Outcomes of oral food challenges in a real-world setting, with predictors of outcomes.

BACKGROUND: Oral food challenge (OFC) remains the reference standard for food allergy (FA) diagnosis. OBJECTIVE: This study reports a single-center observational experience with all OFCs conducted over 3 years. METHODS: All OFCs performed at an outpatient office were tracked. The OFCs were conducted without strict prespecified inclusion or exclusion criteria. Demographic information along with results of diagnostic testing and results of the OFCs were recorded. RESULTS: A total of 1132 OFCs were performed, with a median age of 4 years (interquartile range = 2.0-10.0). Of the 1132 OFCs, 862 (76.1%) tolerated the food, whereas 232 (20.5%) experienced a reaction, and 38 (3.4%) did not complete the OFC because of food refusal. The highest percentage of tolerated food was shellfish (91.1%), with the lowest percentage of tolerated food being baked egg (66.1%). There were 66 (5.8%) OFCs that were deemed to be high risk, of which 35 (53.0%) tolerated the food. More than 50% of reactions occurred on the first or second dose, with the most common clinical symptom being urticaria or angioedema, with 29.2% of reactions treated with epinephrine. There were several factors that predicted tolerating an OFC, including the food challenge, the reason for food avoidance, older age at the time of OFC and less reactive skin prick testing, and lower food-specific immunoglobulin E levels. CONCLUSION: Certain factors can predict tolerating an OFC, and even those considered to be high risk can be safely completed in an outpatient setting, with most tolerating the food, and most reactions not requiring treatment with epinephrine.

Treatment strategies for the yellow zone.

OBJECTIVE: To evaluate relevant studies and documents that address treatment strategies for acute loss of asthma control (yellow zone). DATA SOURCES: Publications available on various treatment strategies for the yellow zone, Global Initiative for Asthma, and FDA Drug Safety Communication. STUDY SELECTIONS: Studies that assessed the effectiveness of specific therapies as yellow zone strategies were included in this review. RESULTS: Multiple yellow zone strategies exist, but only a few have been shown consistently effective. No specific evidence suggests that scheduled SABA can prevent exacerbation. Results for intermittent leukotriene receptor antagonist use have been mixed. Strong evidence supports intermittent inhaled corticosteroid (ICS) dosing for preschool-aged children with intermittent viral-induced wheeze, but data regarding this strategy for older children and adults are limited. As for short-term increase in scheduled ICS controller, doubling the dose seems to be ineffective, whereas results for a more substantial increase in ICS dose (quadrupling and quintupling) have been mixed. Dynamic dosing appears most promising, because symptom-driven ICS in tandem with rescue beta agonist use (whether short- or long-acting) is the strategy with the most robust data demonstrating reduction in exacerbations while minimizing ICS exposure. CONCLUSION: Varying study designs and the heterogeneity of asthma itself likely account for the difference in outcomes seen with the various yellow zone intervention strategies studied. More studies are needed to determine the right yellow zone therapies for the right patients, but this is likely to be most effective through a personalized approach.

Barriers to self-administered therapy for hereditary angioedema.

Presently, the movement of care for hereditary angioedema (HAE) is out of the clinic, emergency department, and hospitals and into the home. Much of the transition relies on specialized nurses who teach patients self-administration skills. Our goal was to assess nurses to uncover barriers that they have encountered in an effort to improve self-therapy education and patient care. A survey of 21 questions was sent to 38 HAE home care nurses throughout the United States. Results were collected anonymously and data were analyzed. Nurses feel that there is an increased need for teaching patients self-therapy skills. The majority are very comfortable teaching self-administration and troubleshooting-associated problems. Perceived difficulties in providing adequate teaching include distance to patient's home and logistics of coordinating, scheduling, and obtaining supplies. Teaching is preferred when done at home by a visiting nurse with a care partner available and multiple training sessions are needed. Very few patients refused self-administration after initially being taught; reasons cited for refusal include fear of injection or infection, lack of skills, interference of daily activities, and financial restraints. As for nurses, they were most worried about safety, lack of skill retention, and inappropriate use of the drug. Self- administration of HAE treatment is increasingly more accessible and should be offered to patients as a safe and practical option. The barriers to self-administration revealed in this study include distance to the patient's home, coordinating care, obtaining medications/equipment, and scheduling training sessions. Moving to self- or home treatment through nursing instruction will improve patient's independence and quality of life, lead to earlier therapy, and reduce costs associated with care.

Graded Administration of Second Dose of Moderna and Pfizer-BioNTech COVID-19 mRNA Vaccines in Patients With Hypersensitivity to First Dose.

Two mRNA coronavirus disease 2019 (COVID-19) vaccines, Moderna and Pfizer-BioNTech, require 2 doses for maximum efficacy. This case series reports the safety and immunogenicity of a graded administration of the second dose of the Moderna and Pfizer-BioNTech COVID-19 vaccines in patients with immediate hypersensitivity reactions to the first dose.