A Phased Approach to Resuming Suspended Allergy/Immunology Clinical Services.

In early 2020, the first US and Canadian cases of the novel severe acute respiratory syndrome coronavirus 2 infection were detected. In the ensuing months, there has been rapid spread of the infection. In March 2020, in response to the virus, state/provincial and local governments instituted shelter-in-place orders, and nonessential ambulatory care was significantly curtailed, including allergy/immunology services. With rates of new infections and fatalities potentially reaching a plateau and/or declining, restrictions on provision of routine ambulatory care are lifting, and there is a need to help guide the allergy/immunology clinician on how to reinitiate services. Given the fact that coronavirus disease 2019 will circulate within our communities for months or longer, we present a flexible, algorithmic best-practices planning approach on how to prioritize services, in 4 stratified phases of reopening according to community risk level, as well as highlight key considerations for how to safely do so. The decisions on what services to offer and how fast to proceed are left to the discretion of the individual clinician and practice, operating in accordance with state and local ordinances with respect to the level of nonessential ambulatory care that can be provided. Clear communication with staff and patients before and after all changes should be incorporated into this new paradigm on continual change, given the movement may be forward and even backward through the phases because this is an evolving situation.

What is anaphylaxis?

PURPOSE OF REVIEW: In the century since the discovery of anaphylaxis, research has yet to identify the mechanisms that cause a localized allergic response to become rapidly generalized, and particularly why only some sensitized individuals develop the clinical reaction on exposure. The possible components and steps in the process (proven and hypothetical) are reviewed with respect to their variation and regulation and their potential for therapeutic intervention. RECENT FINDINGS: Studies of insect sting allergy have revealed some of the gaps in our understanding, the relatively poor predictive value of our diagnostic tests, and more recently the early evidence for 'priming' of basophils and mast cells as a precursor or predictor of clinical reactivity. Recent literature has elucidated some of the products and regulatory pathways of the cells involved in the initiation of the anaphylactic response, the role of neurologic pathways, and the possible 'on-off switches' at the level of the immunoglobulin E receptors and their related signaling pathways. SUMMARY: This review incorporates old and new observations that may be related to the puzzling characteristics of anaphylaxis. Recognizing the gaps in our understanding helps to identify many areas that require further study and presents promising targets for future treatment and prevention of anaphylaxis.