Future Directions of Allergen Immunotherapy for Allergic Rhinitis: Experts' Perspective.

Allergen immunotherapy (AIT) is broadly used all over the world as the only available disease-modifying treatment option. The aim of this experts' perspective is to address 7 important unmet needs for the further direction of AIT and to provide the readership with the authors' positions on these topics. An international group of experts in the field of AIT have formulated 7 important aspects for the future position of AIT, performed a current literature review, and proposed a consented position on these topics. The aspects discussed and consented by the authors include: (1) alternative routes of allergen application in AIT, (2) potential of recombinant vaccines, (3) the role of allergy diagnosis based on component-resolved diagnosis for AIT composition, (4) the impact of COVID-19 vaccination for further innovations in AIT, (5) potential of combining biologics to AIT, (6) future innovations in high-risk children/adolescents, and (7) the future regulatory position on AIT. Important unmet needs and topics for AIT have been addressed in this expert review. The authors' views and personal position on these 7 aspects have also been elaborated.

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.

Telemedicine beyond the pandemic: challenges in the pediatric immunology clinic.

INTRODUCTION: Telemedicine and electronic medical records (EMRs) have revolutionized healthcare in recent years, offering numerous benefits that improve the delivery of care and the overall patient outcomes. AREAS COVERED: Telemedicine allows providers to diagnose and treat patients remotely, often eliminating the need for face-to-face visits. Its benefits include improved access to care, convenience for patients, and reduced costs both for patients and providers. When used with remote patient monitoring and remote therapeutic monitoring, continuous care becomes possible. EMRs allow providers to store, access, and share patient information more efficiently than paper charts. The benefits of EMRs include improved patient safety, increased efficiency, and reduced costs. EXPERT OPINION: The combination of telemedicine with EMRs makes it possible to envision the advent of computer-assisted diagnosis (CAD). This technology uses artificial intelligence and machine learning algorithms to analyze medical information including images, clinical and physiologic data, test results and remotely obtained information to support healthcare providers in making accurate diagnoses. By providing providers with what is essentially a second opinion, CAD systems can help prevent misdiagnoses and improve the quality of care. Such systems are not meant to replace healthcare providers, but rather to support them in making more informed and accurate diagnoses.

The evolving landscape of immunotherapy for the treatment of allergic conditions.

Allergic conditions, such as asthma, chronic urticaria, atopic dermatitis (AD), and eosinophilic esophagitis, have long been treated with oral and topical steroids which resulted in negative off-target effects. However, newer biologic medications are increasingly being developed and approved for treatment of these conditions. These medications have a variety of mechanisms of action to target pathophysiology specific to these diseases. As biologics become more targeted, fewer off-target effects are seen improving tolerability for patients as well as expanded options for treatment of these conditions. This review discusses monoclonal antibody therapies (omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, tezepelumab, and tralokinumab) including their safety and use in asthma, chronic urticaria, AD, and eosinophilic esophagitis.

Hypersensitivity Pneumonitis: Updates in Evaluation, Management, and Ongoing Dilemmas.

Hypersensitivity pneumonitis (HP) is a heterogenous disease entity characterized by an aberrant immune response to inhalational antigens. Disease modification hinges on early antigen remediation with a goal to attenuate immune dysregulation. Disease severity and progression are mediated by an interface between degree, type and chronicity of exposure, genetic predisposition, and biochemical properties of the inducing agent. Guidelines have provided a standardized approach; however, decision-making remains with many clinical dilemmas. The delineation of fibrotic and nonfibrotic HP is crucial to identify the differences in clinical trajectories, and further clinical trials are needed to understand optimal therapeutic strategies.

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.

The Regulatory Environment of Telemedicine After COVID-19.

The COVID-19 pandemic has created many barriers to providing health care, yet it also has created new opportunities. Although telemedicine was a nascent means of health care delivery before COVID-19, it now is one of the principal means for doing so today, and it is likely to remain so. Whether this will happen may depend in part on continued relaxation of regulations that hampered it before the pandemic. Whereas enforcement of compliance with Health Information Portability and Accountability Act will most likely resume, platform operators and providers have had an opportunity to prepare for this. State licensure requirements may also resume; however, the regulations were in the process of becoming more liberal before COVID-19 so that process might continue. There is no reason to anticipate that payment for telemedicine services including check-ins, remote physiologic and therapeutic monitoring, and relaxation of location and service requirements will end. For these reasons, telemedicine therefore is likely to continue as an important part of medical practice.

Implementation of EMR-based standardized antibiotic desensitization protocols and its impact on providers.

Background: As desensitization protocols become more readily available and published, more institutions are implementing them and searching for ways to streamline the process. There have been no published studies to date on the effect that electronic medical record systems (EMR) have on the safety and efficiency of ß-lactam antibiotic desensitization. Objective: The purpose of this study was to evaluate the changes in workflow, efficiency, and medical errors after implementation of ß-lactam antibiotic desensitization. Methods: A collaborative effort between the Allergy/Immunology Division and the Pharmacy Department led to the creation and implementation of antibiotic desensitization order sets. Pre- and postimplementation of ß-lactam antibiotic surveys were sent to pharmacists and allergy/immunology fellows and attendings at a single-center tertiary care center. Results: There were only 26 valid respondents (12.3%) to both the pre- and postimplementation surveys. The percentage of respondents who thought that the time needed to prepare desensitization materials was < 4 hours increased from 23% to 77% (p < 0.001). The percentage of respondents who thought that the time needed to input electronic desensitization orders was < 1 hour increased from 19% to 54% (p = 0.002). The percentage of respondents who identified zero errors increased from 42% to 92% (p = 0.001). The perception of the overall desensitization process efficiency significantly increased (p < 0.001). Conclusion: Creation of standardized electronic ß-lactam antibiotic desensitization order sets significantly decreased the time taken to order and prepare materials and increased overall efficiency.

Comparison of management options for specific antibody deficiency.

Background: Specific antibody deficiency is a primary immunodeficiency characterized by normal immunoglobulins with an inadequate response to polysaccharide antigen vaccination. This disease can result in recurrent infections, the most common being sinopulmonary infections. Treatment options include clinical observation, prophylactic antibiotic therapy, and immunoglobulin supplementation therapy, each with limited clinical data about their efficacy. Objective: This study aimed to identify whether there was a statistically significant difference in the rate of infections for patients who were managed with clinical observation, prophylactic antibiotics, or immunoglobulin supplementation therapy. Methods: A retrospective chart review was conducted. Patients were eligible for the study if they had normal immunoglobulin levels, an inadequate antibody response to polysaccharide antigen-based vaccination, and no other known causes of immunodeficiency. Results: A total of 26 patients with specific antibody deficiency were identified. Eleven patients were managed with immunoglobulin supplementation, ten with clinical observation, and five with prophylactic antibiotic therapy. The frequency of antibiotic prescriptions was assessed for the first year after intervention. A statistically significant rate of decreased antibiotic prescriptions after intervention was found for patients treated with immunoglobulin supplementation (n = 11; p = 0.0004) and for patients on prophylactic antibiotics (n = 5; p = 0.01). There was no statistical difference in antibiotic prescriptions for those patients treated with immunoglobulin supplementation versus prophylactic antibiotics (p = 0.21). Conclusion: Prophylactic antibiotics seemed to be equally effective as immunoglobin supplementation therapy for the treatment of specific antibody deficiency. Further studies are needed in this area.

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.

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.

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.