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Samarakoon U, Accarino J, Wurcel AG, Jaggers J, Judd A, Blumenthal KG. Penicillin allergy delabeling: Opportunities for implementation and dissemination. Ann Allergy Asthma Immunol 2023; 130:554-564. [PMID: 36563744 DOI: 10.1016/j.anai.2022.12.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.
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Affiliation(s)
- Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Jordon Jaggers
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Allen Judd
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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2
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Medicine resident perceptions regarding β-lactam antibiotic prescribing in patients with penicillin allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:638-641.e1. [PMID: 36280135 DOI: 10.1016/j.jaip.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/14/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
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3
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Izadi N, Saff RR. Allergy and immunology interest and exposure among US medical students and residents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2022; 1:305-308. [PMID: 37779536 PMCID: PMC10509886 DOI: 10.1016/j.jacig.2022.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/28/2022] [Accepted: 08/02/2022] [Indexed: 10/03/2023]
Abstract
Background Despite the immense burden of allergic disease, the allergy and immunology (AI) workforce in the United States continues to shrink. Fellowship applications for AI have declined sharply in contrast to those in more popular specialties. Objectives Here we have sought to evaluate the current level of AI interest and exposure among early trainees in the United States, as well as their perspective on how to improve interest in the field. Methods An 18-item questionnaire was sent via e-mail list-serve to 2 groups: (1) mostly residents in the American Academy of Allergy, Asthma & Immunology (AAAAI) with interest in AI and (2) medical students in the American Medical Student Association (AMSA) whose specialty interests were not known. Results In the AAAAI group, 412 members were surveyed and 70 responses were received. In the AMSA group, 4778 members were surveyed and 47 responses were received. More individuals in the AAAAI group interacted with their AI division than in the AMSA group (73% vs 19% [P < .001]). On average, the AAAAI group would "probably" pursue AI whereas the AMSA group who would "definitely not" do so (P < .001). Almost all of the AMSA group (94%) had heard of AI before, but only 19% of them interacted with AI at their program. Regarding ways to increase interest in AI, the top responses for both groups were clinical exposure via electives and shadowing (a score of 4.69 on a 5-point scale) and didactic exposure via lectures and presentations (a score of 4.29). Conclusions Our study suggests that increasing AI opportunities for didactics and clinical exposure may lead medical students to develop more interest in pursuing the field. Some strategies are also discussed.
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Affiliation(s)
- Neema Izadi
- Division of Clinical Immunology and Allergy, Children’s Hospital Los Angeles/Keck School of Medicine of the University of Southern California, Los Angeles, Calif
| | - Rebecca R. Saff
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
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4
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Zembles TN, Vyles DE, Mitchell ML. Management of Children with Reported Penicillin Allergies. Infect Dis Clin North Am 2022; 36:219-229. [DOI: 10.1016/j.idc.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Anstey KM, Tsao L, Otani IM. Drug Allergy Delabeling Programs: Recent Strategies and Targeted Populations. Clin Rev Allergy Immunol 2022; 62:484-504. [PMID: 35031956 DOI: 10.1007/s12016-021-08913-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Drug allergy delabeling programs have become an essential element of antibiotic stewardship. Development of delabeling programs involves careful selection of target patient population, thoughtful design of delabeling approach, stakeholder engagement, assembly of key team members, implementation, and evaluation of clinical and safety outcomes. Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment. This review provides an overview of current risk stratification methods and β-lactam cross-reactivity data and summarizes how different inpatient and outpatient delabeling programs have used these concepts in delabeling algorithms. β-Lactam delabeling programs for inpatients, pediatric patients, and programs utilizing telehealth have been implemented with good outcomes. This review also focuses on delabeling programs for high-risk populations likely to benefit from first-line β-lactam antibiotics. These populations include perioperative, prenatal, and immunocompromised patients. Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use. This article reviews delabeling strategies utilized by these programs with a focus on highlighting elements key to their success and future areas for innovation.
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Affiliation(s)
- Karen M Anstey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code UHN67, Portland, OR, 97239, USA.
| | - Lulu Tsao
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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Catalano AC, Pittet LF, Choo S, Segal A, Stephens D, Cranswick NE, Gwee A. Impact of Antibiotic Allergy Labels on Patient Outcomes in a Tertiary Paediatric Hospital. Br J Clin Pharmacol 2021; 88:1107-1114. [PMID: 34388858 DOI: 10.1111/bcp.15038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Antibiotic allergies are reported in 5 to 15% of children. This study aimed to evaluate the impact of common β-lactam antibiotic allergy labels (AALs) on hospital treatment, focussing on length of stay and appropriateness of antibiotic prescribing. STUDY DESIGN Retrospective cohort study over 21-months at the Royal Children's Hospital Melbourne, Australia. A subset of children with the most common β-lactam allergies, and who required admission for intravenous antibiotics over a 12-month period, was analysed for appropriateness of prescribing. Non-allergic patients were matched to evaluate associations between AALs and hospital treatment. RESULTS There were 98,912 children admitted over the study period, of whom 938 (1%) had at least one AAL on first admission. Of all encounters, 5145 (2.5%) were for children with AALs. The most common AALs were to amoxicillin and amoxicillin-clavulanic acid combinations (40.8%), cefalexin (14.4%) and trimethoprim-sulfamethoxazole (9.7%). For the subset, there were 66 admissions for children who required intravenous antibiotics. Documentation was adequate for 27% of AALs. Inappropriate prescribing occurred in almost half (47%). Hospital stay was longer for children with AALs (median 4.7 days; IQR 2.3 to 9.2) compared to non-allergic controls (median 3.9 days; IQR 1.9 to 6.8; P=0.02). Children with AALs were more likely to receive restricted antibiotics (aOR 3.03; 95%CI, 1.45 to 6.30; p=0.003). CONCLUSION This is the first study to demonstrate high rates of inappropriate prescribing in children with AALs. Children with AALs were significantly more likely to receive restricted antibiotics and had a longer length of stay compared with non-allergic controls.
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Affiliation(s)
- Anthony C Catalano
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laure F Pittet
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Sharon Choo
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Allergy and Immunology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Ahuva Segal
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - David Stephens
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Noel E Cranswick
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Amanda Gwee
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
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DALES, Drug Allergy Labels in Elective Surgical patients: a prospective multicentre cross-sectional study of incidence, risks, and attitudes in penicillin de-labelling strategies. Br J Anaesth 2021; 127:897-904. [PMID: 34243942 DOI: 10.1016/j.bja.2021.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/23/2021] [Accepted: 05/30/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We sought to define the prevalence and nature of patient-reported drug allergies, determine their impact on prescribing, and explore drug allergy knowledge and attitudes amongst anaesthetists. METHODS We performed a prospective cross-sectional study in 213 UK hospitals in 2018. Elective surgical patients were interviewed, with a detailed allergy history taken in those self-reporting drug allergy. Anaesthetists completed a questionnaire concerning perioperative drug allergy. RESULTS Of 21 219 patients included, 6214 (29.3 %) (95% confidence interval [CI]: 28.7-29.9) reported drug allergy. Antibiotics, NSAIDs, and opioids were the most frequently implicated agents. Of a total of 8755 reactions, 2462 (28.1%) (95% CI: 29.2-31.1) were categorised as high risk for representing genuine allergy after risk stratification. A history suggestive of chronic spontaneous urticaria significantly increased the risk of reporting drug allergy (odds ratio 2.68; 95% CI: 2.4-3; P<0.01). Of 4756 anaesthetists completing the questionnaire, 1473 (31%) (95% CI: 29.7-32.3) routinely discuss perioperative allergy risk with patients. Prescribing habits in the presence of drug allergy labels differ depending on the implicated agent. Most anaesthetists (4678/4697; 99.6%) (95% CI: 99.4-99.8) prescribe opioids when reactions are consistent with side-effects, although 2269/4697 (48%) (95% CI: 46.9-49.7) would avoid the specific opioid reported. CONCLUSIONS Almost 30% of UK elective surgical patients report a history of drug allergies, but the majority of reported reactions are likely to be non-allergic reactions. Allergy labels can impact on perioperative prescribing through avoidance of important drugs and use of less effective alternatives. We highlight important knowledge gaps about drug allergy amongst anaesthetists, and the need for improved education around allergy.
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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Jain PD, Gupta RS, Chadha AS, Warren CM, Rao VV, Putcha UK. Knowledge, attitude, and practices of medical clinicians regarding food allergy and anaphylaxis in Hyderabad, India. Ann Allergy Asthma Immunol 2020; 125:560-564. [PMID: 32619591 DOI: 10.1016/j.anai.2020.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Food allergy (FA) is a chronic condition of emerging global concern. Surveys have been conducted in numerous countries to assess physician knowledge, attitude, and practices (KAP) pertaining to FA and anaphylaxis, and substantial deficits in their KAP were identified. OBJECTIVE To assess the KAP of medical clinicians in Hyderabad, India, with respect to FA and anaphylaxis. METHODS A regionally representative sample of 570 physicians including 113 general practitioners, 123 pediatricians, 110 pulmonologists, 113 dermatologists, and 111 gastroenterologists were recruited from all major institutions in Hyderabad, India. A validated questionnaire was used to assess their KAP. RESULTS Overall, 90% of questions were correctly answered and differences emerged with respect to specific items, namely the following: (1) the lateral thigh being the preferred location for epinephrine administration (P = .001); (2) a positive skin prick test or radioallergosorbent test is sufficient for FA diagnosis (P = .04); and (3) the appropriate epinephrine dose for a 27-kg child (P = .006). Approximately 95% of the participants in each group were confident in their ability to care for patients with FA, yet 91% desired additional periodic FA training sessions. CONCLUSION Survey findings suggest that although FA knowledge among South Indian clinicians seems high across all major specialties who care for patients with FA, there are differences in the level of knowledge among them, which in turn reflects the differences in attitude and approach toward their patients. These FA care providers still desire to further participate in continuing medical education efforts in the field of food allergy. Efforts to provide periodic training and education for all FA clinical care providers remain vital in South India.
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Affiliation(s)
- Priyanka D Jain
- Division of Pathology and Microbiology, National Institute of Nutrition, Hyderabad, India
| | - Ruchi S Gupta
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Avneet S Chadha
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher M Warren
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vishnu V Rao
- National Institute of Medical Statistics, New Dehli, India
| | - Uday K Putcha
- Division of Pathology and Microbiology, National Institute of Nutrition, Hyderabad, India
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10
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Electronic Consultations in Allergy/Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2594-2602. [DOI: 10.1016/j.jaip.2019.05.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/08/2019] [Accepted: 05/18/2019] [Indexed: 11/20/2022]
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Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clin Infect Dis 2019; 66:329-336. [PMID: 29361015 DOI: 10.1093/cid/cix794] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background A reported penicillin allergy may compromise receipt of recommended antibiotic prophylaxis intended to prevent surgical site infections (SSIs). Most patients with a reported penicillin allergy are not allergic. We determined the impact of a reported penicillin allergy on the development of SSIs. Methods In this retrospective cohort study of Massachusetts General Hospital hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, and coronary artery bypass grafting patients from 2010 to 2014, we compared patients with and without a reported penicillin allergy. The primary outcome was an SSI, as defined by the Centers for Disease Control and Prevention's National Healthcare Safety Network. The secondary outcome was perioperative antibiotic use. Results Of 8385 patients who underwent 9004 procedures, 922 (11%) reported a penicillin allergy, and 241 (2.7%) had an SSI. In multivariable logistic regression, patients reporting a penicillin allergy had increased odds (adjusted odds ratio, 1.51; 95% confidence interval, 1.02-2.22) of SSI. Penicillin allergy reporters were administered less cefazolin (12% vs 92%; P < .001) and more clindamycin (49% vs 3%; P < .001), vancomycin (35% vs 3%; P < .001), and gentamicin (24% vs 3%; P < .001) compared with those without a reported penicillin allergy. The increased SSI risk was entirely mediated by the patients' receipt of an alternative perioperative antibiotic; between 112 and 124 patients with reported penicillin allergy would need allergy evaluation to prevent 1 SSI. Conclusions Patients with a reported penicillin allergy had a 50% increased odds of SSI, attributable to the receipt of second-line perioperative antibiotics. Clarification of penicillin allergies as part of routine preoperative care may decrease SSI risk.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston
| | - Erin E Ryan
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston.,Infection Control Unit, Massachusetts General Hospital, Boston
| | - Yu Li
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Hang Lee
- Harvard Medical School, Boston.,Biostatistics Center, Massachusetts General Hospital, Boston
| | - James L Kuhlen
- Acadia Allergy and Immunology, Department of Medicine, University of South Carolina School of Medicine, Greenville, South Carolina
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston.,Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston.,Infection Control Unit, Massachusetts General Hospital, Boston
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12
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Jiang J, Gallagher JL, Szkodon JW, Syed M, Gobin KS, Gupta RS, Bilaver LA. The development and evaluation of peer food allergy education videos for school-age youth. Ann Allergy Asthma Immunol 2019; 123:107-108. [PMID: 30959102 DOI: 10.1016/j.anai.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/21/2019] [Accepted: 04/02/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Jialing Jiang
- Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Joel L Gallagher
- Allergy and Asthma Center of North Carolina, Cone Health Medical Group, Greensboro, North Carolina
| | - Jolanta W Szkodon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Maaria Syed
- Advocate Aurora Healthcare, Aurora, Illinois
| | - Karina S Gobin
- Allergy, Sinus, and Asthma Professionals, Melrose Park, Illinois
| | - Ruchi S Gupta
- Northwestern Feinberg School of Medicine, Chicago, Illinois; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lucy A Bilaver
- Northwestern Feinberg School of Medicine, Chicago, Illinois.
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Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393:183-198. [PMID: 30558872 PMCID: PMC6563335 DOI: 10.1016/s0140-6736(18)32218-9] [Citation(s) in RCA: 331] [Impact Index Per Article: 66.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023]
Abstract
Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jonny G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Controversies in Drug Allergy: Drug Allergy Pathways. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:46-60.e4. [PMID: 30573422 DOI: 10.1016/j.jaip.2018.07.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/16/2022]
Abstract
Drug allergy pathways are standardized approaches for patients reporting prior drug allergies with the aim of quality improvement and promotion of antibiotic stewardship. At the International Drug Allergy Symposium during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization Joint Congress in Orlando, Florida, drug allergy pathways were discussed from international perspectives with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. In this expert consensus document, we review current pathways, and detail important considerations in devising, implementing, and evaluating beta-lactam allergy pathways for hospitalized patients. We describe the key patient and institutional factors that must be considered in risk stratification, the central feature of pathway design. We detail shared obstacles to widespread beta-lactam allergy pathway implementation and identify potential solutions to address these challenges.
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15
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Blumenthal KG, Shenoy ES, Wolfson AR, Berkowitz DN, Carballo VA, Balekian DS, Marquis KA, Elshaboury R, Gandhi RG, Meka P, Kubiak DW, Catella J, Lambl BB, Hsu JT, Freeley MM, Gruszecki A, Wickner PG. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:616-625.e7. [PMID: 28483315 DOI: 10.1016/j.jaip.2017.02.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
Abstract
Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10% to 15% of inpatients reporting a previous penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at 5 hospitals within a single health care system in the Boston area. In this article, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective was to detail the lessons learned while empowering others to be part of this important, multidisciplinary work to improve the care of patients with reported beta-lactam allergies.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | | | - Diana S Balekian
- Allergy Unit, Department of Medicine, North Shore Medical Center, Salem, Mass; Asthma and Allergy Affiliates, Salem, Mass
| | - Kathleen A Marquis
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Ramy Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Ronak G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Praveen Meka
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - David W Kubiak
- Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass
| | | | - Barbara B Lambl
- Division of Infectious Diseases, Department of Medicine, North Shore Medical Center, Salem, Mass
| | - Joyce T Hsu
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - Alana Gruszecki
- Pharmacy Department, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:82-89. [PMID: 28958745 DOI: 10.1016/j.jaip.2017.07.033] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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Robinson M, Greenhawt M, Stukus DR. Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department. Ann Allergy Asthma Immunol 2017; 119:164-169. [PMID: 28711194 DOI: 10.1016/j.anai.2017.06.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/15/2017] [Accepted: 06/02/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Epinephrine is the first-line treatment for anaphylaxis but may be underused by patients and medical personnel. OBJECTIVE To evaluate factors associated with anaphylaxis management before arrival at the emergency department (ED) or urgent care center (UCC). METHODS We performed a retrospective review of electronic medical records for all patients aged 0 to 25 years presenting with anaphylaxis to the ED or UCC at a pediatric academic referral center during 2009 to 2013. RESULTS A total of 408 patients (mean age, 7.25 years; 62% male) were included for analysis. Only 148 patients (36.3%) received epinephrine before arrival at the ED or UCC. Reactions occurring at home (n = 36/114) were less likely to be treated with epinephrine compared with reactions occurring at school (n = 30/49) (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.15-0.59). The odds of receiving epinephrine before arrival at the ED or UCC were significantly lower with a 2-organ system (OR, 0.50; 95% CI, 0.30-0.85) or 3-organ system (OR, 0.41; 95% CI, 0.21-0.81) presentation compared with 1-organ system involvement. Foods (342 [83.8%]) were the most commonly reported provoking trigger. Patients who did not receive epinephrine before arrival at the ED or UCC were significantly less likely to be discharged to home (OR, 0.56; 95% CI, 0.37-0.86; P = .01). CONCLUSION This study identifies factors associated with prehospital management of anaphylaxis for children, which highlight that epinephrine administration may be occurring with considerable delay. Increased awareness and education of caregivers, patients, and medical professionals are necessary to provide optimal management.
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Affiliation(s)
- Melissa Robinson
- Section of Allergy and Immunology, National Jewish Hospital, Denver, Colorado
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital of Colorado, University of Colorado Denver School of Medicine, Denver, Colorado
| | - David R Stukus
- Department of Pediatrics, Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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Blumenthal KG, Lai KH, Huang M, Wallace ZS, Wickner PG, Zhou L. Adverse and Hypersensitivity Reactions to Prescription Nonsteroidal Anti-Inflammatory Agents in a Large Health Care System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:737-743.e3. [PMID: 28110055 DOI: 10.1016/j.jaip.2016.12.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/01/2016] [Accepted: 12/07/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used medications in the United States. NSAID use can be limited by adverse drug reactions (ADRs), including hypersensitivity reactions (HSRs). OBJECTIVE We aimed to use electronic health record data to determine the incidence and predictors of HSRs to prescription NSAIDs. METHODS We performed a retrospective cohort study of all adult outpatients in a large health care system prescribed diclofenac, indomethacin, nabumetone, or piroxicam between January 1, 2004, and September 30, 2012. The primary outcome was an ADR or HSR attributed to the prescribed NSAID within 1 year of prescription, determined from a longitudinal allergy database. We used natural language processing to classify known ADRs as either HSRs or side effects. Multivariable logistic regression models were used to identify independent risk factors for NSAID HSRs. RESULTS Of 62,719 patients prescribed NSAIDs, 1,035 (1.7%) had an ADR, of which 189 (18.3%) were HSRs. Multivariable regression analysis identified that patients with prior drug HSR history (odds ratio [OR] 1.8 [95% CI 1.3, 2.5]), female sex (OR 1.8 [95% CI 1.3, 2.4]), autoimmune disease (OR 1.7 [95% CI 1.1, 2.7]), and those prescribed the maximum standing NSAID dose (OR 1.5 [95% CI 1.1, 2.0]) had increased odds of NSAID HSR. CONCLUSIONS NSAID therapeutic use can be limited by ADRs; about 1 in 5 NSAID ADRs is an HSR. Both patient and drug factors contribute to HSR risk and are important to guide patient counseling.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass.
| | | | - Mingshu Huang
- Biostatistics Center, Massachusetts General Hospital, Boston, Mass
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Li Zhou
- Harvard Medical School, Boston, Mass; Partners eCare, Partners HealthCare System, Boston, Mass; Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Singh S, Singh N. Current trends of management of respiratory diseases by pulmonologists: Results of National Conference of Pulmonary Disease - 2015 survey. Lung India 2017; 34:13-18. [PMID: 28144054 PMCID: PMC5234191 DOI: 10.4103/0970-2113.197093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Context: Respiratory diseases are a common problem in our country and these are associated with significant morbidity and mortality. Aims: The aim of the paper was to analyze the pattern of diagnostic tests used and treatment prescribed for common respiratory diseases. Settings and Design: A total of 1028 pulmonologists, either member of Indian Chest Society or delegate attending the National Conference of Pulmonary Diseases (NAPCON) 2015, participated in the online survey. Subjects and Methods: The survey included questions pertinent to common respiratory diseases such as pulmonary tuberculosis (PTB), bronchial asthma, chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and pneumonia. Results: Investigation used for severity assessment and diagnosis of PTB, was sputum for acid-fast bacilli (83.5%), for IPF was high-resolution computed tomography chest (85.6%), for severe pneumonia was arterial blood gas analysis (69.3%), for asthma was spirometery and peak flow (96.8%) and for COPDs was spirometry (87.2%). The most popular choice of treatment for PTB was directly observed treatment short course (55.7%), for bronchial asthma, it was long-acting beta agonist with inhaled corticosteroids (LABA + ICSs) (41.1%), for COPD, it was LABA, ICS, and long-acting muscarinic antagonist (LABA + ICS + long-acting muscarinic antagonist) (32.4%) and for IPF, it was pirfenidone and N acetyl cysteine (38.3%). About 67.5% of doctors preferred hospitalization for patients with severe pneumonia. About 84.5% pulmonologists ordered diagnostic tests and 55.5% prescribed treatment as per current guidelines. Conclusions: The majority of doctors (70.1%) in our survey followed recommended guidelines for respiratory disease diagnosis and treatment. However, there is a need for upgradation of treatment strategies currently used by doctors.
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Affiliation(s)
- Sheetu Singh
- Department of Chest and Tuberculosis, SMS Medical College, Jaipur, Rajasthan, India
| | - Nishtha Singh
- Consultant, Department of Pulmonary Medicine, Asthma Bhawan, Jaipur, Rajasthan, India
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Stukus DR, Kempe E, Leber A, Thornton D, Scherzer R. Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists. Pediatrics 2016; 138:peds.2016-1602. [PMID: 27940693 DOI: 10.1542/peds.2016-1602] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Immunoglobullin E (IgE)-mediated food allergies affect 5% to 8% of children. Serum IgE levels assist in diagnosing food allergies but have low positive predictive value. This can lead to misinterpretation, overdiagnosis, and unnecessary dietary elimination. Use of IgE food allergen panels has been associated with increased cost and burden. The scale of use of these panels has not been reported in the medical literature. METHODS We conducted a retrospective review of a commercial laboratory database associated with a tertiary care pediatric academic medical center for food IgE tests ordered by all provider types during 2013. RESULTS A total of 10 794 single-food IgE tests and 3065 allergen panels were ordered. Allergists ordered the majority of single-food IgE tests (58.2%) whereas 78.8% of food allergen panels were ordered by primary care providers (PCPs) (P < .001). Of all IgE tests ordered by PCPs, 45.1% were panels compared with 1.2% of orders placed by allergists (P < .001). PCPs in practice for >15 years ordered a higher number of food allergen panels (P < .05) compared with PCPs with less experience. Compared with allergists, PCPs ordered more tests for unlikely causes of food allergies (P < .001). Total cost of IgE testing and cost per patient were higher for PCPs compared with allergists. CONCLUSIONS Review of food allergen IgE testing through a high volume outpatient laboratory revealed PCPs order significantly more food allergen panels, tests for uncommon causes of food allergy, and generate higher cost per patient compared with allergists. These results suggest a need for increased education of PCPs regarding proper use of food IgE tests.
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Affiliation(s)
- David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Erin Kempe
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Amy Leber
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - David Thornton
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Scherzer
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio; and
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Blumenthal KG, Park MA, Macy EM. Redesigning the allergy module of the electronic health record. Ann Allergy Asthma Immunol 2016; 117:126-31. [PMID: 27315742 DOI: 10.1016/j.anai.2016.05.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 05/16/2016] [Accepted: 05/19/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Professional Organization, Boston, Massachusetts.
| | - Miguel A Park
- Allergy and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Eric M Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California
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