Assessing Disparities in the Prevalence of Atopic Comorbidities Among Food-Allergic Children.

BACKGROUND: Previous studies have reported that Black children with food allergy (FA) have higher risk of atopic comorbidities than White children. OBJECTIVE: Our study sought to understand if disparities in the prevalence of atopic comorbidities among children with FA are driven by individual and community-level socioeconomic status (SES). METHODS: We analyzed data from a prospective, multicenter cohort investigating the natural history of pediatric atopy: the Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD) study. A validated, multicomponent area deprivation index (ADI) percentile score was tabulated by the census block group for each subject's home address. The association of ADI with atopic comorbidities in FA was assessed via multivariable regression analysis. RESULTS: Of the 700 children in this study, the mean ADI was 37.7 (95% confidence interval: 35.6-39.7). The mean ADI was higher in children with asthma (43.3) compared with those without asthma (31.8), which remained significant after adjusting for race (P < .0001). Children with allergic rhinitis (AR) had a higher mean ADI (39.1) compared with those without (33.4) (P = .008). ADI was associated with secondhand smoking, parents' education, and household income. Black children had a higher risk for asthma after adjusting for ADI and SES-related factors. CONCLUSION: The independent association of ADI with asthma and AR, regardless of race, suggests a role of neighborhood-level socioeconomic deprivation in the development of these conditions among children with FA. Black children with FA remained at higher risk for asthma after adjusting for SES-related variables, which can indicate an independent risk for asthma in these children.

Self-Efficacy Among Caregivers of Children With Food Allergy: A Cohort Study.

OBJECTIVE: The prevalence of pediatric food allergy (FA) is increasing and, due to early disease onset, requires significant caregiver management that is associated with psychosocial burden. Caregiver perception of how they cope and handle FA-related events (self-efficacy) has been linked to psychosocial outcomes in racially/geographically homogenous samples. This study explores FA-related caregiver self-efficacy and associations with FA-related caregiver quality of life (QoL) in a diverse cohort. METHODS: Caregivers of children, diagnosed with IgE-mediated FA who identified as non-Hispanic Black or White, were recruited from U.S. academic allergy clinics. Caregivers completed demographic and medical questionnaires, the Food Allergy Self-Efficacy Scale for Parents (FASE-P), Food Allergy Independent Measure-Parent Form (FAIM), and the Food Allergy Quality of Life-Parental Burden (FAQL-PB). Bivariate and multivariate associations estimated relationships between study variables. RESULTS: Caregivers of 365 children (Mage = 5.8 years, 62.2% male, 31.1% Black) were enrolled. Caregivers reported high FA self-efficacy (M = 82.06/100), moderate perceptions of risk/FA severity (FAIM: M = 3.9/7), and some limitations on the FAQL-PB (M = 3.9/7). Self-efficacy was related to lower perceptions of risk/FA severity across all demographic groups (r = -.42, p < .001). Caregivers who reported higher self-efficacy reported better QoL, particularly Black caregivers (r = .67). CONCLUSIONS: In this sample of caregivers of children with FA, greater self-efficacy was related to improved QoL regardless of sociodemographic factors. Caregivers' perception of risk was lower for those with greater self-efficacy. Future research into the impact of FA management on QoL among diverse caregivers is needed.

Associations of Food Allergy-Related Dietary Knowledge, Attitudes, and Behaviors Among Caregivers of Black and White Children With Food Allergy.

BACKGROUND: The increasing prevalence of pediatric food allergy (FA) in the United States has disproportionately affected non-Hispanic Black youth. However, racial and other socioeconomic disparities in FA management among caregivers of children with FA remain unclear. OBJECTIVE: To determine associations between socioeconomic, clinical, and health care factors and FA-related knowledge, attitudes, and behaviors among caregivers of Black and White children with FA. DESIGN: Cross-sectional survey analysis from the Food Allergy Outcomes Related to White and African American Racial Differences Study. PARTICIPANTS/SETTINGS: Longitudinal cohort of caregivers of 385 Black and White children with FA ages birth to 12 years residing in Chicago, Illinois, Cincinnati, Ohio, and Washington, DC from 2017 to March 2021. MAIN OUTCOME MEASURES: There were 3 primary outcomes of interest: (1) FA knowledge assessed by scores from the Knowledge Survey, (2) FA-related attitudes assessed by newly developed survey, and (3) food-related behaviors assessed by the FORWARD Diet and Purchasing Habit Surveys completed 6 months postenrollment. ANALYSES: Multivariable linear and logistic regression. RESULTS: The overall response rate to the 6-month postenrollment survey was 51.3% (385 of 751). White caregivers represented 69.4% of the participants. Black race was associated with a 1.5-point mean decrease in FA knowledge score (95% CI: -2.2 to -0.7) compared with White caregivers, and a graduate degree or bachelor's degree was associated with associated with a 1.7-point mean increase (95% CI: 0.8-2.7) and 1.1-point mean increase (95% CI: 0.2-2.0) in FA knowledge score, respectively, compared with caregivers who had less than a bachelor's degree. Multiple FAs and ever visited the emergency department for a food-related allergic reaction were also associated with higher levels of FA knowledge. Ever visited the emergency department for FA was also associated with higher odds of 2 measures of FA attitudes reflecting parental anxiety. Greater FA knowledge scores were consistently associated with lower odds of several FA-related food purchasing and eating behaviors assumed to have elevated risk of FA. Eating food prepared at school was the only FA behavior associated with race. Compared with White children, Black children were 2.5 times more likely to eat school-prepared foods (95% CI: 1.2-5.6). CONCLUSIONS: Findings from this study identified socioeconomic, racial, and clinical factors associated with caregivers' FA-related knowledge, attitudes, and behaviors, but further research is warranted to better understand these relationships.

African American Children Are More Likely to Be Allergic to Shellfish and Finfish: Findings from FORWARD, a Multisite Cohort Study.

BACKGROUND: Despite major differences in health profiles and rates of health care utilization between African American and White children with food allergy (FA), the detailed phenotypic variables that can potentially impact these outcomes have not been thoroughly studied. OBJECTIVE: We aimed to characterize phenotypic differences such as allergies to different foods and allergic comorbidities between African American and White children with FA enrolled in the Food Allergy Outcomes Related to White and African American Racial Differences study. METHODS: Our active, prospective, multicenter cohort study is currently enrolling African American and White children aged 0 to 12 years diagnosed with FA and followed by allergy/immunology clinics at 4 urban tertiary centers in the United States. To evaluate associations between race and phenotypic variables, we used multivariable logistic regression, adjusting for important demographic and confounding factors, as well as potential household clustering. RESULTS: As of May 2020, there were 239 African Americans and 425 Whites with complete intake information enrolled in the study. In comparison with Whites, we found that African Americans had significantly higher adjusted odds of allergy to finfish (odds ratio [OR]: 2.54, P < .01) and shellfish (OR: 3.10, P < .001). African Americans also had higher adjusted odds of asthma than Whites (asthma prevalence of 60.5% in African Americans and 27.2% in Whites; OR: 2.70, P < .001). In addition, shellfish allergy was associated with asthma, after controlling for race. CONCLUSION: Among a diverse cohort of children with physician-diagnosed FA, we observed that African American children had higher odds of allergy to shellfish and finfish, and higher rates of asthma. Interestingly, having asthma was independently associated with allergy to shellfish, after controlling for race.

AAAAI Mast Cell Disorders Committee Work Group Report: Mast cell activation syndrome (MCAS) diagnosis and management.

Our current recommendations for diagnosing and treating primary mast cell (MC) activation syndrome make use of the latest studies and consensus guidelines for clinically recognizing systemic anaphylaxis in real time, regardless of whether allergen-triggered or other pathways are involved; our current understanding of the biomarkers secreted by activated MCs that best discriminate this disorder from other conditions; and the therapeutic drugs that might selectively affect those mediators or MCs themselves. Finding familial or somatic mutations of genes that cause MCs to be hyperactivatable would extend our diagnostic tools and potentially indicate new therapeutic interventions, targeting either the mutated gene product or the associated molecular pathway. In conclusion, we trust that the clinical, laboratory, and therapeutic criteria for primary MC activation syndromes described herein will provide clinicians with practical criteria of sufficient sensitivity and specificity to diagnose most cases without overdiagnosing the disorder in patients who likely have other conditions.

Risk of obstructive sleep apnea in African American patients with chronic rhinosinusitis.

BACKGROUND: It is widely known that patients with chronic rhinosinusitis (CRS) commonly experience sleep disruption. Many of these patients have the associated diagnosis of obstructive sleep apnea (OSA). However, little is known about the risk factors for developing OSA in the CRS population. OBJECTIVE: To identify the risk factors for OSA in CRS to determine who should be screened for OSA among patients with CRS. METHODS: We evaluated a large cohort of patients with confirmed diagnostic criteria for CRS. Patient medical records were reviewed to identify those with OSA confirmed by overnight polysomnography. Records were further reviewed for demographic information (age, sex, race, and ethnicity), body mass index, and medical history, including the presence of nasal polyps, asthma, aspirin-exacerbated respiratory disease, allergic rhinitis, and eczema. The number of endoscopic sinus operations, duration of CRS, presence of subjective smell loss, and computed tomography Lund-Mackay score were also ascertained. RESULTS: A total of 916 patients with CRS were included in the study. Implementation of a multivariable regression model for identifying adjusted risk factors revealed that African American patients had a significantly higher risk for OSA than white patients, with an adjusted odds ratio of 1.98 (95% confidence interval, 1.19-3.29). Furthermore, patients with CRS without nasal polyps were at higher risk for OSA, with an odds ratio of 1.63 (95% confidence interval, 1.02-2.61) compared with patients with CRS with nasal polyps. CONCLUSION: African American patients with CRS were at higher risk for OSA compared with white patients, and this patient group needs to be screened for OSA.

Racial Differences in Food Allergy Phenotype and Health Care Utilization among US Children.

BACKGROUND: Food allergy (FA) is a prevalent condition in the United States, but little is known about its phenotypes in racial minority groups. OBJECTIVE: The objective of this study was to characterize disease phenotypes and disparities in health care utilization among African American (AA), Hispanic, and white children with FA. METHODS: We conducted a large, 2-center, retrospective cohort study of children aged 0-17 years with FA seen in allergy/immunology clinics at 2 urban tertiary care centers in the United States. We used multiple logistic regression analyses adjusted for age, gender, and insurance. RESULTS: The cohort of 817 children was composed of 35% AA, 12% Hispanic, and 53% non-Hispanic white. Compared with non-Hispanic white children, AA children had significantly higher odds of having asthma and eczema (P < .01), and significantly higher odds of allergy to wheat, soy, corn, fish, and shellfish (P < .01). Compared with non-Hispanic white children, Hispanic children had significantly higher odds of allergy to corn, fish, and shellfish (P < .01), and higher odds of eczema (P < .01), but a similar rate of asthma (P = .44). In this cohort, 55%, 18%, and 11% of AA, Hispanic, and white children were covered by Medicaid, respectively (P < .00001). Compared with whites, AA and Hispanic children had a shorter duration of follow-up for FA with an allergy specialist and higher rates of FA-related anaphylaxis and emergency department visits (P < .01). CONCLUSIONS: FA phenotypes and health care utilization differ among children of different racial and/or ethnic backgrounds in the United States that put AA and Hispanic children at higher risks of adverse outcome than white children. These differences include coexistent atopic conditions, less well recognized food allergens, and higher rates of anaphylaxis.

Prevalence of allergic rhinitis and asthma in patients with chronic rhinosinusitis and gastroesophageal reflux disease.

BACKGROUND: An association between chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) has been previously reported; however, the underlying factors linking CRS and GERD remain to be elucidated. OBJECTIVE: To assess the association of GERD and CRS using prospective and retrospective approaches. METHODS: The retrospective study comprised a large cohort of CRS cases, whereas the prospective arm evaluated a series of CRS cases and controls. RESULTS: In the retrospective arm of the study, of the 1066 patients with CRS, 112 (10.5%) had GERD. Among patients with CRS, GERD was associated with higher body mass index, older age, and female sex. The odds ratios (ORs) for asthma and allergic rhinitis in the CRS group with GERD compared with the CRS group without GERD were 2.89 (95% confidence interval [CI], 1.905-4.389) and 2.021 (95% CI, 1.035-3.947). Furthermore, GERD was associated with a greater duration of CRS. Ninety patients with CRS and 81 controls were enrolled in the prospective arm of the study. In the CRS group, GERD was associated with asthma (OR, 4.77; 95% CI, 1.27-18.01). Patients with CRS and GERD had a longer duration and a younger age at onset of CRS. In controls, no association was found between GERD and asthma (OR, 0.67; 95% CI, 0.09-5.19) or allergic rhinitis (OR, 0.35; 95% CI, 0.05-2.59). CONCLUSION: Patients with CRS and GERD are more likely to have atopic conditions and asthma when compared with patients with CRS but without GERD. One of the potential explanations of this link is that comorbid GERD and atopic disease are potential risk factors for development of CRS.

African American Patients with Chronic Rhinosinusitis Have a Distinct Phenotype of Polyposis Associated with Increased Asthma Hospitalization.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common inflammatory disease of the upper airways that is often categorized into subtypes including "with" and "without" nasal polyps. However, the influence of multiple important epidemiologic factors, including race, on CRS has not been investigated. OBJECTIVE: The present study assessed various phenotypic characteristics of CRS in patients, living in the United States, with different racial backgrounds. METHODS: We performed a large retrospective cohort study of patients with CRS treated at a large urban tertiary care referral center in Chicago. RESULTS: African American (AA) patients with CRS living in Chicago were more likely to report hyposmia as a symptom of CRS. Furthermore, AA patients with CRS who failed medical therapy and required surgical intervention had a significantly higher frequency of nasal polyposis and aspirin-exacerbated respiratory disease, and a higher disease severity index on computed tomography imaging than did white patients with CRS. The increased polyposis in AAs was associated with increased hospitalization for asthma. There were no differences in the prevalence of atopy, asthma, atopic dermatitis, food allergy, duration of disease, or number of surgeries between different races. CONCLUSIONS: AAs with refractory CRS are at increased risk for nasal polyposis, smell loss, aspirin-exacerbated respiratory disease, and a greater severity of disease based on imaging, resulting in increased health care utilization.

Neutrophil-like low-density granulocytes are elevated in patients with moderate to severe persistent asthma.

BACKGROUND: Elevations in neutrophil-like low-density granulocytes (LDGs) are observed in association with disease severity in some autoimmune and other disorders. This study evaluated whether a similar association with disease severity is observed in asthma. OBJECTIVE: To determine LDG levels in peripheral blood mononuclear cells of subjects with intermittent or mild persistent asthma, subjects with moderate persistent or severe persistent (SP) asthma, and control subjects without a history or allergy or asthma. METHODS: A brief medical history and physical examination, spirometry, and measurement of fraction of exhaled nitric oxide were performed. The LDGs were quantified by polychromatic flow cytometry. RESULTS: The LDGs displaying the same phenotype as those described previously for LDGs in other diseases were significantly elevated in peripheral blood mononuclear cells of subjects with moderate persistent or SP asthma. The LDGs comprised up to 39% of peripheral blood mononuclear cells, with elevated LDG levels most prevalent in subjects with SP asthma. The highest LDG levels were observed in 4 subjects with SP asthma. Fraction of exhaled nitric oxide levels and body mass were significantly increased in subjects with low LDG levels compared with control subjects, whereas fraction of exhaled nitric oxide levels and body mass were not elevated in subjects with moderate persistent or SP asthma and high LDG levels compared with control subjects. CONCLUSION: These findings identify a previously unrecognized association between LDG levels and asthma severity. Identification of the factor(s) responsible for the increased LDG levels in moderate persistent or SP asthma may provide a serum biomarker to aid in the identification of neutrophil-associated phenotypes of severe asthma.

In vitro evaluation of intestinal epithelial TLR activation in preventing food allergic responses.

Alterations in the gut microbiota composition are associated with food allergy. Toll-like receptors (TLRs) respond to microbial stimuli. We studied the effects of the ligation of TLRs on intestinal epithelial cells (IECs) in preventing an allergic effector response. IEC monolayers (T84 cells) were co-cultured with CD3/28-activated PBMCs from healthy controls or atopic patients and simultaneously apically exposed to TLR2, TLR4 or TLR9 ligands. The barrier integrity of T84 cell monolayers was significantly reduced upon co-culture with PBMCs of food allergic subjects compared to healthy subjects. Apical exposure of IECs to a TLR9 ligand prevented PBMC-induced epithelial barrier disruption. Using PBMCs from food allergic subjects, apical TLR9 activation on IECs increased the IFN-γ/IL-13 and IL-10/IL-13 ratio, while suppressing pro-inflammatory IL-6, IL-8 and TNF-α production in an IEC-dependent manner. Hence, the activation of apical TLR9 on IECs, potentially by microbiota-derived signals, may play an important role in the prevention of allergic inflammation.