High-income ZIP codes in New York City demonstrate higher case rates during off-peak COVID-19 waves.

Introduction: Our study explores how New York City (NYC) communities of various socioeconomic strata were uniquely impacted by the COVID-19 pandemic. Methods: New York City ZIP codes were stratified into three bins by median income: high-income, middle-income, and low-income. Case, hospitalization, and death rates obtained from NYCHealth were compared for the period between March 2020 and April 2022. Results: COVID-19 transmission rates among high-income populations during off-peak waves were higher than transmission rates among low-income populations. Hospitalization rates among low-income populations were higher during off-peak waves despite a lower transmission rate. Death rates during both off-peak and peak waves were higher for low-income ZIP codes. Discussion: This study presents evidence that while high-income areas had higher transmission rates during off-peak periods, low-income areas suffered greater adverse outcomes in terms of hospitalization and death rates. The importance of this study is that it focuses on the social inequalities that were amplified by the pandemic.

Gross Hematuria and Lower Urinary Tract Symptoms Associated With Military Burn Pits Exposures in US Veterans Deployed to Iraq and Afghanistan.

OBJECTIVE: The aim of the study is to describe rates of hematuria and other lower urinary tract symptoms, including self-reported cancer rates, among veterans postburn pits emissions exposure during deployment to Iraq and Afghanistan. METHODS: US post-9/11 veterans with burn pits emissions exposure confirmed via DD214 forms in the Burn Pits360.org Registry were sent a modified survey. Data were deidentified and anonymously coded. RESULTS: Twenty-nine percent of the 155 respondents exposed to burn pits self-reported seeing blood in their urine. The average index score of our modified American Urological Association Symptom Index Survey was 12.25 (SD, 7.48). High rates of urinary frequency (84%) and urgency (76%) were self-reported. Bladder, kidney, or lung cancers were self-reported in 3.87%. CONCLUSIONS: US veterans exposed to burn pits are self-reporting hematuria and other lower urinary tract symptoms.

Attenuation of Human Growth Hormone-Induced Rash With Graded Dose Challenge.

Adult growth hormone (GH) deficiency is rare and requires replacement with extrinsic/synthetic injection. GH hypersensitivity has been reported; specifically, atopic patients may develop rashes from somatotropin therapy. Allergic and non-allergic skin reactions to recombinant human GH are uncommon and infrequently reported. We describe a graded-dose challenge with intravenous Norditropin® in a 65-year-old atopic adult woman who developed a severe whole-body rash with Norditropin FlexPro® administration on several occasions but was negative on skin-prick testing to Norditropin® percutaneously and intradermally, but the patch testing was positive for gold and nickel. The patient was registered as a direct admission to the emergency room at a university hospital for a rapid antigen coronavirus disease 2019 (COVID-19) testing after having received two COVID-19 vaccinations and re-testing four months after vaccination. She was then directly admitted to a non-COVID-19 intensive care unit with direct bedside supervision by a registered nurse and a physician board certified in internal medicine, allergy/immunology, and pulmonary diseases. The patient brought a Norditropin® pen which our pharmacy team attached to a compatible syringe for dilutions. A graded dose challenge at a final dosage of 0.1 mL was performed and the patient was monitored for allergic and other adverse drug reactions, which did not occur. At the time of writing this case report, the patient has been maintained on Norditropin FlexPro® 0.1 mL and has not experienced any adverse reactions, including recurrent skin eruptions. The case presented is the first to describe a patient who successfully tolerated a graded dose challenge of an adult patient to GH replacement therapy (as Norditropin®) under supervision in an intensive care unit, whereas prior to reporting of this case, a graded dose challenge to GH replacement therapy had only been successfully performed in a child using another formulation of somatotropin (Humatrope®). Hence, this case lends support that graded dose challenge with somatotropin analogs may be considered for patients with isolated GH deficiency such as in the case presented here.

Pediatric COVID toes and fingers.

The emergence of the coronavirus disease 2019 (COVID-19) worldwide pandemic has been associated with a new constellation of cutaneous features in children. Among the unusual dermatologic presentations are the so-called COVID toes, inflammatory nodules of the feet and toes, sometimes involving the hands and fingers. These lesions mimic acral pernio, the synonym being chilblains. Unlike adult patients with COVID toes, children are less likely to manifest symptomatic COVID-19. Although a few studies have found some linkage to COVID-19 through the serum IgA or IgG severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein, other studies have no demonstrable linkage suggesting that barefoot children in cold weather develop such lesions. It appears that the chilblain-like lesions related to the period of the COVID-19 pandemic may reflect a brisk immune response portending a good prognosis and perhaps some form of innate immunity. The possible need to screen for coagulopathy is unclear, but this has been suggested in one report. Until we fully understand the pattern of immune response to COVID-19, questions may persist as to how disease manifestations are linked to SARS-CoV-2 exposures.

Influenza Vaccination Quality Improvement as a Model for COVID-19 Prophylaxis.

INTRODUCTION: Many comparisons have been made on the effect and impact of COVID-19 on influenza pandemics of history. Therefore, it is reasonable to infer that the strategies utilized by healthcare providers to improve influenza vaccination rates can similarly be applied to the administration of a COVID-19 vaccine. The purpose of this study was to determine the rationale of low influenza vaccination rates in an urban allergy clinic and how to improve patient education and knowledge regarding the importance of influenza vaccination. A three-year comparison of interventions is presented as well as its application to future COVID-19 vaccinations. METHODS: This study was performed at an outpatient allergy and clinical immunology practice (MSBI) with hospital affiliation in New York City, New York. A quality improvement medical committee was formed to optimize influenza vaccination rates to greater than 71% and established standardized protocols regarding patient intake workflows, vaccine counseling, and documentation. Patient records from four providers were used for this study to compare pre-and post-intervention rates. RESULTS: 984 patients met inclusion criteria, with a normal distribution of ages (18-80), race, and sex. Average vaccination rates prior to the intervention were 9.25-13.60%. The average vaccination rate after the intervention was 91.34%. DISCUSSION: The MSBI quality improvement study identified key areas to address in improving influenza vaccination rates. Vaccine hesitancy, public misinformation, and ambivalence surrounding vaccination with egg allergies or during a subcutaneous immunotherapy injection were all topics addressed during the 2018-2019 intervention year. Additional attention was also put toward provider education and standardization of documentation. Shared decision making and intensive education/outreach efforts are needed by physicians and patients alike to overcome vaccine hesitancy. In comparing this to upcoming COVID-19 vaccine challenges, similar barriers will likely also need to be addressed. Greater research is needed to understand patient motivations regarding hesitancy specific to the COVID-19 vaccine. CONCLUSION: As evidenced in the yearly battle with influenza and now the COVID-19 pandemic, it has become essential to identify and implement multi-level strategies to maximize vaccination rates, especially amid a global pandemic. With COVID-19 vaccines reaching emergency approval stages, it is important for healthcare providers to start creating workflows and strategies to address patient inquiries. The influenza vaccination quality improvement project presented here can be used as a guideline for future evaluations of COVID-19 vaccination efforts.

Concomitant atopic dermatitis and narcolepsy type 1: psychiatric implications and challenges in management.

Atopic dermatitis (AD) and narcolepsy type 1 (NT1) are two distinct diseases that have not been classically shown to be related. The potential connection between the known immunological aetiology of AD and the proposed autoimmune pathophysiology of dysregulation in NT1; however, is the subject of ongoing speculation and debate with advances in gene sequencing and technology. Here, we present a case of a patient with concomitant refractory AD and NT1 and review the current research on their immunological relationship and the challenges in management relative to disease burden and psychiatric comorbidities.

Unique Challenges of Atopy Treatment in the Correctional Facility System: A Case Study.

The United States houses one of the largest populations of incarcerated individuals in the world. By extension, the healthcare needs of incarcerated individuals are molded by the unique environmental and institutional circumstances that are less often a concern for the general nonincarcerated community. Conjugal visits pose a distinctive challenge for administration and physicians alike as this presents an intersection between the isolated, controlled correctional facility system and the broader, outside world. Here we present a case of severe urticaria and anaphylaxis associated with a patient's conjugal visits as well as the challenges in management and treatment of atopy relative to the correctional facility system.

Diet and atopic dermatitis.

Dermatologists and pediatric dermatologists frequently treat patients with atopic dermatitis (AD), and patients and guardians often associate AD with food allergies. A common misconception is that dietary restrictions will resolve the disease. The role of diet is evolving in the discussion of AD. The American Academy of Dermatology (AAD) has recently provided recommendations on diet and therapies for AD. This article reviews recent scientific data on the role of foods and dietary modifications in the management of AD as both an intervention and as prevention.

Association between climate factors, pollen counts, and childhood hay fever prevalence in the United States.

BACKGROUND: Climate factors and pollen counts may play a role in hay fever. OBJECTIVE: We sought to determine the impact of specific climate factors and pollen counts on the US prevalence of hay fever and statewide variation in prevalence. METHODS: We used a merged analysis of the 2007 National Survey of Children's Health from a representative sample of 91,642 children aged 0 to 17 years and the 2006-2007 National Climate Data Center and Weather Service measurements of relative humidity (%), indoor heating degree days, precipitation, Palmer Hydrological Drought Index, clear sky and issued ultraviolet indices, stratospheric ozone levels, and outdoor air temperature and National Allergy Bureau total pollen counts. Multivariate survey logistic regression models controlled for sex, race/ethnicity, age, household income, and birthplace. RESULTS: The US prevalence of hay fever in childhood was 18.0% (95% CI, 17.7% to 18.2%), with the highest prevalence in southeastern and southern states. Hay fever prevalence was significantly lower with second and third quartile mean annual relative humidity (logistic regression, P ≤ .01 for both), fourth quartile mean annual Palmer Hydrological Drought Index (P = .02), third and fourth quartile mean annual heating degree days (P < .0001 for both), and third and fourth quartile mean annual stratospheric ozone levels but increased with second, third, and fourth quartile mean annual temperature (P ≤ .02 for both), fourth quartile mean annual precipitation (P = .0007), mean total pollen counts (P = .01), and second, third, and fourth quartile issued ultraviolet index (P ≤ .0001 for all). Principal-component analysis was also used to determine the combined effects of correlated climate variables and pollen counts. CONCLUSIONS: This study provides evidence of the influence of climate on the US prevalence of childhood hay fever.

Complementary and alternative medicines and childhood eczema: a US population-based study.

The prevalence of complementary and alternative medicine (CAM) use in US children with eczema is unknown. Furthermore, it is unknown whether CAM use in the United States is associated with higher eczema prevalence. We sought to determine the eczema prevalence in association with CAM usage. We analyzed data from the 2007 National Health Interview Survey that included a nationally representative sample of 9417 children ages 0 to 17 years. Overall, 46.9% (95% confidence interval, 45.6%-48.2%) of children in the United States used 1 or more CAM, of which 0.99% (0.28%-1.71%) used CAM specifically to treat their eczema, including herbal therapy (0.46%), vitamins (0.33%), Ayurveda (0.28%), naturopathy (0.24%), homeopathy (0.20%), and traditional healing (0.12%). Several CAMs used for other purposes were associated with increased eczema prevalence, including herbal therapy (survey logistic regression; adjusted odds ratio [95% confidence interval], 2.07 [1.40-3.06]), vitamins (1.45 [1.21-1.74]), homeopathic therapy (2.94 [1.43-6.00]), movement techniques (3.66 [1.62-8.30]), and diet (2.24 [1.10-4.58]), particularly vegan diet (2.53 [1.17-5.51]). In conclusion, multiple CAMs are commonly used for the treatment of eczema in US children. However, some CAMs may actually be harmful to the skin and be associated with higher eczema prevalence in the United States.

A study of IgE sensitization and skin response to histamine in Asian-Pacific American adults.

Allergic disorders and skin response to histamine have been noted to vary in different ethnicities. We investigated IgE-mediated allergic sensitization and skin response to histamine in Asian Pacific Americans (APAs), black and Hispanic Americans, and white adults. A retrospective questionnaire-based study was performed of 2222 adults presenting at a New York City allergy referral center from 1994 to 2003. Questionnaire data included sex, age, and ethnicity and personal and family history of atopic disorders. Skin-prick test (SPT) data included saline and histamine controls and response to a standardized panel of 10 aeroallergens. APA patients had a lower odds of asthma (adjusted odds ratio [aOR], 0.68; 95% confidence interval [CI], 0.52-0.89; p = 0.005) and/or animal allergies (aOR, 0.64; 95% CI, 0.50-0.82; p = 0.0003). Histamine response was not significantly different in APA (aOR, 0.90; 95% CI, 0.73-1.12; p = 0.36) or Hispanic Americans (aOR, 1.03; 95% CI, 0.85-1.24; p = 0.76), but was higher in black Americans (aOR, 2.32; 95% CI, 1.67-3.21; p < 0.0001). APA had higher odds of a positive SPT to trees (aOR, 1.49; 95% CI, 1.16-1.91; p = 0.002), grasses (aOR, 1.32; 95% CI, 1.05-1.43; p = 0.02), feathers (aOR, 1.65; 95% CI, 1.31-2.09; p < 0.0001), and cockroaches (aOR, 1.37; 95% CI, 1.10-1.62; p = 0.005). Moreover, APA had a higher total number of positive SPTs when compared with white patients (5.5 ± 3.2 versus 4.9 ± 3.3; aOR, 1.34; 95% CI, 1.10-1.62 p = 0.004). APA adults in our patient population had more IgE sensitizations but not an increased skin response to histamine. In contrast, black Americans had increased skin response to histamine.

Formoterol fumarate inhalation powder vs albuterol nebulizer for the treatment of asthma in the acute care setting.

BACKGROUND: Although albuterol remains the standard treatment for asthma in the emergency department, formoterol fumarate may be more advantageous, with its rapid and long-lasting bronchodilation. OBJECTIVE: To compare formoterol fumarate with albuterol in controlling acute asthma exacerbation. METHODS: Patients aged 18 to 65 years who presented to the emergency department with mild to moderate asthma exacerbation (peak expiratory flow rate [PEFR], 40%-60% of predicted) were randomized to receive either formoterol fumarate aerolizer (12 microg) or albuterol nebulizer (2.5 mg) every 30 minutes up to 2 treatments. Symptom scores and PEFRs were measured at each treatment. RESULTS: Thirty-four patients (19 in the albuterol arm and 15 in the formoterol fumarate arm) were enrolled. At 30 and 60 minutes, the mean PEFR of the albuterol group increased from 43.7% of predicted to 51.9% of predicted and 54.6% of predicted, respectively, and the formoterol fumarate group had changes in the mean PEFR from 49.3% of predicted to 55.5% of predicted and 57.3% of predicted, respectively, and the mean change in the 2 groups was not significantly different at 30 and 60 minutes (P = .64 and .57, respectively, by t test). The albuterol group improved in symptom scores by 3.7 and 5.5 from 0 minutes to 30 and 60 minutes, respectively, and in the formoterol fumarate group these values were 3.1 and 4.9 at 30 and 60 minutes, respectively, and the mean change in the 2 groups was not significantly different at 30 and 60 minutes (P = .61 and .76, respectively, by t test). CONCLUSION: Formoterol fumarate is as effective as albuterol inhalation for the treatment of adults with mild to moderate asthma exacerbations in the acute care setting.

Diagnosis and treatment of human seminal plasma hypersensitivity.

BACKGROUND: Human seminal plasma hypersensitivity is a rare disorder that is often misdiagnosed. While this disorder is well described in the allergy and immunology literature, few cases exist in the gynecologic literature. CASE: A young woman presented to our allergy clinic with recurrent vaginal burning, swelling, and itching occurring approximately 10 minutes postcoitally. Semen allergy was suspected. Using her partner's semen, intradermal testing produced 1.6-cm wheal and 6.0-cm flare. The patient underwent intravaginal desensitization, and she and her partner were instructed to have intercourse every 48 hours to maintain desensitization. At 5-month follow-up, they were practicing coitus interruptus with success. CONCLUSION: Human seminal plasma hypersensitivity may mimic chronic vaginitis. The intravaginal graded challenge, a form of immunotherapy used by allergists, remains a mainstay in treatment, but is only effective if maintained correctly.

A case of hydrocortisone desensitization in a patient with radiocontrast-induced anaphylactoid reaction and corticosteroid allergy.

Allergic reactions and systemic desensitization to corticosteroids have been documented rarely in English language literature. These reactions appear more often when the agent is applied topically and may lead to dangerous complications in patients if administered i.v. Therefore, the safety and efficacy of using an i.v. corticosteroid for desensitization in a patient who has a history of allergy to corticosteroid must be weighed carefully, especially when the aim of its use is to prevent an allergic reaction from a second drug. We report a case of successful systemic hydrocortisone desensitization in a patient with radiocontrast-induced anaphylactoid reaction and corticosteroid allergy. Sensitization to corticosteroids was determined through skin testing. The patient was desensitized to hydrocortisone and premedicated with hydrocortisone and diphenhydramine and subsequently underwent cardiac catheterization with radiocontrast without adverse reaction.

A generalized reaction to thimerosal from an influenza vaccine.

BACKGROUND: Thimerosal is a preservative commonly used in ophthalmic solutions, otic drops, and vaccines because of its bactericidal property. OBJECTIVE: To report a case of a generalized reaction to thimerosal in a patient who received an influenza vaccine. METHODS: We describe a patient who developed a generalized maculopapular eruption after receiving a thimerosal-containing influenza vaccine. Patch testing was performed to determine if there was an allergy to thimerosal. RESULTS: Patch testing confirmed a T-cell-mediated sensitivity to thimerosal. CONCLUSIONS: Physicians need to be aware that thimerosal is found in many products, including vaccinations. Clinicians should also be aware that allergic reactions occur with exposure to thimerosal even in vaccines. To our knowledge, this is the first case report in the literature of a generalized reaction to thimerosalfrom an influenza vaccine.

The approach to conception for women with seminal plasma protein hypersensitivity.

PROBLEM: Allergic reactions to human seminal plasma protein has become increasingly recognized in the medical community. Treatment for most allergic conditions usually begins with avoidance of the offending allergen. For women with seminal plasma protein hypersensitivity (SPH) who desire to conceive, this approach is unacceptable. We describe a case report of a woman with an SPH who desired to have unprotected intercourse in order to conceive. METHODS: The patient underwent skin prick testing to her fiancé's fresh undiluted semen. Serum-specific IgG and IgE was performed by ELISA to the fiancé's whole seminal plasma and seminal plasma proteins (SPP). The patient underwent an intravaginal graded challenge to whole seminal fluid. Intrauterine insemination with washed spermatozoa was attempted but in vitro fertilization was subsequently required. RESULTS: The patient had a positive prick test to whole seminal plasma but negative specific IgG and IgE ELISA to SPPs. An intravaginal graded challenge to whole seminal plasma was well tolerated. However, she experienced a subsequent severe local reaction after unprotected intercourse. She deferred treatment with systemic desensitization to relevant SPPs. She failed intrauterine insemination but successfully conceived with in vitro fertilization. CONCLUSION: This case report emphasizes that SPH is not associated with sterility. It also indicates that whole seminal plasma graded challenge is not uniformly successful for the treatment of SPH.

Comparison of high-dose inhaled flunisolide to systemic corticosteroids in severe adult asthma.

OBJECTIVE: To investigate whether, after 48 h of IV treatment with corticosteroids, the use of high-dose inhaled flunisolide is as effective as systemic corticosteroids in adults hospitalized for a severe asthma exacerbation. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Inpatient, an urban teaching hospital medical ward; outpatient, asthma clinic affiliated with the hospital. PARTICIPANTS: Forty patients aged 18 to 55 years with asthma exacerbation requiring hospitalization. INTERVENTIONS: Inhaled flunisolide via metered-dose inhaler (250 micro g per activation) eight puffs bid compared to systemic corticosteroids alone, following eight doses of IV corticosteroids. MEASUREMENTS AND RESULTS: Peak expiratory flow rate (PEFR), FEV(1), and symptom scores were recorded on day 1 (at presentation to the emergency department) and day 7, at an outpatient follow-up visit. From day 1 to day 7, mean PEFR increased from 190 to 379 L/min in the flunisolide group, and from 207 to 347 L/min in the systemic corticosteroids group (p = 0.95; 95% confidence interval [CI], - 66.3, infinity ). Mean FEV(1) increased from 1.6 to 2.3 L in the flunisolide group, and from 1.4 to 2.1 L in the systemic corticosteroids group (p = 0.33; 95% CI, - 21.7, infinity ). Changes in symptom scores were - 0.7 in the flunisolide group and - 0.9 in the systemic corticosteroids group (p = 0.39; 95% CI, - 0.4, infinity ). Hospital readmission rates on day 7 were zero for both groups. CONCLUSIONS: High-dose inhaled corticosteroids are as effective as systemic corticosteroids during a 7-day period following admission to the hospital for severe asthma.