Clinical Predictors and Outcomes of Oral Food Challenges Illustrate Differences Among Individual Tree Nuts.

BACKGROUND: Although allergy to tree nuts is often considered a single entity, there is heterogeneity in patient reactivity and immune response to different tree nuts. OBJECTIVE: We sought to characterize tree nut oral food challenges (OFCs) in a pediatric population performed at a single center over a 12-year period and determine differences in OFC outcome to different tree nuts. METHODS: A retrospective chart review was conducted in patients (0-20 years) who completed an unblinded OFC to any tree nut from 2007 to 2019 at Lurie Chlildren's Hospital of Chicago. Differences among almond, cashew, hazelnut, and walnut challenges were compared, and probability curves were used to estimate positive predictive values (PPVs) of specific IgE at OFC. RESULTS: A total of 531 tree nut OFCs were included. The mean age at OFC was 7.77 years (standard deviation, 4.33). Overall, 74.0% of children passed clinically indicated OFCs. Of the 4 most commonly challenged tree nuts, almost all patients passed OFC to almond (97.3%) and hazelnut (87.9%). Pass rates were lower for cashew (65.3%) and walnut (57.0%), P < .0001. The odds of failure were 0.83 times lower for patients who were avoiding without a previous reaction compared with those who had previously reacted (P = .0025). CONCLUSIONS: The majority of patients pass low-risk almond and hazelnut OFCs. PPVs at the 50th percentile for walnut (2.84 kU/L) and cashew (3.35 kU/L) were lower than those previous studies have suggested.

Use of alcohol biomarkers to identify alcohol misuse in organ donors.

Phosphatidylethanol is a direct alcohol biomarker for identifying alcohol misuse. It carries several advantages over other alcohol biomarkers, including a detection half-life of several weeks and little confounding by patient characteristics or organ dysfunction. The aim of this study is to derive an optimal phosphatidylethanol cut point to identify organ donors with alcohol misuse, and to assess the impact of alcohol misuse on organ allocation. Discrimination of phosphatidylethanol was evaluated using the area under the ROC curve from a mixed effects logistic regression model. Phosphatidylethanol had an area under the ROC curve of 0.89 (95% CI 0.80-0.98). A phosphatidylethanol cut point of ≥84 ng/mL provided optimal discrimination for the identification of alcohol misuse with a sensitivity of 75% (95% CI 52.9%-89.4%) and a specificity of 97% (95% CI 91%-99%), a positive predictive value of 82% (95% CI 59%-94%), and a negative predictive value of 95% (95% CI 89%-98%). In deceased organ donors who had been critically ill, phosphatidylethanol had good test characteristics to discriminate alcohol misuse. Other alcohol biomarkers performed poorly in deceased organ donors. Liver allocation was decreased in donors with alcohol misuse by proxy history, but not in those with phosphatidylethanol >84 ng/mL, revealing possible information bias in liver allocation.

Recent alcohol use prolongs hospital length of stay following lung transplant.

Little is known about the alcohol habits of people with advanced lung disease. Following lung transplantation, patients are asked to abstain from or minimize alcohol use. The aim of this investigation was to assess alcohol use in a cohort of patients with advanced lung disease undergoing evaluation for lung transplant. This is a prospective observational investigation comparing patient self-report of alcohol use with their responses on the Alcohol Use Disorders Identification Test (AUDIT), and alcohol biomarkers collected at the time of transplant. There were 86 included in the cohort, 34% currently using alcohol, 13% had AUDIT scores >3, and 10% had positive results for alcohol biomarkers at the time of transplantation. Patients with evidence of recent alcohol use prior to lung transplant surgery had a 1.5-fold increase in hospital length of stay following lung transplant (P = .028), spent 3 times as long on mechanical ventilation after transplant, and required intensive care unit monitoring nearly 3 times longer than those without recent alcohol use (P = .008). There were no differences in primary graft dysfunction, although several patients with recent alcohol use had post-transplant atrial arrhythmias, acute kidney injury, and acute cellular rejection. Abstaining from alcohol use may optimize outcomes following lung transplant.

Cut-Point Levels of Phosphatidylethanol to Identify Alcohol Misuse in a Mixed Cohort Including Critically Ill Patients.

BACKGROUND: Although alcohol misuse is associated with deleterious outcomes in critically ill patients, its detection by either self-report or examination of biomarkers is difficult to obtain consistently. Phosphatidylethanol (PEth) is a direct alcohol biomarker that can characterize alcohol consumption patterns; however, its diagnostic accuracy in identifying misuse in critically ill patients is unknown. METHODS: PEth values were obtained in a mixed cohort comprising 122 individuals from medical and burn intensive care units (n = 33), alcohol detoxification unit (n = 51), and healthy volunteers (n = 38). Any alcohol misuse and severe misuse were referenced by Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C scores separately. Mixed-effects logistic regression analysis was performed, and the discrimination of PEth was evaluated using the area under the receiver-operating characteristic (ROC) curve. RESULTS: The area under the ROC curve for PEth was 0.927 (95% CI: 0.877, 0.977) for any misuse and 0.906 (95% CI: 0.850, 0.962) for severe misuse defined by AUDIT. By AUDIT-C, the area under the ROC curves was 0.948 (95% CI: 0.910, 0.956) for any misuse and 0.913 (95% CI: 0.856, 0.971) for severe misuse. The PEth cut-points of ≥250 and ≥400 ng/ml provided optimal discrimination for any misuse and severe misuse, respectively. The positive predictive value for ≥250 ng/ml was 88.7% (95% CI: 77.5, 95.0), and the negative predictive value was 86.7% (95% CI: 74.9, 93.7). PEth ≥ 400 ng/ml achieved similar values, and similar results were shown for AUDIT-C. In a subgroup analysis of critically ill patients only, test characteristics were similar to the mixed cohort. CONCLUSIONS: PEth is a strong predictor and has good discrimination for any and severe alcohol misuse in a mixed cohort that includes critically ill patients. Cut-points at 250 ng/ml for any, and 400 ng/ml for severe, are favorable. External validation will be required to establish these cut-points in critically ill patients.