Clinical Allergy and Immunology

Background: A substantial proportion of the world's population is exposed to indoor dampness-related exposures. Since the 1990s, studies have assessed the relation between indoor dampness and mold and rhinitis, but the evidence has been inconclusive. No previous meta-analysis has been reported on this topic. Objective: We conducted a systematic review and meta-analysis of studies on the relations between indoor dampness and mold and the risk of different types of rhinitis and investigated whether these relations differ according to the type of exposure. Methods: A systematic search of the Ovid MEDLINE and EMBASE databases was conducted (1950 through August 2012), and reference lists of relevant articles were reviewed. Crosssectional, case-control, and cohort studies in children or adults were selected according to a priori criteria and evaluated by 3 authors independently. Results: Thirty-one studies on rhinitis, allergic rhinitis (AR), or rhinoconjunctivitis were included. In meta-analyses the largest risk was observed in relation to mold odor (rhinitis: 2.18 [95% CI, 1.76-2.71]; AR: 1.87 [95% CI, 0.95-3.68]). The risk related to visible mold was also consistently increased (rhinitis: 1.82 [95% CI, 1.56-2.12]; AR: 1.51 [95% CI, 1.39-1.64]; rhinoconjunctivitis: 1.66 [95% CI, 1.27-2.18]). In addition, exposure to dampness was related to increased risk of all types of rhinitis. Conclusion: This meta-analysis provides new evidence that dampness and molds at home are determinants of rhinitis and its subcategories. The associations were strongest with mold odor, suggesting the importance of microbial causal agents. Our results provide evidence that justifies prevention and remediation of indoor dampness and mold problems, and such actions are likely to reduce rhinitis. (

A anafilaxia provocada pela ingestão de farinhas contaminadas por ácaros, nomeadamente farinha de trigo, é uma entidade rara. Descrevemos o caso de um rapaz de 12 anos, com antecedentes de rinite alérgica e suspeita de hipersensibilidade a anti-inflamatórios não esteroides, que apresentou dois episódios de anafilaxia sem desencadeante conhecido. Ambos os episódios ocorreram após ingestão de alimentos, que foram posteriormente tolerados. Realizaram-se testes cutâneos por picada para aeroalergénios e para os alimentos ingeridos antes das reações, positivos para ácaros e farinha de trigo do pacote utilizado e negativos para o extrato comercial de trigo, gliadina e farinha de trigo com e sem fermento de novos pacotes. Assumiu-se o diagnóstico de “síndrome da panqueca” e comprovou-se a hipersensibilidade a ibuprofeno, por resultado positivo em prova de provocação oral. Apresentamos este caso por se tratar de um diagnóstico que exige elevado nível de suspeição, devendo ser considerado no ...

Psoriatic arthritis (PsA) is a chronic inflammatory disease affecting peripheral and axial joints, usually associated with psoriasis (PsO) and involving various systems and organs (eye inflammation, such as uveitis; and involvement of nail and enthesis), and it usually requires a multidisciplinary treatment approach. Tumor necrosis factor-a (TNF-a) is overexpressed in psoriatic synovium and skin plaques and its selective inhibition by anti-TNF-a agents has been demonstrated to reduce TNF-a levels in the articular environment, reversing the synovial hyperproliferative phenotype. Studies performed on anti-TNF-a agents in PsA demonstrated that they are able to reduce neutrophil and macrophage infiltration as well as vascular cell adhesion protein 1 expression with ensuing synovial thickness normalization. The efficacy of anti-TNF-a agents for all PsA manifestations (peripheral arthritis, axial involvement, enthesopathy, and skin disease) suggests that anti-TNF-a efficacy might be related to the ability to influence angiogenesis and osteoclastogenesis, reduce synovial inflammation, and slow radiological disease progression. This review describes the role of anti-TNF-a in each manifestation of PsA. (

The unavailability of standardized parameters in bowel ultrasonography (US) commonly used in Crohn's disease (CD) and the shortage of skilled ultrasonographers are 2 limiting factors in the use of this imaging modality around the world. The aim of this study is to evaluate interobserver agreement among experienced sonographers in the evaluation of bowel US parameters in order to improve standardization in imaging reporting and interpretation. Fifteen patients with an established diagnosis of CD underwent blinded bowel US performed by 6 experienced sonographers. Prior to the evaluation, the sonographers and clinical and radiological IBD experts met to formally define the US parameters. Interobserver agreement was tested with the Quatto method (s). All operators agreed on the presence/absence of CD lesions and distinguished absence of/mild activity or moderate/severe lesions in all patients. S values were moderate for bowel wall thickness (s = 0.48, P = n.s.), bowel wall pattern (...

Normal mouse lungs lack appreciable numbers of mast cells (MCs) or MC progenitors (MCp's), yet the appearance of mature MCs in the tracheobronchial epithelial surface is a characteristic of allergic, T-cell-dependent pulmonary inflammation. We hypothesized that pulmonary inflammation would recruit MCp's to inflamed lungs and that this recruitment would be regulated by distinct adhesion pathways. Ovalbumin-sensitized and challenged mice had a greater than 28-fold increase in the number of MCp's in the lungs. In mice lacking endothelial vascular cell adhesion molecule 1 (VCAM-1) and in wild-type mice administered blocking monoclonal antibody (mAb) to VCAM-1 but not to mucosal addressin CAM-1 (MadCAM-1), recruitment of MCp's to the inflamed lung was reduced by greater than 75%. Analysis of the integrin receptors for VCAM-1 showed that in β7 integrin-deficient mice, recruitment was reduced 73% relative to wild-type controls, and in either BALB/c or C57BL/6 mice, mAb bloc...

RATIONALE: Histamine H 3 and H 4 histamine receptors are involved in immune modulation. Peripheral blood mononuclear cells (PBMC) and dendritic cells (DCs) derived from PBMC synthesize cytokines and chemokines which may be modulated by blockade of H 3/ H 4 histamine receptors. METHODS: PBMC and DCs derived from 10 healthy donors were cultivated in the presence of dual H3/4 histamine receptor antagonist Ciproxifan (10 -5M ). The concentrations of cytokines and chemokines in 48-hour cultures were assessed by Multiplex assays using Luminex xMAP technology.

RATIONALE: Knowledge of TGFb regulation of the immune system stems predominantly from animal and in vitro studies. Heterozygous mutations in TGFbR1, TGFbR2 and SMAD3 have been associated with familial thoracic aortic aneurysms and aortic dissections (TAAD). These patients offer an opportunity to study their immune development when the TGFbeta pathway is defective. METHODS: Flow cytometry was used to analyze PBMC from patients with TAAD (n59) and age-matched healthy controls (HC, n58). Th1 and Th17 were determined with intracellular cytokine staining for IFNg and IL17A. Foxp3+ Tregs were detected with anti-Foxp3 (259D). CD19+ were analyzed for naive (IgD+CD27-), unswitched (IgD+CD27+) and switched memory (IgD-CD27+). Plasmacytoid (CD303+pDC) and myeloid (CD1c+mDC) were defined within lineage-1 negative population. RESULTS: %CD3-CD16+NK, CD3+CD16+NKT, CD4+, CD8+ and CD4+CD45RA+ in TAAD were similar to HC. Average %CD19+ (20.8vs7.3, p50.006) and naive B cells (81.3vs66.6, p50.004) were higher in TAAD. The unswitched were similar but the switched B cells were lower (8.6vs15.5, p50.01). While the %Tregs were similar, there was a remarkable reduction (1/2-3 folds) in Foxp3 concentration based on median fluorescence intensity of Foxp3 in TAAD. There was a significant reduction of %Th17 (0.14vs0.61, p50.01), while the Th1 were similar. % pDC (9.4vs24.1, p50.009) and %mDC (11.4vs17.9, p50.01) were also lower in TAAD. CONCLUSIONS: These results demonstrate for the first time in humans of the involvement of TGFbeta signaling in B cells, DCs, Th17 and Treg development. Further studies and monitoring of the clinical effects of these immunological perturbations in these TAAD patients are needed to appreciate the impact of their underlying disease.

in the form of showing pornographic material among male students (41 subjects [23%]) and touching of breasts (58 subjects [33.9%]) among females. The minimum age of victims at the time of the first incident was Ͼ16 years in 83 subjects (48.5%). The abuser was a friend in 32.1% (29 in males and 27 in females) of the cases. The perpetrators of sexual abuse were males for 132 subjects of both genders. In 56% (96 subjects), the time of abuse was between 2 and 10 PM. Forty-one subjects (23%) currently experience abuse memories in the form of unwanted scenes flashing in dreams, difficulty in maintaining relationships, feeling of guilt, fear, or nausea when touched, and disturbing sexual thoughts, alone or in combination. CONCLUSIONS: These results provide baseline information on the prevalence and type of sexual abuse among adolescents. Abuse involved both genders, but the perpetrators were male. For nearly one fourth of the students the incident seems to have left a long-term psychological impact on the victim.

The measurement of the fraction of exhaled breath temperature has been used as a noninvasive biomarker in the detection of airway diseases. The purpose of our study was to compare the fraction of exhaled breath temperature (EBT) in patients with controlled and uncontrolled asthma to establish its use as a biomarker. EBT reports peripheral airway temperature (T 3 max), central (T 1 max) and the relationship between both (Rel T1/T3). METHODS: We reviewed a total of 40 records of adult asthmatic patients that were consulted at the Regional Center of Allergy and Clinical Immunology at the University Hospital in Monterrey, Mexico and to whom the EBT was measured. Patients were classified as uncontrolled or controlled asthma by the Asthma Control Test and doses of inhaled corticosteroid were documented. EBT was compared among both group of patients. Data was analyzed using SPSS 23.0. RESULTS: Nineteen patients (47.5%) had controlled asthma while 21 (52.5%) were uncontrolled. The mean of T 3 max temperature in controlled asthma using low doses of corticosteroids was 29.5; in patients with uncontrolled asthma and higher doses of inhaled corticosteroids, the mean was 28.1 with p5 0.032. CONCLUSIONS: Patients with uncontrolled asthma and higher doses of inhaled corticosteroids showed significant difference in EBT measurements compared to controlled asthma, establishing the EBT as a useful biomarker.

RATIONALE: Bacterial infections can prevent expression of allergic phenotype in atopic individuals, whereas appearance of bacterial infections in individuals with developed allergic phenotype can exacerbate their allergic response. The most implicated microorganism in allergic rhinitis (AR) is Staphylococcus aureus (S. aureus), which sets super-antigens free that activate T cells, causing higher inflammatory response, that can lose control and may not respond to treatment. Purpose of this study was to compare specific IgE against S. aureus levels in patients with AR and controls as healthy patients. METHODS: Transversal, retrospective and observational study. We selected 42 subjects between 18-75 years old with AR diagnosis or as control group, and analyzed serum for A, B, C and TSST specific IgE S. aureus toxins by InmunoCap. In controls, negative allergy was corroborated by clinical history and aeroallergen skin prick test. RESULTS: Of the 42 analyzed samples, 20 corresponded to AR patients (65% male, and 35% female) and 22 controls (55% female and 45% male). For the AR group, the specific IgE S. aureus toxins ranges were reported as: A (0.00-1.67), B (0.00-41.20), C (0.00-38.40) and TSST (0.00-0.68); and for control group: A (0.00-0.38), B (0.00-0.39), C (0.00-0.85) and TSST (0.00-0.35). A Statistical difference was found in both groups in specific IgE for toxins A (P50.036), B (P50.041) and TSST (P50.004). CONCLUSIONS: Our data suggest that AR patients have higher levels of specific IgE for S. aureus. Therefore it is necessary to identify in patients who present with frequent exacerbations

We have studied the effect of a topically administered glucocorticoid, J!uticasone propionate (FP), on infiltration and activation of eosinophils in the nasal mucosa after provocation with allergen. Forty-four patients with seasonal allergic rhinitis entered a double-blind, crossover study in which they underwent treatment with either FP (200 pg once #daily) or identical placebo for 2 weeks. Patients then underwent nasal-allergen provocation followed by nasal lavage and biopsy at one of several time points between 0 and 8 hours. Patients subsequent& received the alternate treatment for 2 weeks before repeat allergen provocation, nasul lavuge, and biopsy, as before. Biopsy specimens of nasal mucosa obtained during the immediate allergic response demonstrated an influx of eosinophils (stained by monoclonal antibody EGI) of similar magnitude during both FP and placebo treatment. Significantly, fewer esoinophils in these biopsy specimens were activated (stained by monoclonal antibody EG2) after treatment with FP compared with that afrer placebo treatment (median values, 8.8 and 36.6 cells per square millimeter, respectively: p < 0.02). The concentration of eosinophil cationic protein in nmal lavage juid was significantly elevated above baseline from 2 to 8 hours after allergen, and thi.s increase was abolished by treatment with FP. These results suggest that topical glucocorticoids inhibit allergen-induced activation of eosinophils in allergic rhinitis. (.I ALLERGY CLIN IMMCJKOL 1992;89:951-7.

The maxillary sinus floor elevation procedure has gained popularity with predictable results, and is a safe, acceptable technique for bone augmentation, providing a base for dental implant treatment. Faint radiopaque lesions at the base of the maxillary sinus are frequent diagnoses on radiographs and must be identified during dental implant planning. The use of autografts, xenografts, allografts, and alloplasts or a combination between them has been demonstrated to be effective for increasing bone height and bone volume in maxillary sinus. The objective of this study was to evaluate the outcome of subjects with considerable sinus membrane pathology (test group) undergoing maxillary sinus floor augmentation using Platelet Rich Fibrin (PRF) as a filling material, in association with the Bio-Oss and Sint-Oss and simultaneous implant placement in a one-stage surgical procedure. All patients reported no pain to percussion, no sign of tissue suffering to the soft peri-implant tissues, the...

Obstructive sleep apnea syndrome (OSAS) is a phenomenon of repeated, episodic reduction, or cessation of airflow (hypopnea/apnea) as a result of upper airways obstruction. First-line treatment in younger children is adenotonsillectomy, although other available treatment options in middle-aged adults include continuous positive airways pressure (CPAP) and airway adjuncts. Oral appliances (OA) are a viable treatment alternative in patients with OSAS. The objective of this study was to assess, in a 1-year follow-up study, an OA in OSAS patients. The participants were subjected to polysomnographic examination with a validated device (MicroMESAM). Eight participants were fitted with a Thornton Adjustable Positioner (TAP). The participants were asked to wear the test appliance for 7 nights, and in case of compliance, for 6 months. The selected patients record their usage of the appliance and any adverse effects in a treatment journal. The research focused on the following outcomes: sleep ...

Background: Considering that non-eosinophilic esophagitis eosinophilic gastrointestinal disorders (EGIDs) could mimic serious surgical conditions, including hypertrophic pyloric stenosis, intussusception, and bowel perforation, this study investigates these disorders as major causes of gastrointestinal surgery in children. Materials and Methods: Children who had undergone gastrointestinal surgery between March 2017 and March 2018 at Mofid Children's Hospital in Tehran City, Iran, were randomly selected to perform a rigorous and complete re-evaluation of the pathology to determine the presence of eosinophils or eosinophil-related inflammation in the tissue samples collected after surgery. Traditional hematoxylin and eosin staining was used to quantify eosinophils and their footprints. Trichrome staining was also applied to measure the tissue fibrosis. Results: A total of 72 pediatric patients with a median age of 2.5 years, suffering from constipation and abdominal pain were studied. The majority of patients were primarily diagnosed with Hirschsprung's syndrome (38.9%), followed by imperforated anus (34.7%) and ileal atresia (16.7%). Among the studied patients ten (13.9%) were confirmed to have tissue eosinophilia, compatible with the conventional method of non-EoE-EGID diagnosis. More evidence supporting the presence of tissue eosinophils was infiltration of 1-26 eosinophils in the muscular and subserosal layers of more than 97% of samples, degranulated eosinophils and multi-nucleated cells in 6(8.3%) tissue samples, and different levels of tissue fibrosis in 37 patients (51.4%). Conclusion: Non-EoE EGIDs should be considered in the context of severe relapsing gastrointestinal complications requiring urgent or emergent surgical interventions, particularly in subjects without a convenient response after surgery.

Objectives to evaluate changes in demographic, clinical and histological presentation, and prognosis of lupus nephritis (Ln) over time. We studied a multicentre cohort of 499 patients diagnosed with Ln from 1970 to 2016. the 46-year follow-up was subdivided into three periods (p): p1 1970-1985, p2 1986-2001 and p3 2002-2016, and patients accordingly grouped based on the year of Ln diagnosis. predictors of patient and renal survival were investigated by univariate and multivariate proportional hazards Cox regression analyses. Survival curves were compared using the log-rank test. results A progressive increase in patient age at the time of Ln diagnosis (p<0.0001) and a longer time between systemic lupus erythematosus onset and Ln occurrence (p<0.0001) was observed from 1970 to 2016. during the same period, the frequency of renal insufficiency at the time of Ln presentation progressively decreased (p<0.0001) and that of isolated urinary abnormalities increased (p<0.0001). no changes in histological class and activity index were observed, while chronicity index significantly decreased from 1970 to 2016 (p=0.023). Survival without end-stage renal disease (ESrd) was 87% in p1, 94% in p2% and 99% in p3 at 10 years, 80% in p1 and 90% in p2 at 20 years (p=0.0019). At multivariate analysis, male gender, arterial hypertension, absence of maintenance immunosuppressive therapy, increased serum creatinine, and high activity and chronicity index were independent predictors of ESrd. Conclusions Clinical presentation of Ln has become less severe in the last years, leading to a better long-term renal survival. Lupus nephritis (LN) is a frequent and severe manifestation of systemic lupus erythematosus (SLE) and is characterised by a relapsing and remitting clinical course. [2] Renal involvement occurs at the time of SLE diagnosis or during the course of the disease in up to two-thirds of patients. 5 6 Clinical presentation varies from asymptomatic urinary abnormalities to chronic irreversible renal insufficiency. Although renal involvement is still considered a strong predictor of death and end-stage renal disease (ESRD), 8 9 both patient and renal survival have significantly improved in the last few decades [13] and the rate of renal flares has considerably decreased over time as well. The improvement in LN prognosis has been attributed to many factors including the better understanding of SLE pathogenesis, new treatment options and strategies, and improved management of hypertension, infections and other comorbidities. To the best of our knowledge, no studies have evaluated whether changes in demographic, clinical and histological features at the time of LN presentation have occurred over the last decades and whether these changes have had an influence on the disease management and outcome. The objective of our study was to examine the changes in demographic, clinical and histological features at the time of LN onset in a large cohort of patients during a 46-year follow-up. We looked at changes in LN prognosis during the course of the follow-up and searched for the prognostic factors associated with patient and renal outcomes. Four hundred and ninety-nine patients were included in this retrospective study of prospectively collected data. Inclusion criteria were American College of Rheumatology criteria-based diagnosis of SLE 15 and biopsy-proven LN performed between

Background: There are no published data on peanut sensitization in Egypt and the problem of peanut allergy seems underestimated. We sought to screen for peanut sensitization in a group of atopic Egyptian children in relation to their phenotypic manifestations. Methods: We consecutively enrolled 100 allergic children; 2-10 years old (mean 6.5 yr). The study measurements included clinical evaluation for site of allergy, possible precipitating factors, consumption of peanuts (starting age and last consumption), duration of breast feeding, current treatment, and family history of allergy as well as skin prick testing with a commercial peanut extract, and serum peanut specific and total IgE estimation. Children who were found sensitized to peanuts were subjected to an open oral peanut challenge test taking all necessary precautions. Results: Seven subjects (7%) were sensitized and three out of six of them had positive oral challenge denoting allergy to peanuts. The sensitization rates did not vary significantly with gender, age, family history of allergy, breast feeding duration, clinical form of allergy, serum total IgE, or absolute eosinophil count. All peanut sensitive subjects had skin with or without respiratory allergy. Conclusions: Peanut allergy does not seem to be rare in atopic children in Egypt. Skin prick and specific IgE testing are effective screening tools to determine candidates for peanut oral challenging. Wider scale multicenter population-based studies are needed to assess the prevalence of peanut allergy and its clinical correlates in our country.

The recent identification of loss-of-function mutations in the structural protein filaggrin as a widely replicated major risk factor for eczema sheds new light on disease mechanisms in eczema, a disease that had heretofore largely been considered to have a primarily immunologic etiopathogenesis. The filaggrin gene (FLG) mutation findings are consistent with a recently proposed unifying hypothesis that offers a mechanistic understanding of eczema pathogenesis synthesizing a heritable epithelial barrier defect and resultant diminished epidermal defense mechanisms to allergens and microbes, followed by polarized T H 2 lymphocyte responses with resultant chronic inflammation, including autoimmune mechanisms. Although compelling evidence from genetic studies on FLG implicates perturbed barrier function as a key player in the pathogenesis of eczema in many patients, much is still unknown about the sequence of biologic, physicochemical, and aberrant regulatory events that constitute the transition from an inherited barrier defect to clinical manifestations of inflammatory eczematous lesions and susceptibility to related atopic disorders. The exact contribution of FLG to the wider atopic story, factors modifying FLG expression, and the role of other barrier proteins remain to be delineated. In this review we highlight recent advances in our understanding of the FLG genetics in the cause of eczema and related complex diseases.

Background: In 2014, germline signal transducer and activator of transcription (STAT) 3 gain-of-function (GOF) mutations were first described to cause a novel multisystem disease of early-onset lymphoproliferation and autoimmunity. Objective: This pivotal cohort study defines the scope, natural history, treatment, and overall survival of a large global cohort of patients with pathogenic STAT3 GOF variants. Methods: We identified 191 patients from 33 countries with 72 unique mutations. Inclusion criteria included symptoms of immune dysregulation and a biochemically confirmed germline heterozygous GOF variant in STAT3. Results: Overall survival was 88%, median age at onset of symptoms was 2.3 years, and median age at diagnosis was 12 years. Immune dysregulatory features were present in all patients: lymphoproliferation was the most common manifestation (73%); increased frequencies of double-negative (CD42CD82) T cells were found in 83% of patients tested. Autoimmune cytopenias were the second most common clinical manifestation (67%), followed by growth delay, enteropathy, skin disease, pulmonary disease, endocrinopathy, arthritis, autoimmune hepatitis, neurologic disease, vasculopathy, renal disease, and malignancy. Infections were reported in 72% of the cohort. A cellular and humoral immunodeficiency was observed in 37% and 51% of patients, respectively. Clinical symptoms dramatically improved in patients treated with JAK inhibitors, while a variety of other immunomodulatory treatment modalities were less efficacious. Thus far, 23 patients have undergone bone marrow transplantation, with a 62% survival rate. Conclusion: : STAT3 GOF patients present with a wide array of immune-mediated disease including lymphoproliferation, autoimmune cytopenias, and multisystem autoimmunity. Patient care tends to be siloed, without a clear treatment strategy. Thus, early identification and prompt treatment implementation are lifesaving for STAT3 GOF syndrome. (J Allergy Clin Immunol 2022;nnn:nnn-nnn.

Human immunoglobulin prepared for intravenous administration (IGIV) has a number of important uses in the treatment of disease. Some of these are in diseases for which acceptable treatment alternatives do not exist. In this review we have evaluated the evidence underlying a wide variety of IGIV uses and make specific recommendations on the basis of these data. Given the potential risks and inherent scarcity of IGIV, careful consideration of the indications for and administration of IGIV is warranted. (

Chronic rhinosinusitis (CRS) is a complex disease consisting of several disease variants with different underlying pathophysiologies. Limited knowledge of the mechanisms of these disease subgroups is possibly the greatest obstacle in understanding the causes of CRS and improving treatment. It is generally agreed that there are clinically relevant CRS phenotypes defined by an observable characteristic or trait, such as the presence or absence of nasal polyps. Defining the phenotype of the patient is useful in making therapeutic decisions. However, clinical phenotypes do not provide full insight into all underlying cellular and molecular pathophysiologic mechanisms of CRS. Recognition of the heterogeneity of CRS has promoted the concept that CRS consists of multiple groups of biological subtypes, or "endotypes," which are defined by distinct pathophysiologic mechanisms that might be identified by corresponding biomarkers. Different CRS endotypes can be characterized by differences in responsiveness to different treatments, including topical intranasal corticosteroids and biological agents, such as anti-IL-5 and anti-IgE mAb, and can be based on different biomarkers that are linked to underlying mechanisms. CRS has been regarded as a single disease entity in clinical and genetic studies in the past, which can explain the failure to identify consistent genetic and environmental correlations. In addition, better identification of endotypes might permit individualization of therapy that can be targeted against the pathophysiologic processes of a patient's endotype, with potential for more effective treatment and better patient outcomes.

Background: In all societies, the burden and cost of allergic and chronic respiratory diseases are increasing rapidly. Most economies are struggling to deliver modern health care effectively. There is a need to support the transformation of the health care system into integrated care with organizational health literacy. As an example for chronic disease care, MASK (Mobile Airways Sentinel NetworK), a new project of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, and POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure. Three aspects of care pathways are being developed: (i) Patient participation, health literacy and self-care through technology-assisted "patient activation", (ii) Implementation of care pathways by pharmacists and (iii) Nextgeneration guidelines assessing the recommendations of GRADE guidelines in rhinitis and asthma using real-world evidence (RWE) obtained through mobile technology. The EU and global political agendas are of great importance in supporting the digital transformation of health and care, and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care. In 20 years, ARIA has considerably evolved from the first multimorbidity guideline in respiratory diseases to the digital transformation of health and care with a strong political involvement.

The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing ''The diagnosis and Management of Rhinitis: An Updated Practice Parameter.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm develo...

The LEAP study showed that peanut consumption in early life dramatically reduced the prevalence of peanut allergy among high risk children. As a result, the NIAID revised its clinical guidelines to recommend high risk children be introduced to peanut at an early age instead of practicing peanut avoidance. Our objective was to compare Arah1, Arah2, Arah3, Arah6, and Arah8 allergen levels and composition in multiple early peanut intervention products currently available. METHODS: Extracts from six commercial products (100mg/sample) commonly used in oral immunotherapy trials or advertised as peanut intervention products were analyzed by ELISA for Arah1, Arah2, Arah3, Arah6 and Arah8 using purified natural or recombinant allergen standards. The limits of detection of the ELISA were: Arah1, 32ng/ml; Arah2, 2ng/ ml; Arah3, 1ng/ml; Arah6, 0.8ng/ml and Arah8, 2ng/ml. RESULTS: When comparing results of all six products, Arah3 was present in the highest concentration (2,638-33,026mg/g) overall, followed by Arah2 (23-10,226mg/g), Arah6 (21-5,235mg/g), and Arah1 (50-4,167mg/ g), while Arah8 (<1mg/g) was present in the lowest amounts, if not undetectable. The PB2, powdered peanut butter, contained the highest level of all 5 allergens and Aralyte contained the lowest level of allergens. The most similar products based on allergen levels were Bamba and SimplyPeanutä. CONCLUSIONS: The results show that the five major peanut allergens vary greatly in level and composition amongst the six early peanut intervention products. The results indicate that specific allergen content should be considered when using food formulations or specific foods for clinical trials of oral immunotherapy or prophylactic interventions.

These parameters were developed by the Joint Task Force on Practice Parameters (JTFPP), representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and ACAAI have jointly accepted responsibility for establishing ''The diagnosis and management of acute and chronic urticaria: 2014 update.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants,

These parameters were developed by the Joint Task Force on Practice Parameters (JTFPP), representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing ''A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensintium. D. Wallace is a speaker for the ACAAI, TEVA, and Mylan; is an advisor for Sanofi and Sunovion; is on the executive committee for the ACAAI; and is on the Board of Directors for the World Allergy Organization. The rest of the editors, contributors, and reviewers declare that they have no relevant conflicts of interest.

The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing ''The diagnosis and management of sinusitis: a practice parameter update.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing ''The diagnosis and Management of Rhinitis: An Updated Practice Parameter.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing ''Atopic dermatitis: a practice parameter update 2012.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma & Immunology have jointly accepted responsibility for establishing ''Allergen immunotherapy: A practice parameter third update.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. A current list of published practice parameters of the Joint Task Force on Practice Parameters for Allergy and Immunology can be found in Table in this article's Online Repository at www.jacionline.org. The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions is made subsequently. The Joint Task Force gratefully acknowledges the AAAAI Board of Directors and the ACAAI Board of Regents for their review and support of this document. The authors and editors gratefully acknowledge Susan Grupe and Jessica Karle for their administrative assistance.

The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing ''Attaining optimal asthma control: A practice parameter.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

These parameters were developed by the Joint Task Force on Practice Parameters (JTFPP), representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and ACAAI have jointly accepted responsibility for establishing ''Adverse reactions to vaccines practice parameter 2012 update.'' This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporates the efforts of many participants, no single individual, including those who served on the JTFPP, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. The JTFPP understands that the cost of diagnostic tests and therapeutic agents is an important concern that might appropriately influence the workup and treatment chosen for a given patient. The emphasis of our primary recommendations regarding a medication can vary, for example, depending on third-party payer issues and product patent expiration dates. However, because a given test or agent's cost is so widely variable and there is a paucity of pharmacoeconomic data, the JTFPP generally does not consider cost when formulating practice parameter recommendations. In extraordinary circumstances, when the cost benefit of an intervention is prohibitive as supported by pharmacoeconomic data, commentary might be provided. These parameters are not designed for use by pharmaceutical companies in drug promotion. The Joint Task Force is committed to ensuring that the practice parameters are based on the best scientific evidence that is free of commercial bias. To this end, the parameter development process includes multiple layers of rigorous review. These layers include the work group convened to draft the parameter, the task force reviewers, and peer review by members of each sponsoring society. Although the Task Force has the final responsibility for the content of the documents submitted for publication, each reviewer's comment will be discussed, and reviewers will receive written responses to comments when appropriate. To preserve the greatest transparency regarding potential conflicts of interest, all members of the Joint Task Force and the Practice Parameters Work Groups will complete a standard potential conflict of interest disclosure form, which will be available for external review by the sponsoring organization and any other interested individual. In addition, before confirming the selection of a work group chairperson, the Joint Task Force

Annals of Allergy. J. M. Portnoy has received payment for lectures from Thermo Fisher and Mylan and has consultant arrangements with Thermo Fisher and Sanofi. C. R. Randolph has received payment for lectures from GlaxoSmithKline, TEVA, ViroPharma, Merck, and Dey; has received research support from GlaxoSmithKline, Merck, Amgen, and Genentech/Novartis; and has consultant arrangements with AstraZeneca and Meda. D. Schuller has received travel support from the Joint Council of Allergy, Asthma & Immunology for Joint Task Force meetings. S. L. Spector has stock in GlaxoSmithKline and Merck; has consultant arrangements with Hycor; has received research support from AstraZeneca, GlaxoSmithKline, Amgen, Genentech, Novartis, Teva, Mylan, Sanofi, and Boehringer Ingelheim; and is a speaker/ moderator for the American College of Allergy, Asthma & Immunology. S. Tilles has consultant arrangements with SRXA, Sunovion, and Hycor; has received research support from Astellas, Amphastar, Medimmune, Cephalon, Genentech, Merck, TEVA, Sunovion, Boehringer Ingelheim, Nutricia, Array, Rigel, and AstraZeneca; is Associate Editor of AllergyWatch and the Annals of Allergy; is Assistant Editor of the Joint Task Force for Practice Parameters; and is on the Executive Committee for the Seattle Food Allergy Consortium. D. Wallace has received payment for lectures from TEVA, Mylan Labs, and the American College of Allergy, Asthma & Immunology; is an advisor for Sanofi and Sunovion; is on the Executive Committee of the American College of Allergy, Asthma & Immunology; and is on the Board of Directors for the World Allergy Organization. The rest of the authors declare that they have no relevant conflicts of interest.

RATIONALE: Lipids in the stratum corneum of atopic dermatitis (AD) patients differ substantially in composition from healthy subjects. We hypothesized that these changes are driven by IL-13. METHODS: Lipid profiles from skin tape strips of 25 healthy controls, 30 AD patients, skin-specific inducible K5-tTA-IL-13 transgenic mice and control mice were analyzed by targeted liquid chromatography tandem mass spectrometry (LC-MS/MS). Ca 2+ -differentiated human keratinocytes were stimulated with IL-4/IL-13 with or without STAT6 silencing and lipids were analyzed by LC-MS/MS. Stable isotope pulse-labeling was employed to define changes in sphingolipid metabolism in treated keratinocytes. RESULTS: Lesional skin (stratum corneum) from AD subjects and IL-13 transgenic mice is characterized by increased proportion of a short-chain (N-14:0-24:0) NS-ceramides, sphingomyelins, and 14:0-22:0-lysophosphatidylcholines (LPC) with simultaneous decline in the proportion of corresponding long-chain species (N-26:0-32:0 sphingolipids and 24:0-30:0-LPC) when compared to healthy controls. An increase in short-chain LPC species was also observed in non-lesional AD skin. IL-4/IL-13-driven responses in Ca 2+ -differentiated human keratinocytes in vitro revealed similar changes in aforementioned sphingolipids in response to IL-4/IL-13. Pulse-labeling studies with human keratinocytes in vitro suggest that IL-4/IL-13 inhibit sphingolipid biosynthesis and also inhibit sphingomyelin/ceramide degradation. These changes are blocked by STAT6 silencing with siRNA. CONCLUSIONS: This study confirms the link between dysregulated type 2 immune response and skin lipid abnormalities in AD skin. The similarity in lipid changes between human (AD) and mouse (IL-13-driven) skin, as well as the STAT6-controlled changes in IL-13-treated human keratinocytes in vitro strongly support the pathogenic role of IL-13 in AD skin lipid metabolism.

The immunologic defect in X-linked immunodeficiency and hyperimmunoglobulinemia M (HIM) are related to defective expression of the CD40 ligand (CD4OL). We have studied two female patients with HIM to evaluate the role of CD40/CD40L in the pathogenesis of impaired immunoglobulin switching. In addition to recurrent infections characteristic of humoral immunodeficiencies, the two patients had chronic hepatitis caused by type C virus. Phenotypic characterization of peripheral blood mononuclear cells showed a similar picture in both patients, with a reduction in the absolute numbers of CD4 cells and increased numbers of CD8 and CD3/ DR cells. B cells (CD19+) were reduced in one patient, but CD40 was expressed on all CD19+ cells in both patients. The expression of CD40L was normal on peripheral blood mononuelear cells from the two patients with HIM on both resting and stimulated cells. The combination of anti-CD40 and cytokines (interleukin-2, interleukin-4, and interleukin-lO) was able to restore proliferative capacity to anti-IgM. Peripheral blood mononuclear cells from the two patients with HIM showe d a high spontaneous production of IgM in vitro and no production of IgG or IgE. Our data suggest that the defect of isotype switching in female patients with HIM is not related to defective expression of the CD40/CD40L receptor system. A possible role for chronic hepatitis C virus infection in the pathogenesis of the disease is suggested by the detection of specific production of anti-hepatitis C virus IgM.

RATIONALE: Efficacy and safety of house dust mite (HDM) sublingual tablets have been studied in subjects with HDM-associated allergic rhinitis (HDM-AR). Here, we present results of immunological markers (IgE, IgG 4 ) in two Phase II/III trials. METHODS: Two DBPC trials: Trial-1 in adults (18-50 years; Europe) and Trial-2 in adults/adolescents (12-64 years; Japan) enrolled subjects with HDM-AR for > _1 year (Trial-1) or > _2 years (Trial-2) confirmed by positive skin prick test (nasal provocation test in Japan) and HDM-specific IgE > _0.7 kU/L. In both trials, participants were randomized to receive 300IR, 500IR or placebo once daily for one year. In Trial-1, subjects were followed up for one year post-treatment. HDM-specific IgE and IgG 4 were assessed before and after treatment. End of treatment/baseline ratios were calculated (descriptive analysis). RESULTS: 509 and 968 subjects were enrolled in Europe and Japan, respectively. In both trials, HDM-specific IgE increased (1.2-1.5 fold in Trial-1, 1.8-1.9 fold in Trial-2) in the active groups and remained stable in the placebo group (end of treatment/baseline ratios 0.8-0.9) over treatment. HDM-specific IgG 4 were more than 2 or 3 times higher (2.4-5.1 fold in Trial-1, 2.6-3.7 fold in Trial-2) and little changed in the placebo group (end of treatment/baseline ratios 0.9-1.6). In the year post-treatment of Trial-1, IgE and IgG 4 were still higher in the active groups (1.2 to 3.3 times) compared to the placebo group. CONCLUSIONS: Immunological data from two large Phase II/III trials confirmed that HDM sublingual tablets are immunologically active in HDM-AR subjects over treatment and remained so over the post-treatment year.

Background: Decreased TNF-a production in whole blood after ex vivo LPS stimulation indicates suppression of the Toll-like receptor (TLR)4 pathway. This is associated with increased mortality in pediatric influenza critical illness. Whether antiviral immune signaling pathways are also suppressed in these patients is unclear. Objectives: We sought to evaluate suppression of the TLR4 and the antiviral retinoic acid-inducible gene-I (RIG-I) pathways with clinical outcomes in children with severe influenza infection. Methods: In this 24-center, prospective, observational cohort study of children with confirmed influenza infection, blood was collected within 72 hours of intensive care unit admission. Ex vivo whole blood stimulations were performed with matched controls using the viral ligand polyinosinic-polycytidylic acid-low-molecular-weight/LyoVec and LPS to evaluate IFN-a and TNF-a production capacities (RIG-I and TLR4 pathways, respectively). Results: Suppression of either IFN-a or TNF-a production capacity was associated with longer duration of mechanical ventilation and hospitalization, and increased organ dysfunction. Children with suppression of both RIG-I and TLR4 pathways (n 5 33 of 103 [32%]) were more likely to have prolonged (> _7 days) multiple-organ dysfunction syndrome (30.3% vs 8.6%; P 5 .004) or prolonged hypoxemic respiratory failure (39.4% vs 11.4%; P 5 .001) compared with those with single-or no pathway suppression. Conclusions: Suppression of both RIG-I and TLR4 signaling pathways, essential for respective antiviral and antibacterial responses, is common in previously immunocompetent children with influenza-related critical illness and is associated with bacterial coinfection and adverse outcomes. Prospective testing of both pathways may aid in risk-stratification and in immune monitoring. (

Conflicting results have been reported on the effect of nonsteroidal antiinflammatory drugs on allergen-induced asthmatic responses. The aim of this study was to investigate the effect of inhaled lysine acetylsalicylate (LASA) on the early and late allergen-induced responses. We studied 16 patients with mild, stable asthma who had an early asthmatic response and 10 patients with a dual (early and late) response. Each patient underwent two challenges with a single dose of allergen assessed in a preliminary test, after inhalation of either 720 mg of LASA in 4 ml of saline solution or placebo, according to a randomized, double-blind protocol. Allergeninduced hyperreactivity to methacholine was measured in six patients from each of the early and the dual response groups 2 hours and 24 hours after the challenge, respectively. In the patients with early response, the maximum fall in FEV 1 after challenge was 24% --1% after inhalation of placebo and 14% --2% after inhalation of LASA (p < 0.005). No protection was observed in four patients who received the drug orally instead of by inhalation. In the patients with a dual response, the maximum FEV 1 decrease during the early response was 27% --2% after placebo and 21% --2% after LASA (p < 0.025). During the late response (between 3 and 8 hours), the maximum decrease in FEV 1 was 28% --4% after placebo and 16% ---4% after LASA (p < 0.005). In both groups allergen challenge caused a significant reduction in methacholine PD2o after treatment with placebo but not with LASA. Without allergen challenge, LASA had no effect on methacoline reactivity. We conclude that inhaled LASA significantly reduces both the early and the late asthmatic response to allergen challenge and that it prevents the allergen-induced airway hyperresponsiveness that follows these responses. (

RATIONALE: Epinephrine is a potentially life-saving drug for treating severe allergic reactions. However, allergist trends in use and prescription of epinephrine are unknown. METHODS: A 19-item survey was electronically distributed to a 20% sample of AAAAI members and the entire ACAAI membership, querying prescribing/treatment scenarios/trends. RESULTS: A total of 648 responded, with 97% reporting they routinely prescribe epinephrine auto-injectors (EAI), but only 61.4% routinely provide emergency action plans (EAP). Only 70.1% always prescribe EAI for food allergy patients, in contrast to 92.3% for idiopathic anaphylaxis, 84.4% for venom immunotherapy, 49.4% for biologics, and 29.4% for inhalant immunotherapy. Among EAPs used, 54.9% report always/ sometimes using the AAP version, 33% using the FARE version, 23.7% the ACAAI version, and 17% the AAAAI version. For reaction treatment, 58% reported antihistamines have no/very limited role, though only 8.9% and 7.8% reported they advise or use epinephrine for any home or in-office reaction, respectively. For patients with a history of only mild symptoms, only 13.8% would always recommend epinephrine be used for a food trigger and 20.5% for a venom trigger. Over 2/3 (69%) advise patients carry >2 EAI, and 50.2% advise pre-emptive EIA use for allergen exposure before symptoms emerge. Time in practice was significantly associated with lower odds of EAI prescription for immunotherapy, but not with providing EAP, advising pre-emptive use, or role of antihistamines. CONCLUSIONS: Epinephrine is more routinely prescribed for venom allergy and idiopathic anaphylaxis than food allergy. There are wide variations in practice, with 58% believing antihistamines have no/limited role in treating allergic reactions.

RATIONALE: Epinephrine is a potentially life-saving drug for treating severe allergic reactions. However, allergist trends in use and prescription of epinephrine are unknown. METHODS: A 19-item survey was electronically distributed to a 20% sample of AAAAI members and the entire ACAAI membership, querying prescribing/treatment scenarios/trends. RESULTS: A total of 648 responded, with 97% reporting they routinely prescribe epinephrine auto-injectors (EAI), but only 61.4% routinely provide emergency action plans (EAP). Only 70.1% always prescribe EAI for food allergy patients, in contrast to 92.3% for idiopathic anaphylaxis, 84.4% for venom immunotherapy, 49.4% for biologics, and 29.4% for inhalant immunotherapy. Among EAPs used, 54.9% report always/ sometimes using the AAP version, 33% using the FARE version, 23.7% the ACAAI version, and 17% the AAAAI version. For reaction treatment, 58% reported antihistamines have no/very limited role, though only 8.9% and 7.8% reported they advise or use epinephrine for any home or in-office reaction, respectively. For patients with a history of only mild symptoms, only 13.8% would always recommend epinephrine be used for a food trigger and 20.5% for a venom trigger. Over 2/3 (69%) advise patients carry >2 EAI, and 50.2% advise pre-emptive EIA use for allergen exposure before symptoms emerge. Time in practice was significantly associated with lower odds of EAI prescription for immunotherapy, but not with providing EAP, advising pre-emptive use, or role of antihistamines. CONCLUSIONS: Epinephrine is more routinely prescribed for venom allergy and idiopathic anaphylaxis than food allergy. There are wide variations in practice, with 58% believing antihistamines have no/limited role in treating allergic reactions.