Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases.

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Bypassing the build-up phase for oral immunotherapy in shrimp-allergic children.

Background: Oral immunotherapy is an effective treatment for food allergies; however, its use in clinical practice is limited by resources and lack of standardized protocols for foods other than peanut. Previous studies have suggested that shrimp has a higher threshold for reaction than other allergenic foods, suggesting it may be safe to directly administer maintenance doses of immunotherapy. Methods: Children aged 3-17 years who had 1) skin prick test ≥3 mm and/or specific IgE level ≥0.35 kU/L and convincing objective IgE-mediated reaction to shrimp, or 2) no ingestion history and specific IgE level ≥5 kU/L, underwent a low-dose oral food challenge to 300 mg shrimp protein, with the goal of continuing daily ingestion of the 300 mg maintenance dose as oral immunotherapy. Results: Between January 2020 and April 2023, 17 children completed the low-dose oral food challenge. Nine (53%) tolerated this amount with no reaction, and 8 (47%) had a mild reaction (isolated oral pruritis or redness on chin). Sixteen (94%) continued maintenance low-dose oral immunotherapy eating 300 mg shrimp protein daily. None of the patients developed anaphylaxis related to the immunotherapy. Conclusion: Our case series suggests that some shrimp allergic patients being considered for oral immunotherapy should be offered a low-dose oral food challenge, to potentially bypass the build-up phase of immunotherapy.

Safety and Effectiveness of Bypassing Oral Immunotherapy Buildup With an Initial Phase of Sublingual Immunotherapy for Higher-Risk Food Allergy.

BACKGROUND: Because of its favorable safety, sublingual immunotherapy (SLIT) for food allergy has been proposed as an alternative treatment for those in whom oral immunotherapy (OIT) is of higher risk-older children, adolescents, adults, and those with a history of severe reactions. Although safe, SLIT has been shown to be less effective than OIT. OBJECTIVE: To describe the safety of multifood SLIT in pediatric patients aged 4 to 18 years and the effectiveness of bypassing OIT buildup with an initial phase of SLIT. METHODS: Patients aged 4 to 18 years were offered (multi)food SLIT. Patients built up to 2 mg protein SLIT maintenance over the course of 3 to 5 visits under nurse supervision. After 1 to 2 years of daily SLIT maintenance, patients were offered a low-dose oral food challenge (OFC) (cumulative dose, 300 mg protein) with the goal of bypassing OIT buildup. RESULTS: Between summer 2020 and winter 2023, 188 patients were enrolled in SLIT (median age, 11 years). Four patients (2.10%) received epinephrine during buildup and went to the emergency department, but none experienced grade 4 (severe) reaction. A subset of 20 patients had 50 low-dose OFCs to 300 mg protein and 35 (70%) OFCs were successful, thereby bypassing OIT buildup. CONCLUSIONS: In combination with very favorable safety of SLIT, with no life-threatening reactions and few reactions requiring epinephrine, we propose that an initial phase of SLIT to bypass supervised OIT buildup be considered for children in whom OIT is considered to be of higher risk.

Safety and effectiveness of the Canadian food ladders for children with IgE-mediated food allergies to cow's milk and/or egg.

BACKGROUND: Food ladders are tools designed to facilitate home-based dietary advancement in children with food allergies through stepwise exposures to increasingly allergenic forms of milk and egg. Several studies have now documented safety and efficacy of food ladders. In 2021, we published a Canadian adaptation of the previously existing milk and egg ladders originating in Europe using foods more readily available/consumed in Canada. Our study adds to the growing body of evidence supporting food ladder use and provides safety and effectiveness data for our Canadian adaptation of the milk and egg ladders. METHODS: Surveys were distributed to families of children using the Canadian Milk Ladder and/or the Canadian Egg Ladder at baseline, with follow up surveys at 3 months, 6 months, and 12 months. Data were analyzed using REDCap and descriptive and inferential statistics are presented. RESULTS: One hundred and nine participants were started on milk/egg ladders between September 2020 and June 2022. 53 participants responded to follow up surveys. Only 2 of 53 (3.8%) participants reported receiving epinephrine during the study. Severe grade 4 reactions (defined according to the modified World Allergy Organization grading system) were not reported by any participants. Minor cutaneous adverse reactions were common, with about 71% (n = 10/14) of respondents reporting cutaneous adverse reactions by 1 year of food ladder use. An increasing proportion of participants could tolerate most foods from steps 2-4 foods after 3, 6, and 12 months of the food ladder compared to baseline. CONCLUSION: The Canadian food ladders are safe tools for children with cow's milk and/or egg allergies, and participants tolerated a larger range of foods with food ladder use compared to baseline.

Risk factors associated with safety of preschool peanut oral immunotherapy.

Background: An understanding of how patient characteristics such as age, baseline peanut-specific IgE, and atopic comorbidities may influence potential safety outcomes during peanut oral immunotherapy (P-OIT) could aid in shared decision making between clinicians and patient families. Objective: This study explored the relationship between baseline patient characteristics and reactions during P-OIT using a large sample size to better understand potential risk factors influencing P-OIT safety. Methods: Data were obtained from the Food Allergy Immunotherapy (FAIT) registry, which collects real-world OIT data from community and academic allergy clinics across Canada. Multivariable logistic regression modeling was performed to examine the relationship between baseline patient characteristics and reactions during P-OIT. Multiple imputation was applied to reduce potential bias caused by missingness and to maximize the use of available information to preserve statistical power. Results: Between April 2017 and June 2021, a total of 653 eligible patients initiated P-OIT. Multivariable regression analysis showed pre-OIT grade 2+ initial reaction (odds ratio [OR] = 1.33, 95% confidence interval [CI] 1.10, 1.61), allergic rhinitis (OR = 1.60, 95% CI 1.08, 2.38), older age (OR = 1.01, 95% CI 1.00, 1.02), and higher baseline peanut-specific IgE (OR = 1.02, 95% CI 1.02, 1.03) were associated with grade 2+ reaction during P-OIT after adjusting for potential risk factors. Conclusion: Our study identified several clinically important risk factors for grade 2+ reactions during P-OIT: pre-OIT grade 2+ initial reaction, allergic rhinitis, older age, and higher baseline peanut-specific IgE. These results highlight the need for individualized risk stratification for OIT.

An online survey of clinical practice and confidence in diagnosing acquired apraxia of speech in Cantonese speakers.

PURPOSE: The assessment and diagnosis of apraxia of speech (AOS) have been well studied in the English context, yet there is limited understanding of the clinical practice in speakers of other languages, like Cantonese. This study aimed to obtain information about the clinical practice of assessment methods and diagnostic criteria used, and confidence in diagnosing, AOS in Cantonese speakers. METHOD: An online survey constructed with Google Forms was completed by 27 speech-language pathologists (SLPs) in Hong Kong. The questionnaire comprised 12 questions covering (a) demographic information, (b) experience working with speakers with AOS, (c) confidence in making AOS diagnosis in Cantonese speakers, (d) assessment tasks or methods used for assessing AOS in Cantonese speakers, (e) clinical features used for diagnostic purposes, and (f) assessment tasks used to determine the presence of clinical features for diagnostic purposes. RESULT: All respondents (100%) made AOS diagnoses based on the observed clinical features, while no respondents made diagnoses using only standardised tests or quantitative measures. Six clinical features were commonly used by most of the respondents: articulatory groping (100%), inconsistent articulatory errors (100%), length effects (85.2%), difficulty initiating speech (81.5%), automaticity effects (81.5%), and sound distortions (77.8%). More than half of the respondents collected connected speech samples (64%), and conducted diadochokinesis (64%) and repetition tasks (64%). The average confidence level of the respondents for making AOS diagnoses was fair (3.63/5). CONCLUSION: The SLPs in Hong Kong make AOS diagnoses based on the observed clinical features that have been reported in the English literature. Although some of the clinical features have been updated as non-discriminatory for AOS, they are still being used for AOS diagnosis in Cantonese speakers. Tendencies were observed with respect to the assessment tasks selected. The fair diagnostic confidence level suggests a need for future investigations of AOS in Cantonese speakers and the development of assessment tools.

Using the canadian egg ladder in children with food protein-induced enterocolitis syndrome: a case series.

BACKGROUND: Current management of food protein-induced enterocolitis syndrome (FPIES) involves strict avoidance of the offending food for 12-18 months, followed by oral food challenge (OFC) under physician supervision. OFCs are resource-intensive and there is a lack of a universal standardized protocol for FPIES. Prolonged avoidance may increase the risk of IgE-mediated allergy, particularly in atopic patients. Food ladders have shown success in promoting accelerated tolerance in patients with IgE-mediated allergy. Our case series evaluated the safety of use of the Canadian Egg Ladder in patients with mild-to-moderate FPIES to egg. METHODS: From May 2020 to November 2021, patients with mild-to-moderate FPIES to egg, defined as no history of lethargy or intravenous fluid administration, were started on the Canadian Egg Ladder. Instructions for advancing up the ladder were identical to using the Canadian Egg Ladder in patients with IgE-mediated allergy. Patients were followed every 3-6 months, at which time information was collected regarding progression up the ladder, symptoms while on treatment and interventions required. Treating allergists completed a survey to capture baseline demographic characteristics and prior tolerance to egg. Descriptive statistics were analyzed using MS Excel. RESULTS: Twenty-one patients with mild-to-moderate FPIES were started on the Canadian Egg Ladder. Median age at initiation of the ladder was 10 months (IQR, 9-11). Nineteen (90.5%) patients completed the ladder, tolerating a serving size amount of cooked egg, over a median duration of 7 month (IQR, 4-9 months). Four patients (19.0%) had mild symptoms including vomiting (9.5%), pallor (9.5%), belching (4.8%), irritability (4.8%) and small spit up (4.8%). In three of the four patients, symptoms were the result of accidental exposure to a higher step of the ladder. There were no reports of lethargy. No patients required health care presentation or intravenous fluid administration. No patients discontinued the ladder. CONCLUSIONS: The Canadian Egg Ladder can safely guide the dietary advancement of egg-containing foods in patients with mild-to-moderate FPIES to egg, without the need for prolonged avoidance and resource-intensive OFCs.

High prevalence of de novo metabolic dysfunction-associated fatty liver disease after liver transplantation and the role of controlled attenuation parameter.

BACKGROUND & AIMS: Although non-alcoholic fatty liver disease (NAFLD) remains an uncommon indication for liver transplantation (LT) in the Chinese, the prevalence of NAFLD is increasing. We aimed to determine the prevalence of de novo steatosis and metabolic dysfunction-associated fatty liver disease (MAFLD) after LT. METHODS: Transient elastography assessment for liver stiffness and controlled attenuation parameter (CAP) were performed after LT in 549 patients at median time of 77 months from LT. CAP was compared with implant liver biopsy, and also validated in 42 patients with post-LT liver biopsy. Longitudinal history including diabetes mellitus (DM), dyslipidemia, hypertension, and immunosuppressive regimen were recorded. RESULTS: The optimal cut-off level of CAP for diagnosing at least mild (≥ S1) and moderate-to-severe steatosis (≥ S2/3) was 266 and 293 dB/m respectively, with AUROC of 0.740 and 0.954 respectively. Using this newly derived cut-off, 28.9% patients have de novo NAFLD, of which 95.6% fulfilled the criteria for MAFLD. After multivariate analysis, BMI (HR 1.34), DM (HR 2.01), hypertension (HR 2.03), HDL-cholesterol (HR 0.25), LDL-cholesterol (HR 1.5) and cryptogenic cirrhosis (HR 4.85) were associated with the development of S2/3 graft steatosis. de novo NAFLD was associated with higher incidence of new-onset hypertension (p < 0.001), graft dysfunction (defined as ALT > 40 U/L; p = 0.008), but not associated with graft fibrosis (defined as liver stiffness > 12 kPa; p = 0.761). CONCLUSION: Although NAFLD remains an uncommon primary liver disease indication for LT in Chinese patients, post-transplant de novo graft steatosis is common and the majority is classified as MAFLD. Development of graft steatosis is not associated with an increase in graft fibrosis but was associated with worse metabolic control and graft dysfunction. Routine CAP measurement to detect de novo graft steatosis should be considered after LT regardless of the primary indication of LT.

Post-transplant inflammatory cytokine signature adds value for predicting tumor recurrence after liver transplantation for hepatocellular carcinoma.

BACKGROUND: Cytokines are key regulators of post-transplant inflammation responses which reconstitute post-transplant hepatic and systemic environments to influence the likelihood of tumor relapse. This study investigated the prognostic value of post-transplant cytokines on tumor recurrence after liver transplantation (LT) for hepatocellular carcinoma (HCC). METHODS: A retrospective analysis was conducted in prospectively collected 150 adult HCC patients who received liver transplantation from 1997 to 2015. The post-transplant 41 inflammatory cytokines were quantified by multiplexing analysis and determined their prognostic value for predicting post-LT tumor recurrence by receiver operative characteristic analysis. A prediction model for post-LT tumor recurrence was generated by the logistic regression and internally validated Bootstrapping and compared with external prediction models. RESULTS: Post-transplant circulating CCL11, IFNα2, and IL17A cytokines were identified to be significant predictors of post-LT tumor recurrence and survival. A prediction score composed of the post-transplant 3-cytokine (P3C) signature, UCSF criteria, and pre-LT AFP was established. The P3C-UCSF-AFP score significantly predicted post-LT tumor recurrence and poor survival both in deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT). The P3C-UCSF-AFP score was validated to significantly predict post-LT 2-year and 5-year tumor recurrence, outperforming the RETREAT score, French AFP model, up-to-seven, UCSF criteria, and Milan criteria. Importantly, the P3C-UCSF-AFP score could cost-effectively stratify high-risk recipients subjected to a refinement of post-recurrence survival. CONCLUSION: The integrated P3C-UCSF-AFP score not only compensated for the pre-LT unpredictability and predicted post-LT tumor recurrence accurately, but also guided the clinical refinements of post-LT surveillance and therapeutic strategies in transplant oncology.

Novel Benchmark for Adult-to-Adult Living-donor Liver Transplantation: Integrating Eastern and Western Experiences.

OBJECTIVE: To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). BACKGROUND: LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. METHODS: Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016-2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians. RESULTS: Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI ® ) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI ® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI ® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). CONCLUSIONS: Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide.

Assessment of multiple-opinion referrals and consults at the BC Children's Hospital Allergy Clinic.

BACKGROUND: Allergic disease is on the rise. Waitlists for specialists are long, and many referred patients have already received prior allergic assessment, either by a certified Allergist, Primary Care Provider, or other Specialist. It is important to understand the prevalence and motivating factors for multiple-opinion referrals, to deliver timely assessment for patients with allergic disease. METHODS: A retrospective chart review of demographic information, number of previous consultations, and motivation for new consults and multiple-opinion referrals, of pediatric patients aged 8 months-17 years to BC Children's Hospital Allergy Clinic from September 1, 2016-August 31, 2017, was performed. Referral data including reason for referral or multiple-opinion, primary allergic concerns, and others, from referral forms and consult notes were accessed through local Electronic Medical Records and subsequently analyzed for trends in categorical variables to assess the rationale for and impact of multiple-opinion referrals to our clinic. RESULTS: Of 1029 new referrals received, 210 (20.4%) were multiple-opinion referrals. Food allergy was the predominant allergic concern prompting further opinion (75.7%). The main rationale for seeking further opinions was wanting an assessment by a certified allergist in cases where prior consultation was performed by non-allergist specialist, primary care provider, or alternative health care provider. Of second-opinion referrals generated, 70 (33.3%) initial consultations were performed by an Allergist, whereas 140 (66.7%) were performed by a non-allergist. CONCLUSIONS: Many new consults at the BCCH Allergy Clinic are multiple-opinion assessments, contributing to long waitlists. Advocacy at the systems level through standardized referral guidelines, centralized triaging systems, and stronger support for Primary Care Providers is needed to provide better access in Canada for children needing a specialized Allergist. Trial registration UBC/BCCH Research Ethics Board.

Penicillin de-labelling in vancouver, British Columbia, Canada: comparison of approaches, outcomes and future directions.

BACKGROUND: Inaccurate penicillin allergy labels lead to inappropriate antibiotic prescriptions and harmful patient consequences. System-wide efforts are needed to remove incorrect penicillin allergy labels, but more health services research is required on how to best deliver these services. METHODS: Data was extracted from five hospitals in Vancouver, British Columbia, Canada from October 2018-May 2022. The primary outcomes of this study were to outline de-labelling protocol designs, identify the roles of various healthcare professionals in de-labelling protocols and identify rates of de-labelling penicillin allergies and associated adverse events at various institutions. Our secondary outcome was to describe de-labelling rates for special populations, including pediatric, obstetric and immunocompromised subpopulations. To achieve these outcomes, participating institutions provided their de-labelling protocol designs and data on program participants. Protocols were then compared to find common themes and differences. Furthermore, adverse events were reviewed and percentages of patients de-labelled at each institution and in total were calculated. RESULTS: Protocols demonstrated a high level of variability, including different methods of participant identification, risk-stratification and roles of providers. All protocols used oral and direct oral challenges, heavily involved pharmacists and had physician oversight. Despite the differences, of the 711 patients enrolled in all programs, 697 (98.0%) were de-labelled. There were 9 adverse events (1.3%) with oral challenges with mainly minor symptoms. CONCLUSIONS: Our data demonstrates that de-labelling programs effectively and safely remove penicillin allergy labels, including pediatric, obstetric and immunocompromised patients. Consistent with current literature, most patients with a penicillin allergy label are not allergic. De-labelling programs could benefit from increasing clinician engagement by increasing accessibility of resources to providers, including guidance for de-labelling of special populations.

Challenges, Concerns, and Experiences of Community-Dwelling Older Women with Chronic Low Back Pain-A Qualitative Study in Hong Kong, China.

BACKGROUND AND OBJECTIVES: Although chronic low back pain (CLBP) is known to negatively affect multiple aspects of the lives of older people, prior qualitative studies mainly focused on the lived experiences of older people with CLBP in Western countries. Given cultural and contextual differences and poor understanding of CLBP in older women with CLBP, it is important to better understand the concerns and lived experiences of Chinese older women with CLBP. The current study aimed to investigate the experiences, challenges, concerns, and coping strategies of older women with CLBP in Hong Kong. RESEARCH DESIGN AND METHODS: A total of 15 community-dwelling older women with CLBP aged ≥60 years were recruited from a physiotherapy clinic or a community center for semi-structured interviews. The interviews were audio recorded and transcribed 'verbatim'. The transcription was imported to NVivo 12 software. Thematic analysis was conducted using Braun and Clarke's method. RESULTS: Five themes were identified: (1) physical impacts of CLBP on daily life; (2) psychological influences of CLBP; (3) management of CLBP; (4) family support; and (5) social activities and support. DISCUSSION AND IMPLICATIONS: Negative physical and psychosocial impacts of CLBP were common among older women, and they adopted diverse pain management strategies, although some of their treatment options were influenced by the Chinese culture. Misbeliefs and responses of family and friends also affected their management strategies. Elderly community centers are a significant source of social support for older women with CLBP, making it an ideal platform for establishing self-help groups to facilitate their self-management of CLBP.

Real-World Safety Analysis of Preschool Tree Nut Oral Immunotherapy.

BACKGROUND: Our group previously described preschool peanut oral immunotherapy (OIT) in a real-world, multicenter setting, suggesting that this therapy is safe for most preschoolers. OBJECTIVE: To examine the safety and tolerability of tree nut (TN) OIT in preschoolers in the real world. METHODS: As part of a Canada-wide quality improvement project, TN-OIT (cashew/pistachio, walnut/pecan, hazelnut, almond, and macadamia nut) was performed in preschoolers who had (1) a skin prick test wheal diameter greater than or equal to 3 mm or a specific IgE level greater than or equal to 0.35 kU/L and a convincing objective IgE-mediated reaction or (2) no ingestion history and a specific IgE level greater than or equal to 5 kU/L. Dose escalations were performed every 2 to 4 weeks till a maintenance dose of 300 mg of TN protein was reached. Symptoms were recorded and classified using the modified World Allergy Organization Subcutaneous Immunotherapy Reaction Grading System (1, mildest; 5, fatal). RESULTS: Of the 92 patients who started TN-OIT from 2018 to 2021, 79 (85.9%) underwent single-food TN-OIT and 13 (14.1%) underwent multifood TN-OIT to 2 (10.8%) or 3 (3.3%) TNs. Eighty-nine (96.7%) patients reached maintenance, and 4 (4.3%) dropped out. Sixty-five (70.7%) patients experienced reactions during buildup: 35 (38.0%) grade 1 reactions, 30 (32.6%) grade 2 reactions, no grade 3 or 4 reactions, and 2 (2.17%) received epinephrine. CONCLUSIONS: Preschool TN-OIT in a real-world, multicenter setting appears safe and tolerable, with results comparable with our previously reported peanut OIT findings.

Virtually supported penicillin allergy de-labelling during COVID-19.

BACKGROUND: Penicillin allergy is a commonly listed medication allergy despite rare overall incidence. Many patients erroneously have this label, which has personal, health, and societal costs. Penicillin allergy delabelling requires an oral challenge, which can be a rate limiting step in the de-labeling process; this is even more relevant with the reduction of in-person visits during the COVID-19 pandemic. OBJECTIVE: To identify the utility and broader applicability of using a virtually supported platform, initially adopted given COVID-19 restrictions, to expedite penicillin oral provocation challenge and penicillin de-labeling in patients at low to moderate risk of immediate hypersensitivity reaction and based on shared decision making. METHODS: Patients in Vancouver catchment area were referred for penicillin allergy and virtually assessed by the consulting allergist between July 2020 and April 2021. Those deemed appropriate for oral challenge based on the allergist consultant were offered the option of a virtual oral provocation challenge to oral amoxicillin in a subsequent virtual visit. Patients who agreed and were consented underwent a virtually supervised oral amoxicillin challenge during the second virtual visit. Findings are summarized in this case series. RESULTS: Twenty-three patients, both adult and pediatric, ranging from no to significant co-morbidities were consented and underwent the virtual challenge. One hundred percent of patients were successful with no reaction after an hour post virtual oral provocation challenge with amoxicillin. CONCLUSION: Virtual medicine is likely to remain in the allergist's practice. Virtually supported penicillin allergy delabelling, based on shared decision making and risk stratification, presents another pathway for penicillin allergy delabelling.

Hyaluronidase Availability in Emergency Rooms: A Statewide Analysis.

Objective: Authors sought to determine the immediate availability of hyaluronidase (HYAL) among emergency rooms (ERs) in California. Background: Hyaluronic acid (HA) fillers are regarded as a safe procedure; however, major ischemic complications do exist, notably blindness and tissue necrosis. The successful management of these vascular events relies on an injector's immediate HYAL, the enzymatic reversal agent for HA. Unfortunately, many barriers exist for injector sites to stock HYAL. As a result, ERs serve as unofficial safety nets in cases when providers encounter an ischemic complication and do not have HYAL in supply. Materials and Methods: Telephone survey inquiring about HYAL availability in all California ERs. Results: This study included 330 California ERs and achieved an 89.7% response rate (n = 296). 45.6% of the surveyed ERs did not have immediate access to HYAL. HYAL availability was positively associated with level I-III adult trauma center status, pediatric trauma center status, children's hospital status, higher bed counts, and regional geography (p < 0.05, all). Conclusions: HYAL availability is unreliable among Californian ERs, posing a potential risk to patient safety.

Robot dramas may improve joint attention of Chinese-speaking low-functioning children with autism: stepped wedge trials.

INTRODUCTION: Children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention. Previous research has found that these children are interested in engaging with social robots. PURPOSE: In the present study, we designed a robot drama intervention for promoting responses to joint attention abilities (RJA) of children with low-functioning autism (IQs < 70). MATERIALS AND METHODS: Using a stepped wedge design, Chinese-speaking children aged six to eight were randomly assigned to three tiers (N = 18). Children of all three tiers had comparable autism severity, language and cognitive function, and joint attention abilities. Tier 1 first received intervention, followed by Tiers 2 and 3. They watched six dramas in which social robots demonstrated RJA behaviours. RESULTS: The RJA of children of all tiers improved after intervention and such improvement was maintained over time. Despite initiation of joint attention (IJA) not being explicitly taught, IJA of all children was found to improve after intervention. CONCLUSIONS: It was, therefore, concluded that a robot drama could enhance the joint attention of children with low-functioning ASD.Implications for rehabilitationIn comparison to typically developing children, children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention.Robot-based drama intervention program was developed to promote responses to joint attention (RJA) abilities of children with low-functioning autism (IQs < 70).Modelling RJA in robot dramas can promote RJA abilities in these children.An improvement in RJA also yielded an increase in the initiation of joint attention (IJA) abilities.Children with low-functioning autism might be able to extract the initiation of joint attention skills from the drama, even though these behaviours were not explicitly taught.

Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood.

BACKGROUND: Up to half of all children who have a tracheostomy will develop a persistent tracheo-cutaneous fistula (TCF) after decannulation. Surgical closure of the TCF is technically easy but post-operative complications can be immediate and life-threatening. These include air leak from the tracheal repair leading to massive surgical emphysema or pneumothorax. We reviewed our experience of TCF closure to try to identify potential risk factors for complications. METHOD: Retrospective case record review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following development of a persistent TCF after decannulation of a tracheostomy. RESULTS: We identified 67 children. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%). Life-threatening air leak occurred in the immediate post-operative period in 2 children (3%). Respiratory distress occurred in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. DISCUSSION: Complications for TCF closure are unfortunately common and it is unclear from the available evidence how best to prevent them. Further research is required.

How We Manage Gastrointestinal Symptoms During Oral Immunotherapy Through a Shared Decision-Making Process-A Practical Guide for the Community Practitioner.

Allergists addressing gastrointestinal (GI) symptoms during oral immunotherapy (OIT) may be biased toward diagnoses related to OIT; however, non-OIT causes may occur. Although there is currently a lack of robust data for evidence-based treatment recommendations, we provide 3 real-world illustrative cases along with a proposed management algorithm for GI symptoms encountered during OIT. This algorithm was developed because of a significant clinical need, given the number of new-to-OIT providers that include practicing allergists, trainees transitioning into practice, and allied health care providers who manage GI symptoms in OIT patients. We developed the algorithm based on the opinions of community and academic allergy clinics across Canada with significant clinical experience offering infant, preschool, and school-aged OIT patients, with gastroenterologist input. Further research is needed to fill the knowledge gaps in the management of GI symptoms during OIT before formal recommendations can be suggested.

Genetic potential for changes in breeding systems: Predicted and observed trait changes during artificial selection for male and female allocation in a gynodioecious species.

PREMISE: Evolution of separate sexes from hermaphroditism often proceeds through gynodioecy, but genetic constraints on this process are poorly understood. Genetic (co-)variances and between-sex genetic correlations were used to predict evolutionary responses of multiple reproductive traits in a sexually dimorphic gynodioecious species, and predictions were compared with observed responses to artificial selection. METHODS: Schiedea (Caryophyllaceae) is an endemic Hawaiian lineage with hermaphroditic, gynodioecious, subdioecious, and dioecious species. We measured genetic parameters of Schiedea salicaria and used them to predict evolutionary responses of 18 traits in hermaphrodites and females in response to artificial selection for increased male (stamen) biomass in hermaphrodites or increased female (carpel, capsule) biomass in females. Observed responses over two generations were compared with predictions in replicate lines of treatments and controls. RESULTS: In only two generations, both stamen biomass in hermaphrodites and female biomass in females responded markedly to direct selection, supporting a key assumption of models for evolution of dioecy. Other biomass traits, pollen and ovule numbers, and inflorescence characters important in wind pollination evolved indirectly in response to selection on sex allocation. Responses generally followed predictions from multivariate selection models, with some responses unexpectedly large due to increased genetic correlations as selection proceeded. CONCLUSIONS: Results illustrate the power of artificial selection and utility of multivariate selection models incorporating sex differences. They further indicate that pollen and ovule numbers and inflorescence architecture could evolve in response to selection on biomass allocation to male versus female function, producing complex changes in plant phenotype as separate sexes evolve.