COVID-19 pandemic: Practical considerations on the organization of an allergy clinic-An EAACI/ARIA Position Paper.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has evolved into a pandemic infectious disease transmitted by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). Allergists and other healthcare providers (HCPs) in the field of allergies and associated airway diseases are on the front line, taking care of patients potentially infected with SARS-CoV-2. Hence, strategies and practices to minimize risks of infection for both HCPs and treated patients have to be developed and followed by allergy clinics. METHOD: The scientific information on COVID-19 was analysed by a literature search in MEDLINE, PubMed, the National and International Guidelines from the European Academy of Allergy and Clinical Immunology (EAACI), the Cochrane Library, and the internet. RESULTS: Based on the diagnostic and treatment standards developed by EAACI, on international information regarding COVID-19, on guidelines of the World Health Organization (WHO) and other international organizations, and on previous experience, a panel of experts including clinicians, psychologists, IT experts, and basic scientists along with EAACI and the "Allergic Rhinitis and its Impact on Asthma (ARIA)" initiative have developed recommendations for the optimal management of allergy clinics during the current COVID-19 pandemic. These recommendations are grouped into nine sections on different relevant aspects for the care of patients with allergies. CONCLUSIONS: This international Position Paper provides recommendations on operational plans and procedures to maintain high standards in the daily clinical care of allergic patients while ensuring the necessary safety measures in the current COVID-19 pandemic.

Olfactory dysfunction is associated with mild cognitive impairment in community-dwelling older adults.

Background: Olfactory impairment is aging related and is associated with cognitive decline in older adults. However, it remains unclear if an olfactory impairment is associated with mild cognitive impairment (MCI) and the degree of impairment in the MCI subtypes. Materials and methods: In a cohort of community-living older adults aged 60 years and above, 670 participants were recruited from the Community Health and Intergenerational (CHI) Study. Olfactory function was assessed using a locally developed nine-item smell test in association with neurocognitive assessments. Analysis of covariance (ANCOVA) was used to examine the association of smell identification score and clinical cognitive status while considering demographic, clinical, and neuropsychological factors with Bonferroni correction for group comparisons. Results: Age-related smell detection between normal aging (NA) and MCI participants had no significant difference. The overall mean smell identification score in older adults was negatively correlated with age. The mean smell identification score of MCI participants was also not significantly different as compared with NA, but an amnestic MCI multiple domain (aMCI_MD) subgroup had significantly lower (impaired) mean smell identification scores compared with the NA and MCI single domain (amnestic and non-amnestic) group. Conclusion: This study demonstrated that olfactory identification impairment is a comorbidity in older adults with amnestic MCI (aMCI) and is a potential marker associated with an early stage of a neurocognitive disorder. The smell test could act as a screening tool to help in the early detection of smell impairment for heterogeneous syndromes of MCI among community-dwelling older adults. Clinicians and researchers could benefit from utilizing the locally developed smell test to screen their patients or research participants before the initiation of an appropriate health intervention or in a clinical trial.

Primary care management of allergic rhinitis: a cross-sectional study in four ASEAN countries.

BACKGROUND: In primary care, general practitioners (GPs) and pharmacists are tasked with the frontline responsibility of identifying and managing allergic rhinitis (AR) patients. There are currently no consolidated data on current treatment practices, patient compliance, and usage of guidelines within Southeast Asian Nations (ASEAN). Objective: To assess the attitudes and practices on AR of GPs and pharmacists in 4 ASEAN countries (Philippines, Indonesia, Thailand, and Malaysia). METHODS: A cross-sectional survey of 329 GPs and 548 pharmacists was conducted from May to November 2019. Participants answered a questionnaire focused on their i) current practice in the management of AR, ii) views on patient compliance, iii) understanding and usage of guidelines. RESULTS: Clinical history was the most preferred method to diagnose AR by 95.4% of GPs and 58.8% of pharmacists. Second-generation antihistamines were the most widely available treatment option in GP clinics and pharmacies (94.8% and 97.2%) and correspondingly the most preferred treatment for both mild (90.3%, 76.8%) to moderatesevere rhinitis (90.3%, 78.6%) by GPs and pharmacists, respectively. Loratadine was ranked as the most preferred 2nd generation antihistamines (GP vs pharmacists: 55.3% vs 58.9%). More than 90% of GPs and pharmacists ranked length and efficacy of treatment as important factors that increase patient compliance. Awareness of the ARIA guidelines was high among GPs (80%) and lower among pharmacists (48.4%). However, only 63.3% of GPs and 48.2% of pharmacists knew how to identify AR patients. CONCLUSIONS: The survey in the 4 ASEAN countries has identified a need to strengthen the awareness and use of ARIA guidelines among the primary care practitioners. Adherence to ARIA guidelines, choosing the appropriate treatment option and prioritizing factors that increases patient compliance may contribute to better management outcomes of AR at the primary care practice.

Assessment of perception, attitude, and practice of primary care practitioners towards allergic rhinitis practice guidelines: Development and validation of a new questionnaire.

BACKGROUND: Primary care practitioners (PCPs), being the front liners, play an important role in treating allergic rhinitis (AR). As there is no proper tool to assess their perception, attitude, and practice in utilizing the guidelines, we aimed to develop and validate a new questionnaire for such purpose. METHODS: The development phase consists of both literature and expert panel review. The validation phase consists of content validity, face validity, and construct validity. Cronbach's alpha was used to verify internal consistency. The development phase produced a questionnaire with 3 domains: perception, attitude, and practice consisting of 60 items (PAP-PCP questionnaire). Item response theory analysis for perception demonstrated the difficulty and discrimination values were acceptable except for 3 items. Exploratory factor analysis for attitude and practice domains showed the psychometric properties were good except for 3 items in practice domain. Experts judgement was used to decide on the final selection of questionnaire which consists of 59 items. RESULTS: The final validated questionnaire has 3 domains with 59 items. All domains had Cronbach's alpha above 0.65 which was reliable. 302 physicians completed the questionnaire. 98% PCPs diagnosed AR based on clinical history. Although, majority agree AR guidelines is useful (67%), they had difficulty in using it to classify AR (54.9%) and determine AR severity (73.9%). Oral anti-histamines (first and second generation) were the most prescribed (>75%) followed by intranasal corticosteroids (59%) and combined intranasal corticosteroid and oral anti-histamine (51%). Majority agreed that treatment efficacy (81.8%), adverse effects (83.8%), fear of adverse effects (73.5%), route of administration (69.4%), dosing frequency (72.5%), taste (64.6%) and cost (73.5%) affect treatment compliance. CONCLUSIONS: The newly developed and validated questionnaire is a promising instrument in understanding the treatment gap in AR. Although further testing and refinement are needed, it provides an initial means for evaluating knowledge and understanding of PCPs in treating AR.

Using Patient Profiles To Guide The Choice Of Antihistamines In The Primary Care Setting In Malaysia: Expert Consensus And Recommendations.

H1-antihistamines are recognized to be effective for conditions such as allergic rhinitis and chronic spontaneous urticaria. However, management of such conditions in the real-world primary care setting may be challenging due to diverse patient-specific considerations, the wide range of antihistamines available, choice of other treatment modalities, and the complexity of interpreting specialist treatment algorithms. Despite regular updates to international guidelines, regional/national surveys of healthcare professionals show a clear gap between guidelines and real-world practice, particularly at the primary care level. This article thus presents the consensus opinion of experts from relevant specialties in Malaysia - allergology, pediatrics, otorhinolaryngology, and dermtology - on harmonizing the use and choice of antihistamines in primary care. Patient profiling is recommended as a tool to guide primary care practitioners in prescribing the appropriate antihistamine for each patient. Patient profiling is a three-step approach that involves 1) identifying the individual's needs; 2) reviewing patient-specific considerations; and 3) monitoring treatment response and referral to specialists in more severe or difficult-to-treat cases. Concurrently, guidelct 3ines should be reviewed and updated periodically to include recommendations that are easily actionable for primary care practitioners.

Control of nasal obstruction in perennial allergic rhinitis.

PURPOSE OF REVIEW: Nasal obstruction, the cardinal symptom of persistent (perennial) allergic rhinitis, is one of the most common symptoms encountered in primary care and in specialist clinics. It is difficult to quantify by clinical examination, and, hence, objective assessment of the nasal airway is critical to rhinologic research. Nasal obstruction in persistent allergic rhinitis must be treated the year round, and therefore treatment choices, costs, and compliance all become important public health issues. RECENT FINDINGS: Many inflammatory and neurogenic mediators released during allergic reactions are able to cause plasma exudation and vasodilatation, with resultant edema and swelling of the nasal mucosa. Recently, technological advancements have made it possible to qualitatively and quantitatively study the nasal airway, providing greater insights into the understanding of physiological fluctuation and pathophysiological manifestations of nasal patency. From recent international guidelines, the management of allergic rhinitis includes combining treatments of the upper and lower airways, by using patient education, allergen avoidance, pharmacological treatment, and specific immunotherapy. Surgery may be needed as an adjunctive intervention. Multiple methods have been introduced to treat turbinate hypertrophy. However, preservation of adequate nasal mucosal function is important, together with long-term results. SUMMARY: It is important that consensus recommendations for the management of allergic rhinitis be designed and implemented by all levels of medical specialists in order to improve treatment outcomes.

The status quo and unmet needs in the management of allergic rhinitis and chronic rhinosinusitis: a Malaysian perspective.

BACKGROUND: Allergic rhinitis and rhinosinusitis, common and debilitating conditions, should be managed in accordance with guideline recommendations. Guideline adherence shows regional differences. As of now, there is little data from Asia and none from Malaysia on the current treatment practices and unmet needs in the management of these conditions. OBJECTIVE: The objective of this study was to assess the current practice in the management of allergic rhinitis and rhinosinusitis by conducting a survey among ear, nose and throat (ENT) specialists, pharmacists, and general practitioners (GPs) in Malaysia. METHODS: We conducted a survey study among ENT specialists, pharmacists, and GPs in Malaysia, who answered a multiple choice questionnaire focused on the current practice in the management of allergic rhinitis and rhinosinusitis in their respective field. More than 200 ENT specialists, 100 pharmacists, and 200 GPs participated in the survey. RESULTS: Antihistamines were the most preferred choice for the treatment of mild allergic rhinitis by ENT specialists (45%), pharmacists (78%), and GPs (51%), with the most preferable duration of <2 weeks. In moderate-to-severe allergic rhinitis, a combination of antihistamines and intranasal steroids was the most preferred treatment of choice in 90% of ENT specialists, 72% of pharmacists, and 69% of GPs. Efficacy of antihistamines was the main criteria of choice in 58%, 53%, and 38% of ENT specialists, pharmacists, and GPs, respectively. Notably, complaints of drowsiness associated with nonsedative antihistamines were the major unmet need identified in the survey. For chronic rhinosinusitis, a combination of antihistamines and intranasal steroids was the most preferred treatment. The majority of the respondents preferred a treatment duration of >3 months with antihistamines. Satisfaction with the recommendations in the current Allergic Rhinitis and its Impact on Asthma (ARIA) guideline was high; 66%, 58%, and 89% of the ENT specialists, pharmacists, GPs, respectively, reported that the current ARIA guidelines are sufficient for their clinical/pharmacy practice. CONCLUSION: The current practices in the management of allergic rhinitis in Malaysia are largely in line with the ARIA guidelines. The majority of physicians and pharmacists are satisfied with the recommendations in the ARIA guidelines.

Frequently asked questions in allergy practice.

BACKGROUND: Over the last 10-20 years, international guidelines and consensus statements for the management of common allergic diseases (e.g. allergic rhinitis and asthma) have been developed and disseminated worldwide. However, their impact on knowledge and standard of clinical practice among primary care physicians and specialists is unknown. OBJECTIVE: To investigate need for an improvement in the dissemination of international guidelines for the diagnosis and management of allergic rhinitis. METHODS: Seven medical students who attended 3-day 1st International Basic Allergy Course (2010) took down all questions raised during the entire course. A systemic analysis of these questions was performed to identify areas for improvement in diagnosis and management of allergic diseases mainly in the Association of Southeast Asian Nations (ASEAN) region. RESULTS: 268 participants, 143 males and 125 females, comprising Ear, Nose and Throat (ENT) specialists (n = 106) and trainees (n = 34), general practitioners (n = 87), and other healthcare professionals (n = 41) attended the course. Of the 103 questions recorded, 59 were regarding treatment modalities in allergy practice such as immunotherapy (n = 38), pharmacologics (n = 15), nasal surgery (n = 2), and others (n = 4). 41 questions (39.8%) have answers based in the Allergic Rhinitis and its Impact on Asthma guidelines (2001 and 2008). Certain questions were selected for further analysis because they appeared to be (a) more commonly asked (e.g. immunotherapy) or (b) were deemed to be challenging or, even controversial (e.g. food allergy and differential diagnosis between vasovagal and anaphylaxis reaction), as the recommendations in current international guidelines were less well-defined. CONCLUSION: Our study identified several problems that, if tackled, could help minimize confusion and provide better care for patients suffering from allergic diseases especially in the ASEAN region.

Management of allergic rhinitis in general practitioners.

For patients suffering from allergic rhinitis (AR), general practitioners (GPs) are often their first source of medical advice. It is one of the top-ten reasons for a visit to the primary care clinics and AR was estimated to be 10-40% of the total patient visits in about 50% of the primary care clinics. The standard of management for AR among GPs is thus a key outcome assessment of AR management and implementation of international guidelines in general healthcare practice.