining eight took place 6 months to 2 years later. Fifteen children tolerated the drug in the second DPT: 88.2% of those reevaluated and 57.5% of the whole study group. The positive predictive value of DPT may be lower than expected. Given the mildness of observed reactions, a second confirmatory DPT is warranted within a few weeks or months.

Quality Improvement to Engage General Pediatrics in Reducing Inaccurate Penicillin Allergy Labels.

To remove inaccurate penicillin allergy labels in the general pediatric clinic setting. From October 2017 through December 2021, this collaborative, quality improvement project used education, feedback, electronic health record alerts, and the introduction of oral amoxicillin challenges in a general pediatric clinic setting with the primary aim of decreasing the proportion of penicillin allergy labeled patients. Control charts were used to track the relationship between interventions and improvements in referral rates to allergy clinic, removal of the allergy label at clinic visits and the overall proportion of clinic patients labeled as PCN allergic. Referral rates to allergy clinic for penicillin allergy labeled patients increased from a baseline mean of 1.9% to 20.4%. The proportion of PCN allergy labeled patients who had the label removed during a pediatric clinic visit increased from a baseline of 1.1% to 6.6%. The overall proportion of penicillin allergy labeled clinic patients decreased from a baseline of 3.4% to 2.2%. With adequate education and collaboration with allergists, general pediatric practitioners can play a significant role in removing inaccurate penicillin allergy labels. Pediatricians can remove some of the burden placed on allergists by evaluating low risk patients in the primary care setting while referring higher risk patients to the specialist.

Hypersensitivity reactions to iodinated radiocontrast media: Cluster analysis reveals distinct clinical phenotypes

BackgroundDrug hypersensitivity reaction (DHR) to iodinated radiocontrast media (iRCM) is reported in 1%–3% of injections. Risk assessment of patients with suspicion of DHR to iRCM relies solely on clinical phenotyping and drug allergy workup. Using a novel unsupervised TwoStep cluster analysis, we aimed to identify prototypic patterns within a large cohort of patients evaluated for a potential iRCM DHR. MethodsA retrospective study was conducted using data from the Drug Allergy and Hypersensitivity Database of the Allergy Unit, University Hospital of Montpellier, Montpellier, France. All referred patients during February 2001 to December 2019 with suspicion of iRCM DHR with either confirmed positive or confirmed negative skin tests were included in the analysis. ResultsA total of 1439 patients were evaluated. The chronology of the index reaction was immediate and nonimmediate in 77.1% and 22.4%, respectively. Cluster analysis categorized the total study population in 5 clusters. Cluster 1 compiled all nonimmediate and cluster 2–5 almost all immediate reactors. Cluster 1 and 2 had recent reactions (<1 y) with mostly known iRCMs and the highest iRCM allergy prevalence (16–17%). In the other clusters, more remote reactions, unknown iRCMs and a lower allergy prevalence (3–8%) was observed. Chronology and semiology of the index reaction were the factors most strongly differentiated among clusters. History of anaphylactic shock and chronology of immediate hypersensitivity reactions were shown to be independent predictors of allergy with adjusted OR (aOR) of 4.68 (95%CI: 3.01–7.27, p < 0.001) and 2.51 (95%CI: 1.67–3.78, p < 0.001), respectively. ConclusionsUnsupervised cluster analysis identified 5 prototypic patterns within patients with a suspected DHR to iRCMs. Well-phenotyped patients cluster together in 2 groups in which the prevalence of allergy is approximately 1 in 6. However, this value decreases for patients with reactions dating back to more than a decade.

Predicting probability of tolerating discrete amounts of peanut protein in allergic children using epitope-specific IgE antibody profiling.

IgE-epitope profiling can accurately diagnose clinical peanut allergy. We sought to determine whether sequential (linear) epitope-specific IgE (ses-IgE) profiling can provide probabilities of tolerating discrete doses of peanut protein in allergic subjects undergoing double-blind, placebo-controlled food challenges utilizing PRACTALL dosing. Sixty four ses-IgE antibodies were quantified in blood samples using a bead-based epitope assay. A pair of ses-IgEs that predicts Cumulative Tolerated Dose (CTD) was determined using regression in 75 subjects from the discovery cohort. This epitope-based predictor was validated on 331 subjects from five independent cohorts (ages 4-25 years). Subjects were grouped based on their predicted values and probabilities of reactions at each CTD threshold were calculated. In discovery, an algorithm using two ses-IgE antibodies was correlated with CTDs (rho=0.61, p< .05); this correlation was 0.51 (p< .05) in validation. Using the ses-IgE-based predictor, subjects were assigned into "high," "moderate," or "low" dose-reactivity groups. On average, subjects in the "high" group were four times more likely to tolerate a specific dose, compared with the "low" group. For example, predicted probabilities of tolerating 4, 14, 44, and 144 or 444 mg in the "low" group were 92%, 77%, 53%, 29%, and 10% compared with 98%, 95%, 94%, 88%, and 73% in the "high" group. Accurate predictions of food challenge thresholds are complex due to factors including limited responder sample sizes at each dose and variations in study-specific challenge protocols. Despite these limitations, an epitope-based predictor was able to accurately identify CTDs and may provide a useful surrogate for peanut challenges.

Peripheral CD23hi/IgE+ Plasmablasts Secrete IgE and Correlate with Allergic Disease Severity.

Production and secretion of IgE by B cells, plasmablasts, and plasma cells is a central step in the development and maintenance of allergic diseases. IgE can bind to one of its receptors, the low-affinity IgE receptor CD23, which is expressed on activated B cells. As a result, most B cells bind IgE through CD23 on their surface. This makes the identification of IgE producing cells challenging. In this study, we report an approach to clearly identify live IgE+ plasmablasts in peripheral blood for application by both flow cytometry analysis and in vitro assay. These IgE+ plasmablasts readily secrete IgE, upregulate specific mRNA transcripts (BLIMP-1 IRF4, XBP1, CD138, and TACI), and exhibit highly differentiated morphology all consistent with plasmablast differentiation. Most notably, we compared the presence of IgE+ plasmablasts in peripheral blood of allergic and healthy individuals using a horse model of naturally occurring seasonal allergy, Culicoides hypersensitivity. The model allows the comparison of immune cells both during periods of clinical allergy and when in remission and clinically healthy. Allergic horses had significantly higher percentages of IgE+ plasmablasts and IgE secretion while experiencing clinical allergy compared with healthy horses. Allergy severity and IgE secretion were both positively correlated to the frequency of IgE+ plasmablasts in peripheral blood. These results provide strong evidence for the identification and quantification of peripheral IgE-secreting plasmablasts and provide a missing cellular link in the mechanism of IgE secretion and upregulation during allergy.

Vaccination counseling with and without excipient skin testing in patients with suspected allergic reactions to mRNA COVID-19 vaccines and patients with atopy.

BackgroundAllergic reactions have been reported with mRNA vaccines for COVID-19 prevention. Patients perceived to be at higher risk for a reaction may be referred to an allergist, although evaluation strategies may differ between allergists.ObjectiveOur aim was to determine outcomes of COVID-19 vaccinations in patients evaluated by an allergist using different approaches.MethodsWe conducted a retrospective case series evaluation of 98 patients seen at the University of Michigan Allergy Clinic for concerns regarding COVID-19 vaccination. Of these 98 patients, 34 underwent skin testing with polyethylene glycol (PEG) 2000 with or without PEG 3350/polysorbate 80 testing.ResultsOf the 34 patients on whom skin testing was performed, 16 underwent testing before vaccination and 18 underwent testing after a reported vaccine-related event. One patient had a positive skin testing result in response to PEG 3350 following a vaccination reaction and natural infection and was advised against a second dose. One patient with a significant history concerning of anaphylaxis in response to PEG had positive results of testing to identify allergy to PEG 2000, PEG 3350, and polysorbate 80 and was advised against vaccination. Of the 98 patients, 63 (64%) tolerated COVID-19 vaccination without complication after evaluation by an allergist.ConclusionNo significant differences were found between vaccination counseling with and without skin testing to excipients. Patients who presented before the first dose of vaccination were more likely to proceed with COVID-19 vaccination and tolerate vaccination without complication.

One-year investigation of nut allergy cases in children referred to the allergy clinic of the children's medical center

Background: The prevalence of allergy to tree nuts is spreading worldwide. Allergy to tree nuts causes more severe clinical symptoms and anaphylaxis attacks are more likely. The present study was conducted in order to investigate the cases of tree nut allergy among children referred to the allergy clinic of the Children's Medical Center in a period of one year (from the beginning of 2018 to its end). Methods: There were 1920 children with a history of atopic disease (asthma, allergic rhinitis, atopic dermatitis, chronic urticaria) with a history of type I allergic reactions. Eighty seven patients with skin, digestive, respiratory symptoms or anaphylaxis after consuming tree nuts were included in the study. A skin test was performed for most of these people, and in some cases, the serum specific IgE level against the desired nuts was requested, and after confirming the positive history of allergy by the mentioned tests, a questionnaire containing 26 questions was completed by the parents to complete the information. Findings: The prevalence of allergy to tree nuts in the studied population was 4.5%. Allergy to almonds is at the top with a frequency of 62.1%. Totally, 55.2% of the patients were males.

National Survey of United Kingdom Paediatric Allergy Services.

Comprehensive national assessments of paediatric allergy services are rarely undertaken, and have never been undertaken in the United Kingdom. A 2006 survey estimated national capacity at 30,000 adult or paediatric new allergy appointments per year and identified 58 hospital clinics offering a paediatric allergy service. The UK Paediatric Allergy Services Survey was the first comprehensive assessment of UK paediatric allergy service provision. All 450 UK hospitals responded to a survey. Paediatric allergy services are provided in 154 lead hospitals with 75 further linked hospitals. All 154 lead paediatric allergy services completed a detailed questionnaire between February 2019 and May 2020. The 154 paediatric allergy services self-define as secondary (126/154, 82%) or tertiary (28/154, 18%) level services. The annual capacity is 85,600 new and 111,400 follow-up appointments. Fifty-eight percent (85/146) of services offer ≤10 new appointments per week (no data provided from 8 services-2 no response, 6 unknown) and 50% (70/139) of the services undertaking challenges undertake ≤2 food or drug challenges per week (no data from 3 challenge services). Intramuscular adrenaline is rarely used during challenges-median annual frequency 0 in secondary services and 2 in tertiary services. Allergen-specific immunotherapy is offered in 39% (60/154) of services, with 71% (41/58) of these centres treating ≤10 patients per annum (no data from 2 immunotherapy services). The 12 largest services see 31% of all new paediatric allergy appointments, undertake 51% of new immunotherapy patient provision and 33% of food or drug challenges. Seventy percent (97/126) of secondary and all tertiary services are part of a regional paediatric allergy network. Only nine services offer immunotherapy for any food (3 for peanut), 10 drug desensitization and 18 insect venom immunotherapy. There has been a fourfold increase in paediatric allergy clinics and an approximately sevenfold increase in new patient appointment numbers in the United Kingdom over the past 15 years. Most services are small, with significant regional variation in availability of specific services such as allergen immunotherapy. Our findings emphasize the need for national standards, local networks and simulation training to ensure consistent and safe service provision.

Mixed-methods evaluation of a nurse-led allergy clinic model in primary care: Feasibility trial.

It is now widely acknowledged that there are serious shortcomings in allergy care provision for patients seen in primary care. We sought to assess the feasibility of delivering and evaluating a new nurse-led allergy service in primary care, measured by recruitment, retention and estimates of the potential impact of the intervention on disease-specific quality of life. Mixed-methods evaluation of a nurse-led primary care-based allergy clinic in Edinburgh, UK undertaken during the period 2017-2021 with a focus on suspected food allergy and atopic eczema in young children, allergic rhinitis in children and young people, and suspected anaphylaxis in adults. Prior to March 2020, patients were seen face-to-face (Phase 1). Due to COVID-19 pandemic restrictions, recruitment was halted between March-August 2020, and a remote clinic was restarted in September 2020 (Phase 2). Disease-specific quality of life was measured at baseline and 6-12weeks post intervention using validated instruments. Quantitative data were descriptively analysed. We undertook interviews with 16 carers/patients and nine healthcare professionals, which were thematically analysed. During Phase 1, 426/506 (84%) referred patients met the eligibility criteria; 40/46 (87%) of Phase 2 referrals were eligible. Males and females were recruited in approximately equal numbers. The majority (83%) of referrals were for possible food allergy or anaphylaxis. Complete data were available for 338/426 (79%) patients seen in Phase 1 and 30/40 (75%) in Phase 2. Compared with baseline assessments, there were improvements in disease-specific quality of life for most categories of patients. Patients/carers and healthcare professionals reported high levels of satisfaction, this being reinforced by the qualitative interviews in which convenience and speed of access to expert opinion, the qualityof the consultation, and patient/care empowerment were particularly emphasised. This large feasibility trial has demonstrated that it is possible to recruit, deliver and retain individuals into a nurse-led allergy clinic with both face-to-face and remote consultations. Our data indicate that the intervention was considered acceptable to patients/carers and healthcare professionals. The before-after data of disease-specific quality of life suggest that the intervention may prove effective, but this now needs to be confirmed through a formal randomised controlled trial. ClinicalTrials.gov reference NCT03826953.

Editorial introductions.

Editorial introductions.

Standardized testing and written communication improve patient understanding of beta-lactam allergy testing outcomes: Amulticenter, prospective study.

Historical penicillin allergy is commonly reported, but the lack of standardized allergy clinic practices may diminish the ability to delabel beta-lactam allergy appropriately. We sought to improve beta-lactam allergy testing and patient understanding of their antibiotic allergy status by standardizing testing and communication practices between 7 adult and pediatric hospital centers. Phase 1 prospectively described the beta-lactam allergy testing practices at each center. Following this, practice was standardized to achieve a defined panel of skin testing reagents, pro forma result letters for patients and referring doctors, and provision of medical alert jewelry to those with confirmed allergy. Testing outcomes and patient perception regarding allergy status 8 weeks postassessment were compared before (phase 1) and after standardization (phase 2). Primary outcomes were the percentage of participants delabeled after testing, and concordance rates between participant perception of their allergy status and their status as determined by the treating physician at 8-week follow-up. Of 195 adult and pediatric participants (median age, 50 years; 21.5% <18 years; 36.9% males), 75% were delabeled of their beta-lactam allergy. No patient experienced anaphylaxis related to any beta-lactam delabeling testing. In phase 1, 75% of participants received written results, 52% were informed verbally, and 48% received results in more than 1 form. All phase 2 participants received written results (P< .01), 61% received verbal results from a physician as well (P> .05). At 8-week follow-up, 54% of phase 1 participants had concordant perceptions of their allergy status as the testing team versus 91.6% in phase2 (P< .001). Of the 17 participants who were delabeled and treated with a beta-lactam antibiotic during the 8-week follow-up period, there were no reported allergic reactions, although 1 participant experienced anaphylaxis following exposure to amoxicillin-clavulanic acid 1 year after delabeling. Standardization of testing and written patient information improved short-term patient perception of beta-lactam allergy status.

Diagnostic Value of a Novel Eosinophil Cationic Protein-Myeloperoxidase Test Paper Before and After Treatment for Allergic Rhinitis.

PurposeTo develop and evaluate the effectiveness/clinical application of an eosinophil cationic protein-myeloperoxidase (ECP-MPO) test paper before and after treatment in patients with allergic rhinitis (AR).Patients and MethodsWe included 40 controls and 106 AR patients who were enrolled in the Allergy Clinic of Renmin Hospital of Wuhan University. Total IgE, specific IgE and skin prick test (SPT) were detected in all participants. AR patients were treated with oral cetirizine hydrochloride for 14 days. The ECP-MPO test paper results, nasal secretion smear and eosinophil counts, rhinoconjunctivitis total nasal symptom score (TNSS), quality of life questionnaire (RQLQ), visual analogue scale (VAS), serum Th1/Th2/Th17 cytokine, and chemokine data were collected pre- and post-treatment. ECP concentrations in nasal secretions were assessed by ELISA. Pearson correlation test and Kappa consistency test were used for statistical analysis.ResultsThe post-treatment colour grade of the ECP-MPO test paper was lower in AR patients than the pre-treatment grade. The chromogenic grade correlated positively with the ECP concentration and the eosinophil count in nasal secretions both before and after treatment. Positive ECP-MPO test paper results were consistent with positive SPT, Der p-IgE and Der f-IgE result (Kappa values, 0.843, 0.810, 0.795, respectively). The pre- and post-treatment chromogenic grades correlated positively with the TNSS (r1=0·691; r2=0·539), RQLQ (r1=0·783; r2=0·625), and VAS (r1=0·703; r2=0·682) scores in AR patients.ConclusionThe ECP-MPO test paper can effectively detect ECP in nasal secretions, and its results are consistent with those from the SPT, Der p-IgE and Der f-IgE result. Its chromogenic grade can reflect the symptom severity and specific cytokine and chemokine levels in AR patients.

Dermatophagoides pteronyssinus allergen Der p 22: Cloning, expression, IgE‐binding in asthmatic children, and immunogenicity

Dust mite extract contains multiple components that, while useful in clinical allergy diagnosis and treatment, can cause serious side effects. Defining components of dust mite extract is important their contributions to allergic disease. This study aimed to characterize a novel dust mite allergen, Der p 22. We amplified the cDNA encoding Der p 22 from total RNA of the mite Dermatophagoides pteronyssinus, and inserted it into an expression construct for transformation to competent cells. Purified recombinant (r) Der p 22 was tested for IgE-binding reactivity in sera obtained from children with allergic asthma by the Affiliated Wuxi Children's Hospital of Nanjing Medical University (Jiangsu, China). rDer p 22 also was used to challenge BALB/c mice to assess effects on T helper cells and cytokine levels and applied to cultured lung epithelial cells to evaluate apoptosis and cytokine secretion. rDer p 22 bound to IgE in 93.75% of sera from pediatric allergic asthma patients. Mice challenged with rDer p 22 had altered Th1/Th2 ratios in spleen and lymph, and lower levels of cytokines IFN-γ but higher levels of IL-4 and IL-10 in alveolar lavage fluid compared with controls (p < .05). Cultured lung epithelial cells had greater apoptosis rates and exhibited higher levels of IL-6, IL-8, and GM-CSF when treated with rDer p 22 compared with control treatment (p < .05). Recombinant Der p 22 exhibited high IgE-binding rates in allergic children, indicating the activity of the recombinant protein and suggesting this novel allergen may be appropriate for inclusion in an allergy diagnostic workup. This finding is supported by in vitro and mouse in vivo studies showing rDer p 22 induced strong allergenic reactivity and apoptosis.

Asia Pacific perspectives on the second year of the COVID-19 pandemic: A follow-up survey.

BackgroundThe Coronavirus disease 2019 (COVID‐19) pandemic is currently in its third year. This follow‐up survey was commissioned by the Asia Pacific Association of Allergy Asthma and Clinical Immunology (APAAACI) Task Force on COVID‐19 to compare and contrast changes in the epidemiology, clinical profile, therapeutics and public health measures of the pandemic in the Asia Pacific region.MethodsA questionnaire‐based survey comprising 32 questions was electronically sent out to all 15 member countries of APAAACI using Survey Monkey® from 1 December 2021 to 28 February 2022.ResultsSeventeen responses were received from 14/15 (93.4%) member countries and 3 individual members. Mild‐to‐moderate COVID‐19 predominated over severe infection, largely contributed by COVID‐19 vaccination programmes in the region. The incidence of vaccine adverse reactions in particular anaphylaxis from messenger ribonucleic acid (mRNA) vaccines was no longer as high as initially anticipated, although perimyocarditis remains a concern in younger males. Novel therapeutics for mild‐to‐moderate disease including neutralizing antibodies casirivimab/imdevimab (REGEN‐COV®) and sotrovimab (Xevudy®), anti‐virals Paxlovid® (nirmatrelvir and ritonavir) and Molnupiravir pre‐exposure prophylaxis for high‐risk persons with Tixagevimab and Cilgavimab (Evusheld) are now also available to complement established therapeutics (e.g., remdesivir, dexamethasone and baricitinib) for severe disease. In the transition to endemicity, public health measures are also evolving away from containment/elimination strategies.ConclusionsWith access to internationally recommended standards of care including public health preventive measures, therapeutics and vaccines among most APAAACI member countries, much progress has been made over the 2‐year period in minimizing the morbidity and mortality from COVID‐19 disease.

COVID vaccination can be performed in patients with a history of allergic reactions to the vaccines or their components: experience from a specialist clinic in South Australia.

BackgroundThe development of vaccines against SARS‐CoV2 has been a key public health response to the COVID‐19 pandemic. However, since their introduction, there have been reports of anaphylactic reactions to vaccines in individuals with history of allergic reactions to other vaccines, excipients or to COVID vaccines.AimA dedicated adult COVID vaccine allergy clinic with a standardised allergy testing protocol was set up to investigate safety and suitability of available COVID vaccines in Australia.MethodsPatients referred to a state‐wide COVID‐19 vaccine allergy clinic between March and August 2021 with a history of allergy underwent skin‐prick testing and intradermal testing to both available vaccine formulations (BNT162b2 and ChAdOx1‐S), excipients (polyethylene glycol and polysorbate 80), excipient‐containing medications and controls. Basophil activation testing was conducted in few subjects with convincing history of immediate type reactions.ResultsFifty‐three patients underwent testing for possible excipient allergy (n = 19), previous non–COVID vaccine reaction (n = 13) or previous reaction to dose 1 of COVID‐19 vaccine (n = 21). Patients were predominantly female (n = 43, 81%), aged 18–83 (median 54) years. Forty‐four patients tested negative and 42 of these received at least their first dose of a COVID‐19 vaccine. Nine patients tested positive to excipients or excipient‐containing medication only (n = 3), or vaccines (n = 6). Five patients were positive to just BNT162b2, 3/5 have been vaccinated with ChAdOx1‐S. One who was skin test positive to both vaccines, but negative BAT to ChAdOx1‐S was successfully vaccinated with ChAdOx1‐S.ConclusionEven in a high‐risk population, most patients can be vaccinated with available COVID‐19 vaccines. This paper reports local experiences using a combined allergy testing protocol with skin testing and BAT during the pandemic.

A Demographics Analysis of IgE- and Non-IgE-mediated Food Allergies in Children

Background: There are three broad types of food allergies, including IgE-mediated reactions, non-IgE-mediated reactions, and mixed reactions. The onset of IgE-mediated food allergies is usually rapid and can sometimes lead to serious illness. Non-IgE-mediated and mixed types of food allergies can cause significant morbidity as a result of chronic disease. Objectives: This study aimed to compare various types of food allergies and discuss the basis of their different presentations. Methods: This study was conducted on children aged 2 - 12 years old with signs or symptoms of food allergy in the allergy clinics of Azad University Hospitals, Tehran, Iran, from January 2019 to January 2020. Food allergy was evaluated in these patients by careful history, physical exam, skin prick test, and atopy patch test. Results: A positive family history of atopy was detected in the first-degree relatives of 82 (63%) patients. All the children were exclusively breastfed at the beginning. A total of 61 patients had positive skin prick test (SPT), and 68 patients had positive atopy patch test (APT) results. Among food allergens, a significant correlation was detected between positive atopic patch test results and hypersensitivity reactions to cow’s milk (P value = 0.001), beef (0.002), and tomato (0.04). There was the same significant correlation between positive skin prick test results, allergens, and wheat (P value = 0.01). Conclusions: Although skin prick and atopy patch tests may help identify the culprit foods, oral food challenges are the mainstay of the diagnosis.

Vaccines against SARS-CoV-2 are safe to administer in patients with antibodies to pegaspargase.

ObjectiveAllergic reactions to pegaspargase during ALL therapy are typically due to antibodies against polyethylene glycol (PEG), which is also used as a stabilizing agent in mRNA‐based SARS‐CoV‐2 vaccines. To evaluate the safety of these vaccines in patients with anti‐pegaspargase antibodies.MethodsWe retrospectively reviewed the records of patients treated for ALL who had received SARS‐CoV‐2 vaccinations. All patients had antibodies against pegaspargase assayed during ALL therapy prospectively and in response to clinical allergies. Symptoms of intolerance to vaccination were gathered retrospectively from chart abstraction.ResultsSARS‐CoV‐2 vaccination was well tolerated in all 78 patients with prior exposure to pegaspargase as part of their leukemia therapy. No reactions were observed in the 54 patients without a history of anti‐pegaspargase antibodies or in 19 patients with antibodies who received mRNA vaccination. 1 patient who received the polysorbate containing Janssen vaccine experienced mild symptoms after vaccination not meeting the criteria of clinical allergy which spontaneously resolved within 25 minutes.ConclusionSARS‐CoV‐2 vaccination is safe in this population.

Cough Presentation and Cough-Related Healthcare Utilization in Tertiary Care: Analysis of Routinely Collected Academic Institutional Database

Routinely collected data (RCD) from electronic health records (EHR) are useful for studying disease epidemiology in the real world. We examined cough presentation and cough-related healthcare utilization using an academic institutional EHR database in Korea. In this retrospective cohort study, patients with subacute (3-8weeks) or chronic cough (> 8weeks in duration) referred to allergy and asthma clinics were studied. Cases were identified using the search term "cough" or "coughing," which is the chief complaint, in the data fields. Structured data, including demographics, medical history, symptoms, and diagnostic tests, were analyzed. Healthcare utilization was assessed for drug prescriptions, additional tests, or outpatient visits for 1year. Cough was the chief complaint in 13,223 cases (46.7%) among 28,312 new referrals for 8years. A total of 3810 subacute and 7150 chronic cough patients were analyzed. The common demographic profile was middle-aged woman (mean age 52.1years), reported in 63% of the cases. Cough was frequently accompanied by anterior nasal (about 50%), lower airway (30%), or acid reflux disease symptoms (20%), and by test abnormalities in chest X-rays (14%), spirometry (23%), or T2 inflammation markers (40%). Chronic cough patients frequently required additional tests (chest CT scan: 24%), drug prescriptions (codeine: 21.5% and oral steroids: 9.9%), and long-term healthcare utilization (16.0%) for 1year. Cough is a common chief complaint at allergy and asthma clinics, but the clinical presentation may be heterogeneous. Further studies are needed to understand long-term outcomes and reduce the disease burden.

Current concepts in optimized construction of allergen immunotherapy vaccines: Practical implications.

The administration of allergen immunotherapy, since its inception more than 100 years ago, remains a therapy unique to the field of allergy and immunology. The practicing, board-certified allergist is best equipped to evaluate and manage the allergic patient. The safety and efficacy of allergen immunotherapy is well established, and both are discussed in specific chapters in this primer. The practical application of each of these within the confines of the shot room (i.e., the places or places in the medical facility where injections are administered in the allergy clinic) are addressed in this chapter. In addition, practical suggestions are provided to enhance patient adherence with allergen immunotherapy while maximizing the practice management model as services are executed. The successful implementation of each of these areas (safety, efficacy, adherence, and profit margin) will allow the practicing allergist to optimize the clinical delivery of allergen immunotherapy within communities and to the patients being served. The optimization of allergen immunotherapy (AIT) depends on four specific defining factors: 1) safety; 2) efficacy; 3) adherence; and 4) profit margin. Identifying specific problems which could impede each of these four factors is necessary to ensure the success of AIT. The practical implications of these core concepts as they apply to AIT will be explored in this chapter.