Real-world experience of pediatric patients treated with peanut (Arachis hypogaea) allergen powder-dnfp.

BACKGROUND: Peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) is the first oral immunotherapy indicated for children aged 4 to 17 years with peanut allergy. There are limited real-world data on patients treated with PTAH. OBJECTIVE: To characterize pediatric patients treated with PTAH and associated treatment patterns in US clinical practice. METHODS: US-based physicians with allergy and immunology training treating patients with peanut allergy aged 4 to 17 years with PTAH were recruited from an existing physician panel and completed an online case report form (October to December 2021) with data abstracted from patient medical charts. Physician practice circumstances, patient characteristics, and PTAH treatment patterns were reported. Time to reach the 300-mg dose and treatment persistence were assessed using Kaplan-Meier analysis. RESULTS: A geographically balanced sample of 43 physicians contributed data for 118 demographically diverse pediatric patients. Patients had heterogeneous diagnostic test results, with a wide range of peanut-specific immunoglobulin E levels; 6.8% received an oral food challenge. During the updosing phase, there were no temporary interruptions and 5.1% of the patients required downdosing. Patients reached the 300-mg dose at a median of 21.3 weeks post-initiation. The rate of PTAH persistence at 24 weeks was 93.4%. Only 1 patient discontinued treatment because of treatment-related systemic allergic symptoms, and the remaining discontinuations were for reasons other than treatment-related symptoms. Prophylactic antihistamines were used by 33.9% of the patients to prevent PTAH adverse effects. CONCLUSION: PTAH was prescribed in demographically diverse patients with a wide range of peanut-specific immunoglobulin E levels. Treatment persistence with PTAH was high in this study population, with a small number of patients experiencing treatment modification.

Computer-Assisted Clinical Diagnosis and Treatment.

PURPOSE OF REVIEW: Computer-assisted diagnosis and treatment (CAD/CAT) is a rapidly growing field of medicine that uses computer technology and telehealth to aid in the diagnosis and treatment of various diseases. The purpose of this paper is to provide a review on computer-assisted diagnosis and treatment. This technology gives providers access to diagnostic tools and treatment options so that they can make more informed decisions leading to improved patient outcomes. RECENT FINDINGS: CAD/CAT has expanded in allergy and immunology in the form of digital tools that enable remote patient monitoring such as digital inhalers, pulmonary function tests, and E-diaries. By incorporating this information into electronic medical records (EMRs), providers can use this information to make the best, evidence-based diagnosis and to recommend treatment that is likely to be most effective. A major benefit of CAD/CAT is that by analyzing large amounts of data, tailored recommendations can be made to improve patient outcomes and reduce the risk of adverse events. Machine learning can assist with medical data acquisition, feature extraction, interpretation, and decision support. It is important to note that this technology is not meant to replace human professionals. Instead, it is designed to assist healthcare professionals to better diagnose and treat patients.

Expert Consensus on SABA Use for Asthma Clinical Decision-Making: A Delphi Approach.

PURPOSE OF REVIEW: A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3). RECENT FINDINGS: In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75-5); SABA use history should be solicited at every patient visit (5, 4.75-5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5-5). Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action.

Pediatric subcutaneous allergen immunotherapy.

Subcutaneous immunotherapy (SCIT) is a widely used therapy for allergic rhinitis and asthma. It is a useful adjunct to standard medical management of these conditions that can lead to long-term benefits and possible resolution of symptoms. The benefits of SCIT, particularly for children, include avoiding prolonged use and side effects from medications, preventing new aeroallergen sensitizations, and reducing the risk of developing asthma. The primary risks of SCIT include local and systemic reactions. Standard schedules for SCIT include advancing through multiple doses usually in four vials (diluted to 1:1000) on a weekly basis; however, there are benefits of using accelerated schedules, especially for children who need to coordinate school and parent work schedules. Special considerations for pediatric patients include fear of needles, avoiding discomfort with injections, consent, optimal injection scheduling, and difficulty communicating about symptoms during reactions in very young children. Overall, SCIT can be a safe and beneficial therapy for children.

Telemedicine and emerging technologies for health care in allergy/immunology.

Telemedicine (TM) has become a popular method of accessing medical services between providers and patients and is viewed as a cost-effective alternative to more traditional episodic face-to-face encounters. TM overcomes 2 barriers that patients face when seeking health care: distance and time. It is as effective as in-person visits for outpatient treatment of asthma, and it is a convenient way to provide inpatient consultations for patients when the allergist practices outside of the hospital. TM also has been used to manage patients with asthma in schools. Patients tend to be as satisfied with TM or they prefer TM over in-person visits, but infrequently they do prefer in-person visits. In addition to virtual visits using TM, there are several emerging technologies that are relevant to the practice of allergy/immunology including electronic diaries (eg, symptoms and medication use), wearable technology (eg, to monitor activity and vital signs), remote patient monitoring (eg, environmental exposures and medication adherence) as well as electronic medical records augmented with clinical decision support. We believe that the use of TM, particularly when combined with information technologies such as electronic health records, has the potential to cause a transformational change in the way care is delivered by altering the process of interaction between patient and provider. TM addresses the shortage of allergy specialists in rural and underserved urban communities and facilitates patient access to allergy services. As patients take more control of their health care, use of TM is likely to increase because a large part of the move to adopt TM is driven by patient preference.

Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis.

Given the burden of disease and the consequences of a diagnosis of peanut allergy, it is important that peanut allergy be accurately diagnosed so that an appropriate treatment plan can be developed. However, a test that indicates there is peanut sensitization present (eg, a "positive" test) is not always associated with clinical reactivity. This practice parameter addresses the diagnosis of IgE-mediated peanut allergy, both in children and adults, as pertaining to 3 fundamental questions, and based on the systematic reviews and meta-analyses, makes recommendations for the clinician who is evaluating a patient for peanut allergy. These questions relate to when diagnostic tests should be completed, which diagnostic tests to utilize, and the utility (or lack thereof) of diagnostic testing to predict the severity of a future allergic reaction to peanut.

Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Diagnosis of peanut allergy using continuous likelihood ratios.

BACKGROUND: Peanut allergy (PA) is associated with an economic and psychological burden on patients and families. Its diagnosis includes tests for peanut specific immunoglobulin E (sIgE), the values of which usually are categorized as positive or negative using a predefined cutoff (usually 0.35 kU/L). With the use of Bayes' theorem, this categorization can be replaced with a continuous interpretation of sIgE, which accounts for the prevalence of PA and history of ingestion. OBJECTIVE: To evaluate a method for estimating the likelihood ratio (LR) for each value of sIgE by performing a pilot investigation with the results of oral food challenges. The LR could be used to estimate the probability of PA. METHODS: The outcomes of oral food challenges and serum IgE values from 117 children seen in an allergy clinic between January 2017 and November 2019 were obtained. Polynomial regression of the receiver operation characteristics curve was used to determine an LR for each value of sIgE. Linear regression was used to estimate an LR for each value of sIgE. RESULTS: sIgE ranged from less than 0.1 kU/L to 35 kU/L. Bayes' theorem and a receiver operation characteristics curve were used to estimate LRs for each value of peanut sIgE. The value of IgE associated with an LR of 1 was 0.22 kU/L, which is comparable to other studies that used a value of 0.35 kU/L to separate positive from negative results. CONCLUSION: When combined with estimates of pretest probability, this method should permit the development of computerized decision-making algorithms to estimate the probability that a patient has PA.

Desensitization to pegaspargase in children with acute lymphoblastic leukemia and lymphoblastic lymphoma.

Hypersensitivity to pegaspargase is associated with inferior survival in pediatric patients with acute lymphoblastic leukemia and lymphoblastic lymphoma. In the past year, drug-supply shortages have led to the lack of an available alternative to pegaspargase. Rather than omit asparaginase from the treatment of acute lymphoblastic leukemia or lymphoblastic lymphoma patients with hypersensitivity to pegaspargase, we continued pegaspargase treatments for nine pediatric patients, utilizing a rapid desensitization protocol. There were no adverse events related to the pegaspargase during desensitization, and all patients who were checked had asparaginase serum levels above the threshold of 0.1 IU/mL at 7 to 14 days after pegaspargase therapy.

A Review of Patient and Provider Satisfaction with Telemedicine.

PURPOSE OF REVIEW: The purpose of this review is to describe the determinants of satisfaction with telemedicine (TM) and how they compare with in-person visits from both the perspective of patients and of providers. RECENT FINDINGS: The use of TM will expand only if patients and providers are at least as satisfied with it as they are with in-person visits. Since deviations from expected care can result in reduced satisfaction regardless of the quality of the visit or objective medical outcomes, it is important to understand and to help form those expectations when possible. Patients consistently report 95-100% satisfaction rate with TM when compared with in-person appointments. They tend to cite the convenience of decreased travel times and costs as the main drivers for satisfaction with TM. Providers tend to be satisfied with TM if they have input into its development, there is administrative support, the technology is reliable and easy to use, and if there is adequate reimbursement for its use. Satisfaction with TM is necessary for adoption of this new technology. To improve satisfaction it is important to consider factors that drive it both for patients and for providers.

Benefits and risks of incorporating virtual visits into an allergy/immunology practice.

Telemedicine (TM) involves the use of technology to overcome the patient care barriers of distance and time. Asynchronous TM can be used to monitor patients remotely and for providers and patients to communicate with each other without needing to be online at the same time. Synchronous TM can include direct-to-consumer visits in which patients use their own equipment to communicate with a provider or facilitated visits in which a patient travels to a clinic to use the clinic's equipment with a facilitator. The advantage of the latter is that a physical examination can be performed. Although some patients and providers may prefer in-person visits, patients who are seen by TM report satisfaction that it is as good as or better than that of an in-person visit. TM can be used in the outpatient setting, in the hospital to perform consults, or in the school. The convenience of TM makes it likely that more patients will adopt TM as their preferred mode of obtaining health care. It is important for allergists to become familiar with this new technology because patients will demand it.

Impact of weather and climate change with indoor and outdoor air quality in asthma: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee.

Weather and climate change are constant and ever-changing processes that affect allergy and asthma. The purpose of this report is to provide information since the last climate change review with a focus on asthmatic disease. PubMed and Internet searches for topics included climate and weather change, air pollution, particulates, greenhouse gasses, traffic, insect habitat, and mitigation in addition to references contributed by the individual authors. Changes in patterns of outdoor aeroallergens caused by increasing temperatures and amounts of carbon dioxide in the atmosphere are major factors linked to increased duration of pollen seasons, increased pollen production, and possibly increased allergenicity of pollen. Indoor air pollution threats anticipated from climate changes include microbial and mold growth secondary to flooding, resulting in displacement of persons and need for respiratory protection of exposed workers. Air pollution from indoor burning of mosquito repellants is a potential anticipatory result of an increase in habitat regions. Air pollution from fossil fuel burning and traffic-related emissions can alter respiratory defense mechanisms and work synergistically with specific allergens to enhance immunogenicity to worsen asthma in susceptible subjects. Community efforts can significantly reduce air pollution, thereby reducing greenhouse gas emission and improving air quality. The allergist's approach to weather pattern changes should be integrated and anticipatory to protect at-risk patients.

Tips for Seeing Patients via Telemedicine.

PURPOSE OF REVIEW: Telemedicine is a technology that permits patients to be seen at a distance. This review describes different types of telemedicine, why they might be useful for a practice, what equipment is needed, and how to select and schedule patients. RECENT FINDINGS: The use of synchronous telemedicine is increasing rapidly and has surpassed 50% of ambulatory encounters in some instances. Management of patients is particularly germane for an allergy practice since it is an outpatient specialty with patients who live in widely distributed locations with limited access to allergists. With utilization of digital exam equipment, in vitro tests for diagnosis, and spirometry at the patient location, there are few clear advantages of seeing patients in-person over virtual visits. Telemedicine is here today. As its use increases, it is critical that allergy specialists embrace this new technology.

Administering a Telemedicine Program.

PURPOSE OF REVIEW: The purpose of this review is to describe the process of administering a telemedicine program including reviewing telemedicine guidelines; discussing licensing, credentialing, and privileging of providers; outlining scheduling and recruitment of patients; and measuring outcomes of a telemedicine program. RECENT FINDINGS: Recent literature findings suggest that telemedicine in specialty clinics continues to grow at a rapid pace. Medical specialty programs should prepare to adopt a practice that includes telemedicine to better serve their patients and families who have expressed significant satisfaction with the delivery of healthcare in this manner. With the appropriate support, any specialty clinic can provide their patients with a telemedicine option which has shown to be highly successful for Children's Mercy Allergy, Asthma, & Immunology Department.

Indoor Environmental Interventions and their Effect on Asthma Outcomes.

PURPOSE OF REVIEW: The use of environmental interventions to improve outcomes in asthmatics has long been an elusive goal. While numerous interventions have been studied, the results of clinical trials have been mixed. This review aims to identify combinations of interventions that have been proven to be effective and to propose a model for using them in a clinical setting. RECENT FINDINGS: An NIH workshop emphasized a need for research to identify effective interventions for reducing indoor exposures and improving asthma outcomes. A number of innovative measures were described, though evidence supporting their use was lacking. A recent systematic review described various interventions for which evidence is available. The greatest challenge for this approach is the same as that for the medical approach to treatment: nonadherence. Given evidence for effective interventions, control of environmental exposures should lead to improved asthma outcomes. Methods to improve adherence need to be identified.

Pharmacologic Treatment of Seasonal Allergic Rhinitis: Synopsis of Guidance From the 2017 Joint Task Force on Practice Parameters.

DESCRIPTION: The Joint Task Force on Practice Parameters, which comprises representatives of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), formed a workgroup to review evidence and provide guidance to health care providers on the initial pharmacologic treatment of seasonal allergic rhinitis in patients aged 12 years or older. METHODS: To update a prior systematic review, the workgroup searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 18 July 2012 to 29 July 2016 to identify studies that addressed efficacy and adverse effects of single or combination pharmacotherapy for seasonal allergic rhinitis. In conjunction with the Joint Task Force, the workgroup reviewed the evidence and developed recommendations about initial treatment approaches by using the Grading of Recommendations Assessment, Development and Evaluation approach. Members of the AAAAI, the ACAAI, and the general public provided feedback on the draft document, which the Joint Task Force reviewed before finalizing the guideline. RECOMMENDATION 1: For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine. (Strong recommendation). RECOMMENDATION 2: For initial treatment of seasonal allergic rhinitis in persons aged 15 years or older, recommend an intranasal corticosteroid over a leukotriene receptor antagonist. (Strong recommendation). RECOMMENDATION 3: For treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the clinician may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment. (Weak recommendation).

American College of Allergy, Asthma & Immunology Position Paper on the Use of Telemedicine for Allergists.

The integration of telecommunications and information systems in health care first began 4 decades ago with 500 patient consultations performed via interactive television. The use of telemedicine services and technology to deliver health care at a distance is increasing exponentially. Concomitant with this rapid expansion is the exciting ability to provide enhancements in quality and safety of care. Telemedicine enables increased access to care, improvement in health outcomes, reduction in medical costs, better resource use, expanded educational opportunities, and enhanced collaboration between patients and physicians. These potential benefits should be weighed against the risks and challenges of using telemedicine. The American College of Allergy, Asthma, and Immunology advocates for incorporation of meaningful and sustained use of telemedicine in allergy and immunology practice. This article serves to offer policy and position statements of the use of telemedicine pertinent to the allergy and immunology subspecialty.

Relation of indoor and outdoor airborne fungal spore levels in the Kansas City metropolitan area.

BACKGROUND: Environmental control is an important component of asthma management for persons with asthma. A damp indoor environment and elevated airborne spore levels are factors in housing environmental control. OBJECTIVES: We investigated if indoor airborne fungal spore levels correlated with outdoor ground-level airborne fungal spores or outdoor centrally collected spore levels as to types and abundance. METHODS: Air collections were taken from home interiors, outdoor areas adjacent to the homes, and at a central location in the metropolitan area at the approximate same time. All air collections were examined and enumerated microscopically, and airborne spore estimates per cubic meter of air were reported for total fungal spores and for 11 identifiable spore groups. RESULTS: The 244 homes in the study were typical of the North American Midwest. The overall mean total spore counts in spores per cubic meter of air was indoors (4076 spores/m3), outdoors at ground level (8899 spores/m3), and outdoor metropolitan area (8342 spores/m3). All of the major indoor taxa were strongly correlated with the mean total spores present in the home. Total outdoor ground spore levels were highly correlated with levels of major outdoor taxa, such as ascospores and Cladosporium. Correlations of indoor spore levels with outdoor spore levels are strong for most major outdoor taxa. Indoor Aspergillus-Penicillium and Chaetomium are significantly correlated between indoor and local ground-level outdoor air. CONCLUSION: Although conditions may exist where indoor or outdoor spore levels were not well aligned, in most circumstances, the outdoor airborne spore community was reflected in the indoor airborne spore community.