Allergy and Clinical Immunology

Identifying Barriers to Implementation of Emergency Epinephrine Bills: The Texas Experience Publication date: Available online 3 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Chih-Yin Yeh, Anita Wheeler, Louise Bethea, J. Andrew Bird, Jannifer Fulbright, Theodore Freeman, Ericka Gonzalez-Reyes, Douglas Jeffrey, Karen Schwind, Wesley Stafford, Pooja Varshney, Crystal Beard, Carla M. Davis

Subcutaneous Immunotherapy Induced Local Skin Necrosis Publication date: Available online 2 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): David Lawrence Brauer, Katharine Woessner, Ronald Simon, Brian Modena, Andrew White

Reply Publication date: Available online 2 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): T. Ted Song, Phil Lieberman

Maculopapular Cutaneous Mastocytosis in a Diverse Population Publication date: Available online 2 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Arnold S. Kirshenbaum, Hanna Abuhay, Hyejeong Bolan, Dean D. Metcalfe, Melody C. Carter

Tissue compression and epinephrine deposition Publication date: Available online 2 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Sten Dreborg, Harold Kim

Cost-utility of routine testing in chronic urticaria/angioedema: A cohort study Publication date: Available online 1 May 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Carrillo-Martin Ismael, Matthew G. Dudgeon, Chamorro-Pareja Natalia, Daniela A. Haehn, Maritza G. Rivera-Valenzuela, Aaron C. Spaulding, Michael G. Heckman, Nancy N. Diehl, Joan M. Irizarry-Alvarado, Haytham Helmi, Alexei Gonzalez-Estrada Abstract Background Chronic urticaria/angioedema (CUA) guidelines recommend limiting tests to diagnose and assess prognosis, activity and severity. Routine testing in CUA might substantially increase cost of disease without benefiting outcome. Objective To evaluate the utility of tests in CUA and how they influence the cost of disease Methods We reviewed 725 Electronic Medical Records (EMR) of patients who were evaluated for CUA between 2010 and 2018 at a tertiary care center. The sample was gathered through the search of International Classification of Diseases 9th and 10th revisions (ICD-9 and ICD-10) codes pertaining to CUA. Analyses were made to evaluate changes in outcome for patients on who at least one test was performed to evaluate CUA, the costs generated by these tests, and the tendencies to order specific tests from 2010 through 2018. Results Out of 725 patients (age median 47, women 73.1%), 543 (74.8%) had at least one test performed. Tests had an elevated percentage of normal results (>90%). Five patients (0.9%) had a change in outcome and 8 patients were given a different diagnosis (0.1% each). Evaluation, management, and tests accounted for most of the costs. Costs remain similar between 2010-2014 (mean $569) and 2015-2018 (mean $569). Conclusion In CUA, tests rarely uncover underlying conditions or lead to changes in management and outcome, but they substantially increase the costs generated by the disease. Adherence to current recommendations to limit testing might help reducing the financial burden of CUA and improve delivery of care.

Epidemiology of Anaphylaxis in Critically-Ill Children in the United States and Canada Publication date: Available online 30 April 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Nicole B. Ramsey, Danielle Guffey, Katherine Anagnostou, Nana E. Coleman, Carla M. Davis Abstract Background Anaphylaxis is a rapid-onset, multi-system and potentially fatal hypersensitivity reaction with varied reports of prevalence, incidence and mortality. There are limited cases reported of severe and/or fatal pediatric anaphylaxis. Objective This study describes the largest cohort of intensive care unit (ICU) pediatric anaphylaxis admissions with a comprehensive analysis of identified triggers, clinical and demographic information, and probability of death. Methods We describe the epidemiology of pediatric anaphylaxis admissions to North American pediatric intensive care units (PICUs) that were prospectively enrolled in the Virtual Pediatric Systems (VPS) database from 2010-2015. One-hundred-and-thirty-one pediatric intensive care units (PICUs) in North America (United States and Canada) were queried for anaphylaxis ICD-9 or ICD-10 codes from the VPS database from 2010-2015 in the United States (US) and Canada. One-thousand-nine-hundred-eighty nine patients under 18 years were identified out of 604,279 total number of patients admitted to a PICU in the database during this time frame. Results The primary outcome was mortality, which was compared with patient and admission data using Fisher's exact test. Secondary outcomes (intubation, length of stay, mortality risk scores, systolic blood pressure, and pupillary reflex) were analyzed using the Kruskal Wallis test or Wilcoxon rank sum tests, as appropriate. One-thousand-nine-hundred and eighty-nine patients with an anaphylaxis ICD code were identified in the database. One percent of patients died due to critical anaphylaxis. Identified triggers for fatal cases were peanuts, milk and blood products. Peanuts were the most common trigger. Children were mostly male when under thirteen years, and mostly female when thirteen years and older. Average length of stay was two days. There was a higher proportion of Asian patients under two years or when the trigger was food. Conclusions This is the largest study to describe pediatric critical anaphylaxis cases in North America and identifies food as the most common trigger. Death occurs in 1% of cases with intubation occurring most commonly in the first hour. The risk for ICU admission in children underscores the serious nature of anaphylaxis in this population.

Identifying an At-Risk Population for Poor Asthma Outcomes: Data from the American Lung Association Asthma Clinical Trials Registry Publication date: Available online 28 April 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Sonali Bose, Robert J. Henderson, Linda Rogers, Thomas Casale, Gwen Skloot, Xavier Soler, Robert A. Wise, Loretta G. Que

Asthma-COPD overlap - a discordance between patient populations defined by different diagnostic criteria Publication date: Available online 26 April 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Adam Barczyk, Marta Maskey-Warzęchowska, Katarzyna Górska, Marek Barczyk, Krzysztof Kuziemski, Paweł Śliwiński, Halina Batura-Gabryel, Robert Mróz, Aleksander Kania, Andrzej Obojski, Maciej Tażbirek, Natalia Celejewska-Wójcik, Katarzyna Guziejko, Beata Brajer-Luftmann, Damian Korzybski, Iwona Damps-Kostańska, Rafał Krenke ABSTRACT Background The concordance between asthma-chronic obstructive pulmonary disease overlap (ACO) defined according to GINA/GOLD and other diagnostic criteria is unknown. Objective To assess the concordance between different ACO definitions and to estimate the definition-based ACO prevalence and characteristics. Methods A prospective, real life study based on a 32-item dataset was performed in a mixed population of asthma and COPD patients. Five different definitions of ACO, including the GINA/GOLD criteria were analyzed. Results 1609 patients were included in the final analysis. Application of Venn diagram for ACO populations resulted in 31 ACO subpopulations, which were further reduced to 6 separate populations by introducing a rank order for the analyzed definitions to classify patients from intersecting groups. Overall, the level of agreement between different ACO definitions was poor. Cohen's kappa coefficient for the agreement between ACO GINA/GOLD definition with other ACO definitions varied from 0.06 to 0.21. Only 2 patients (0.12%) met all the ACO definitions. Definition-based ACO prevalence ranged between 3.8% (Spanish criteria) and 18.4% (clinician's diagnosis). 573 (33.4%) patients met the criteria from at least one ACO definition. Patients who could not be classified as "pure" asthma, "pure" COPD or ACO accounted for as much as 27.5% of the whole investigated group. The most severe symptoms were observed in ACO patients defined as COPD and asthma diagnosed < 40 yrs of age. Conclusions The current ACO definitions identify distinct populations which share only a small number of common features and present with different disease phenotypes. ACO prevalence is highly variable, depending on the definition applied.

The Limited Value of Prolonged Drug Challenges in Nonimmediate Amoxicillin (Clavulanic Acid) Hypersensitivity Publication date: Available online 26 April 2019 Source: The Journal of Allergy and Clinical Immunology: In Practice Author(s): Athina L. Van Gasse, Didier G. Ebo, Anca M. Chiriac, Margo M. Hagendorens, Margaretha A. Faber, Samuel Coenen, Chris H. Bridts, Christel M. Mertens, Luc S. De Clerck, Vito Sabato Background Misdiagnosis of amoxicillin (clavulanic acid) (AX(/CL)) hypersensitivity has serious consequences. A drug challenge (DC) is the final diagnostic to affirm or infirm AX(/CL) hypersensitivity. However, uncertainties remain whether a prolonged drug challenge (pDC) should benefit the diagnosis of a nonimmediate AX(/CL) hypersensitivity. Objective To assess the added value of a standardized 7-day pDC in the diagnosis of nonimmediate or unclear penicillin hypersensitivity. Methods A total of 132 patients with a history of a nonimmediate hypersensitivity reaction or an unclear reaction to AX(/CL) or an undefined penicillin with a negative diagnostic workup including a single-day DC (DC) with AX(/CL) were selected. In all these patients, an additional pDC with AX(/CL) was planned. Thirteen patients started the pDC immediately after the DC. To ensure that hypersensitivity symptoms manifesting during the pDC course do not result from the DC, in the remaining 119 patients, the pDC was scheduled after a washout of 1 week. Results A total of 128 patients (12 without washout, 116 with washout) completed the pDC. Three patients reacted with a mild maculopapular exanthema. However, the value of a pDC was evidenced in only 1 patient who reacted during her pDC after an uneventful washout. In 2 patients pDC was cancelled because they reacted during the washout. Conclusions A pDC is of limited added value to the diagnostic algorithms of nonimmediate hypersensitivity reaction or unclear hypersensitivity reactions to AX(/CL). In our hands, the traditionally recommended diagnostic algorithm that offers a 1-day DC as a final diagnostic in patients with negative workup for AX(/CL) is appropriate.