Potential food allergens in medications

Using Fume Hood to Reduce Nurses' Exposure to Particulate Matters Dispersed Into the Air During Pill Crushing

BACKGROUND

Pill crushing is a common practice in patient care settings. Crushing pills can disperse particulate matter (PM) into indoor air. The PM is a widespread air pollutant composed of microscopic particles and droplets of various sizes and may carry active and/or inactive ingredients nurses can inhale. This study aimed to quantify PM sizes and concentration in indoor air when pills are crushed and examine the role of a fume hood in reducing particulate pollution.

METHODS

Two scenarios (with and without a fume hood) representing nurses' pill-crushing behaviors were set up in a positive-pressure cleanroom. Two acetaminophen tablets (325 mg/tablet) were crushed into powder and mixed with unsweetened applesauce. The PM sizes and concentrations were measured before and during crushing.

RESULTS

Different sizes of PM, including inhalable, respirable, and thoracic particles, were emitted during medication crushing. The total count of all particle sizes and mass concentrations of particles were significantly lower during crushing when a fume hood was used (p = .00).

CONCLUSION

Pill crushing increases PM and should be considered a workplace safety health hazard for nurses. Healthcare professionals should work under a fume hood when crushing pills and wear proper protective equipment. The findings of significant particulate pollution related to pill crushing suggest that further research is warranted.

Evaluation and Management of Food Allergies in the Emergency Department

Food allergies are a common and serious cause of illness, accounting for an increasing number of emergency department visits annually. Although definite diagnosis lays outside of an emergency department visit, the clinical management of the most serious food allergies highlights emergency care. The staple of acute care remains epinephrine in association with antihistamines and steroids. The greatest threat remains undertreatment for this group of disorders and underutilization of epinephrine. Those who have been treated for a food allergy need a follow-up allergist evaluation, guidance of food avoidance, and avoidance of foods with cross-sensitivities as well as ready access to epinephrine.

Open sesame: Shedding light on an emerging global allergen

BACKGROUND

Sesame allergy has been characterized in the Middle East for some time. However, it has become more widely recognized as foods containing sesame and sesame seeds have become increasingly available in Australia, Europe, and North America. With the passage of the Food Allergy Safety, Treatment, Education, and Research Act in 2021, the United States will join other countries in identifying sesame as a major food allergen and require sesame to be labeled as a food allergen beginning in 2023.

OBJECTIVE

To review the literature related to sesame allergy as an increasingly recognized food allergen around the world.

DATA SOURCES

English-language articles retrieved by PubMed searches with relevance to sesame allergy.

STUDY SELECTIONS

Articles were included using the search terms "sesame allergy" and "sesame seed allergy."

RESULTS

A total of 69 relevant articles regarding sesame allergy, relating to its prevalence, clinical presentation, natural history, allergenic epitopes, diagnosis, and treatment, were selected.

CONCLUSION

In recent decades, considerable gains have been made in determining prevalence and natural history of sesame allergy. With increased recognition and prevalence come the need for reliable methods of identification of sesame allergy and approaches for management.

Lactose-Containing Dry-Powder Inhalers for Patients with Cow's Milk Protein Allergy-The Conundrum; A National Survey of Pediatric Pulmonologists and Allergologists

Introduction: Several dry-powder inhalers (DPIs) contain lactose which may be contaminated with milk proteins. Confusion exists pertaining to DPI use in patients with cow's milk protein allergy (CMPA). Methods: A computerized survey sent via e-mail to pediatric pulmonologists and allergologists. Results: A total of 77 out of 232 (33.2%) doctors replied, of whom 80.5% were pediatric pulmonologists. A total of 69 of 77 (89.6%) were specialists, 37.6% with more than 15 years of experience. The most commonly used DPIs were formoterol + budesonide and vilanterol + fluticasone. A total of 62 out of 77 (80.5%) responders knew these DPIs contained lactose. A total of 35 out of 77 (45.5%) doctors who replied did not know that DPI leaflets list CMPA as a contra-indication to DPI administration. Of these, 4 (11.4%) stated that they would instruct patients with CMPA to stop DPIs, and 7 (20%) would avoid recommending DPIs. A total of 42 out of 77 (54.5%) responders were aware of this warning, yet 13 of these 42 (30.9%) continued to recommend lactose-containing DPIs without hesitation and 18 of these 42 (42.8%) responders prescribed DPIs but considered allergy severity. Conclusions: Almost half of certified, experienced pediatric pulmonologists and allergologists were unaware of the warning to administer DPIs to patients with CMPA. Most doctors who do know of this warning still continue to prescribe these DPIs.

Immediate Hypersensitivity Reactions Induced by COVID-19 Vaccines: Current Trends, Potential Mechanisms and Prevention Strategies

As the world deals with the COVID-19 pandemic, vaccination remains vital to successfully end this crisis. However, COVID-19-vaccine-induced immediate hypersensitivity reactions presenting with potentially life-threatening systemic anaphylactic reactions are one of the reasons for vaccine hesitancy. Recent studies have suggested that different mechanisms, including IgE-mediated and non-IgE-mediated mast cell activation, may be involved in immediate hypersensitivity. The main culprits triggering hypersensitivity reactions have been suggested to be the excipients of vaccines, including polyethylene glycol and polysorbate 80. Patients with a history of allergic reactions to drugs, foods, or other vaccines may have an increased risk of hypersensitivity reactions to COVID-19 vaccines. Various strategies have been suggested to prevent hypersensitivity reactions, including performing skin tests or in vitro tests before vaccination, administering different vaccines for the primary and following boosters, changing the fractionated doses, or pretreating the anti-IgE antibody. This review discusses the current trends, potential mechanisms, and prevention strategies for COVID-19-vaccine-induced immediate hypersensitivity reactions.

Predicting the Activities of Drug Excipients on Biological Targets using One-Shot Learning

Excipients are major components of drugs and are used to improve drug attributes such as stability and appearance. Excipients approved by the U.S. Food and Drug Administration (FDA) are regarded as safe for humans in allowed concentrations, but their potential interactions with drug targets have not been investigated systematically, which might influence a drug's efficacy. Deep learning models have been used for the identification of ligands that could bind to the drug targets. However, due to the limited available data, it is challenging to reliably estimate the likelihood of a ligand-protein interaction. One-shot learning techniques provide a potential approach to address this low data problem as these techniques require only one or a few examples to classify the new data. In this study, we apply one-shot learning models to data sets that include ligands binding to G-protein-coupled receptors (GPCRs) and kinases. The predicted results suggest that one-shot learning could be used for predicting ligand-protein interactions, and the models attain better performance when protein targets contain conserved binding pockets. The trained models are also used to predict interactions between excipients and drug targets, which provides a potential efficient strategy to explore the activities of drug excipients. We find that a large number of drug excipients could interact with biological targets and influence their function. The results demonstrate how one-shot learning can be used to make accurate predictions for excipient-protein interactions, and these methods could be used for selecting excipients with limited drug-protein interactions.

Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative

OBJECTIVES

Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module.

METHODS

We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list.

RESULTS

We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods.

CONCLUSIONS

Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.

Age-related differences in characteristics of anaphylaxis in Chinese children from infancy to adolescence

Background

Little is known about anaphylaxis in Chinese children. This study aimed to determine the age-specific patterns of anaphylaxis in Chinese children.

Methods

We conducted a retrospective study of anaphylaxis cases attending an allergy department in a tertiary children's hospital.

Results

A total of 279 anaphylactic reactions in 177 patients were analyzed. Overall, 57.6% (102/177) of first anaphylaxis events occurred in infants (0-2 ys). Foods were the most common culprits (88.5%), followed by food + exercise/exercise (4.7%), and drugs (4.3%). The main food allergens were cow's milk (32.9%), egg (21.4%), and wheat (20.7%) in infants, compared with fruits/vegetables at 35.9% in preschool-age children (3-6 ys) and 31.6% in school-age children (7-12 ys). The most commonly implicated drug triggers were vaccines (n = 5, comprising DTaP n = 2, group A + C meningococcal polysaccharide vaccine n = 1, Sabin vaccine n = 1, and not specified n = 1). Among the 5 vaccine-induced anaphylaxis patients, 4 had severe cow's milk allergy. The clinical manifestations were mainly mucocutaneous (86.0%), followed by respiratory (68.8%), gastrointestinal (23.7%), neurological (10.4%), and cardiovascular (0.7%). Compared with patients of other ages, infants had higher rates of hives (0-2ys 77.4%, 3-6ys 50%,7-12ys 57.9%, 13-17ys 38.9%, p = 0.016) and vomiting (0-2ys 20.7%, 3-6ys 1.6%,7-12ys 8.8%, p < 0.001), while wheezing was more frequent in school-age children (0-2ys 21.4%, 3-6ys 25%, 7-12ys 38.6%, 13-17ys 5.6%, p = 0.017) and abdominal pain was more common in adolescents (0-2ys 2.1%,3-6ys 15.6%, 7-12ys 14.0%, 13-17ys 72.3%, p < 0.001). Regarding treatment, 9.3% of anaphylaxis events and 24.1% of life-threatening reactions were treated with epinephrine.

Conclusions

We observed age-related clinical patterns of anaphylaxis in this study, with hives and vomiting most commonly reported in infants and cardiovascular symptoms rarely reported in children. Wheat was the third most culprit food allergen after egg and milk in infancy. Education regarding more aggressive use of epinephrine in the emergency setting is clearly needed. Recognition of age-related symptoms in anaphylaxis can aid physicians in prompt diagnosis and acute management.

Evaluation and Management of Food Allergies in the Emergency Department

Food allergies are a common and serious cause of illness, accounting for an increasing number of emergency department visits annually. Although definite diagnosis lays outside of an emergency department visit, the clinical management of the most serious food allergies highlights emergency care. The staple of acute care remains epinephrine in association with antihistamines and steroids. The greatest threat remains undertreatment for this group of disorders and underutilization of epinephrine. Those who have been treated for a food allergy need a follow-up allergist evaluation, guidance of food avoidance, and avoidance of foods with cross-sensitivities as well as ready access to epinephrine.

Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions

Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.

New perspectives on propofol allergy

PURPOSE

Propofol is an intravenous sedative used in many patient populations and care settings. Although generally considered safe and effective, the drug has historically been avoided in patients with reported allergies to egg, soy, and/or peanut on the basis of the manufacturer's prescribing information. Concerns exist for potential adverse events, increased medication costs, reduced efficacy, and risk of medication errors when using alternative agents. Here we present a critical examination of the literature concerning cross-reactivity of food allergies with propofol to provide evidence-based recommendations for the evaluation and management of potential allergic reactions.

SUMMARY

Literature regarding the history of propofol allergy warnings and clinical trial data were assessed to provide an alternative perspective on avoidance of propofol in patients with food allergies. Suspected trigger molecules are discussed with evaluation of the antigenic potential of excipient ingredients used in the manufacture of multiple propofol formulations. Evidence-based recommendations are provided for pharmacist-led screening of adult patients with reported food allergies to support selection of propofol or alternative therapy.

CONCLUSION

There is a lack of definitive evidence that propofol must be routinely avoided in patients with reported allergies to egg, soy, and/or peanut products. Data from clinical trials suggest that propofol is safe for patients with nonanaphylactic food allergies. Patients who do experience allergic reactions following administration of propofol should undergo further testing to definitively identify the specific trigger and prevent future unnecessary avoidance of preferred medication regimens. Pharmacists can play an important role in interviewing patients with reported food allergies to better determine the risk vs benefit of propofol avoidance.

Adverse reactions to food additives

Food additives are naturally occurring or synthetic substances that are added to food to modify the color, taste, texture, stability, or other characteristics of foods. These additives are ubiquitous in the food that we consume on a daily basis and, therefore, have been the subject of much scrutiny about possible reactions. Despite these concerns, the overall prevalence of food additive reactions is 1-2%, with a minority of the wide variety of symptoms attributed to food-additive exposure being reproduced by double-blind placebo controlled challenges. Reactions can be broadly classified into either immunoglobulin E (IgE)- and non-IgE-mediated reactions, with natural additives accounting for most IgE-mediated reactions, and both natural and synthetic additives being implicated in the non-IgE-mediated reactions. Reactions that include asthma exacerbations, urticaria and/or angioedema, or anaphylaxis with ingestion of a food additive are most deserving of further allergy evaluation. In this article, we discussed the different types of adverse reactions that have been described to various food additives. We also reviewed the specifics of how to evaluate and diagnose a food additive allergy in a clinic setting.

Historical Evolution and Provider Awareness of Inactive Ingredients in Oral Medications

PURPOSE

A multitude of different versions of the same medication with different inactive ingredients are currently available. It has not been quantified how this has evolved historically. Furthermore, it is unknown whether healthcare professionals consider the inactive ingredient portion when prescribing medications to patients.

METHODS

We used data mining to track the number of available formulations for the same medication over time and correlate the number of available versions in 2019 to the number of manufacturers, the years since first approval, and the number of prescriptions. A focused survey among healthcare professionals was conducted to query their consideration of the inactive ingredient portion of a medication when writing prescriptions.

RESULTS

The number of available versions of a single medication have dramatically increased in the last 40 years. The number of available, different versions of medications are largely determined by the number of manufacturers producing this medication. Healthcare providers commonly do not consider the inactive ingredient portion when prescribing a medication.

CONCLUSIONS

A multitude of available versions of the same medications provides a potentially under-recognized opportunity to prescribe the most suitable formulation to a patient as a step towards personalized medicine and mitigate potential adverse events from inactive ingredients.

Food allergy management

Optimal management of food allergy is complex and multifaceted. Management of food allergy includes ensuring proper diagnosis, monitoring for the emergence of natural tolerance, screening for nutritional and psychosocial issues, and educating the patient and family on living with food allergies across childhood. Education must encompass successfully avoiding the trigger food, recognizing and treating allergic reactions, and navigating living with food allergies. Allergists can help families prepare for specific situations, such as working with daycares, schools, after-school activities and camps, traveling, and dining out. In addition, psychosocial issues such as anxiety and bullying should be addressed, and counseling with regard to emerging therapies discussed. Managing children with food allergies requires continual follow up with regard to these issues, and the needs of families will change over time. Allergists can guide the family as the child grows and transitions to adulthood when managing food allergy.

ELQ-331 as a prototype for extremely durable chemoprotection against malaria

Background

The potential benefits of long-acting injectable chemoprotection (LAI-C) against malaria have been recently recognized, prompting a call for suitable candidate drugs to help meet this need. On the basis of its known pharmacodynamic and pharmacokinetic profiles after oral dosing, ELQ-331, a prodrug of the parasite mitochondrial electron transport inhibitor ELQ-300, was selected for study of pharmacokinetics and efficacy as LAI-C in mice.

Methods

Four trials were conducted in which mice were injected with a single intramuscular dose of ELQ-331 or other ELQ-300 prodrugs in sesame oil with 1.2% benzyl alcohol; the ELQ-300 content of the doses ranged from 2.5 to 30 mg/kg. Initial blood stage challenges with Plasmodium yoelii were used to establish the model, but the definitive study measure of efficacy was outcome after sporozoite challenge with a luciferase-expressing P. yoelii, assessed by whole-body live animal imaging. Snapshot determinations of plasma ELQ-300 concentration ([ELQ-300]) were made after all prodrug injections; after the highest dose of ELQ-331 (equivalent to 30 mg/kg ELQ-300), both [ELQ-331] and [ELQ-300] were measured at a series of timepoints from 6 h to 5½ months after injection.

Results

A single intramuscular injection of ELQ-331 outperformed four other ELQ-300 prodrugs and, at a dose equivalent to 30 mg/kg ELQ-300, protected mice against challenge with P. yoelii sporozoites for at least 4½ months. Pharmacokinetic evaluation revealed rapid and essentially complete conversion of ELQ-331 to ELQ-300, a rapidly achieved (< 6 h) and sustained (4–5 months) effective plasma ELQ-300 concentration, maximum ELQ-300 concentrations far below the estimated threshold for toxicity, and a distinctive ELQ-300 concentration versus time profile. Pharmacokinetic modeling indicates a high-capacity, slow-exchange tissue compartment which serves to accumulate and then slowly redistribute ELQ-300 into blood, and this property facilitates an extremely long period during which ELQ-300 concentration is sustained above a minimum fully-protective threshold (60–80 nM).

Conclusions

Extrapolation of these results to humans predicts that ELQ-331 should be capable of meeting and far-exceeding currently published duration-of-effect goals for anti-malarial LAI-C. Furthermore, the distinctive pharmacokinetic profile of ELQ-300 after treatment with ELQ-331 may facilitate durable protection and enable protection for far longer than 3 months. These findings suggest that ELQ-331 warrants consideration as a leading prototype for LAI-C.

Hazardous Medications in Children with Egg, Red Meat, Gelatin, Fish, and Cow's Milk Allergy

Childhood food allergies are a growing public health problem. Once the offending food allergens have been identified, a strict elimination diet is necessary in treatment or prevention of most of the allergic reactions. Accidental food ingestion can lead to severe anaphylaxis. Food- derived substances can be used in medications at various stages of the manufacturing process. In this review, the possible roles of medications which may contain egg, red meat, gelatin, and fish allergens on allergic reactions in children with food allergy were evaluated.

Preventing iatrogenic gelatin anaphylaxis

OBJECTIVE

To assess the iatrogenic risks of gelatin allergy and identify resources for patient management.

DATA SOURCES

A literature review was performed using PubMed and public databases provided by the National Library of Medicine.

STUDY SELECTIONS

Reports of iatrogenic gelatin allergy associated with vaccines, hemostatic agents, intravenous colloids, medicinal capsules, and intraoperative surgical supplies.

RESULTS

Gelatin ingredients may not be identified by electronic medical record safeguards, and an exhaustive listing of potential iatrogenic exposures is elusive. The National Library of Medicine AccessGUDID (https://accessgudid.nlm.nih.gov/) can be a useful resource in evaluating medical devices for gelatin content. Unexpected sources of iatrogenic gelatin exposure include hemostatic agents, vascular grafts, intravascular cannulas, bone replacement implants, and emergency resuscitation fluids.

CONCLUSION

Vigilance is important within medical systems to avoid inadvertent gelatin exposure when caring for patients with gelatin allergy. Additional safeguards are needed to remove latent health care system errors that fail to prevent gelatin administration in this at-risk population.

"Inactive" ingredients in oral medications

Oral forms of medications contain "inactive" ingredients to enhance their physical properties. Using data analytics, we characterized the abundance and complexity of inactive ingredients in approved medications. A majority of medications contain ingredients that could cause adverse reactions, underscoring the need to maximize the tolerability and safety of medications and their inactive ingredients.

Food Allergy Management

The management of food allergies requires the cooperation of the food allergic person, physician, family, and social contacts. For children, school management of food allergies is a key component of the overall approach. Recognition of the signs and symptoms of allergic reactions and preparation to administer the appropriate treatment of mild and severe symptoms in the event of accidental exposure is necessary. Avoidance of food allergens is facilitated by label reading and dietary guidance is extremely important to minimize nutritional deficiencies. Medications and vaccines with food-derived excipients generally do not need to be avoided because, in most cases, they contain little food protein.

Propofol Use in Pediatric Patients With Food Allergy and Eosinophilic Esophagitis

Propofol is a safe, well-tolerated anesthetic that is labeled as contraindicated in patients with egg or soy allergy. This contraindication has become increasingly problematic given the rising incidence of food allergy and eosinophilic esophagitis (EoE). To address this issue, we studied practice patterns of propofol use for esophagogastroduodenoscopies in children with EoE and food allergies at our institution. A retrospective observational study of 1365 esophagogastroduodenoscopies from January 2013 to June 2014 was performed. Data were analyzed using Student t tests, chi square tests, Fisher exact tests, and multivariable logistic regression. We found that propofol was used significantly less in patients with egg or soy allergy, and in patients with EoE, even after adjusting for the presence of food allergy. There was no difference in complication rates relative to propofol use. Propofol was used safely in pediatric patients with EoE and food allergy in this limited single-center review.

Hypersensitivities to sesame and other common edible seeds

Several seeds have been increasingly incorporated in various food items, with consequent risk of hypersensitivity reactions that are often severe. Identification of the specific seed as the culprit is often not explored or is difficult to verify. In this article, we reviewed the English literature from January 1930 to March 2016 using PubMed and Google Scholar searching for publications relevant to hypersensitivity to common edible seeds, namely sesame, sunflower seed, poppy seed, pumpkin seed, flaxseed, and mustard seed. Considering the worldwide consumption of those seeds, the number of published articles on the subject was relatively small and was mainly as case reports rather than large series. Allergy to sesame was more reported than to other seeds, with an estimated prevalence of 0.1-0.2%. In this review, we summarize the information relevant to each of the six seeds and their oils regarding the manifestations, routes of exposure, identified major allergens, and cross-reactivity with other seeds or other foods. We also addressed the important role of a thorough history taking in suspecting seed allergy, the limited reliability of routine diagnostic procedures, and the importance of verification by appropriate challenge tests. At present, management is basically dietary avoidance and the use of symptomatic medications that may include epinephrine auto-injectors. We did not encounter any well-designed studies on immunotherapy for seed allergy, but it is hoped that such a gap be filled by the development of safe effective protocols in the near future.

International Consensus (ICON): allergic reactions to vaccines

BACKGROUND

Routine immunization, one of the most effective public health interventions, has effectively reduced death and morbidity due to a variety of infectious diseases. However, allergic reactions to vaccines occur very rarely and can be life threatening. Given the large numbers of vaccines administered worldwide, there is a need for an international consensus regarding the evaluation and management of allergic reactions to vaccines.

METHODS

Following a review of the literature, and with the active participation of representatives from the World Allergy Organization (WAO), the European Academy of Allergy and Clinical Immunology (EAACI), the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the American College of Allergy, Asthma, and Immunology (ACAAI), the final committee was formed with the purpose of having members who represented a wide-range of countries, had previously worked on vaccine safety, and included both allergist/immunologists as well as vaccinologists.

RESULTS

Consensus was reached on a variety of topics, including: definition of immediate allergic reactions, including anaphylaxis, approaches to distinguish association from causality, approaches to patients with a history of an allergic reaction to a previous vaccine, and approaches to patients with a history of an allergic reaction to components of vaccines.

CONCLUSIONS

This document provides comprehensive and internationally accepted guidelines and access to on-line documents to help practitioners around the world identify allergic reactions following immunization. It also provides a framework for the evaluation and further management of patients who present either following an allergic reaction to a vaccine or with a history of allergy to a component of vaccines.

Food entries in a large allergy data repository

OBJECTIVE

Accurate food adverse sensitivity documentation in electronic health records (EHRs) is crucial to patient safety. This study examined, encoded, and grouped foods that caused any adverse sensitivity in a large allergy repository using natural language processing and standard terminologies.

METHODS

Using the Medical Text Extraction, Reasoning, and Mapping System (MTERMS), we processed both structured and free-text entries stored in an enterprise-wide allergy repository (Partners' Enterprise-wide Allergy Repository), normalized diverse food allergen terms into concepts, and encoded these concepts using the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) and Unique Ingredient Identifiers (UNII) terminologies. Concept coverage also was assessed for these two terminologies. We further categorized allergen concepts into groups and calculated the frequencies of these concepts by group. Finally, we conducted an external validation of MTERMS's performance when identifying food allergen terms, using a randomized sample from a different institution.

RESULTS

We identified 158 552 food allergen records (2140 unique terms) in the Partners repository, corresponding to 672 food allergen concepts. High-frequency groups included shellfish (19.3%), fruits or vegetables (18.4%), dairy (9.0%), peanuts (8.5%), tree nuts (8.5%), eggs (6.0%), grains (5.1%), and additives (4.7%). Ambiguous, generic concepts such as "nuts" and "seafood" accounted for 8.8% of the records. SNOMED-CT covered more concepts than UNII in terms of exact (81.7% vs 68.0%) and partial (14.3% vs 9.7%) matches.

DISCUSSION

Adverse sensitivities to food are diverse, and existing standard terminologies have gaps in their coverage of the breadth of allergy concepts.

CONCLUSION

New strategies are needed to represent and standardize food adverse sensitivity concepts, to improve documentation in EHRs.

2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized. Advances in epidemiology, diagnosis, and management in healthcare and community settings are highlighted. Additionally, new information about patient factors that increase the risk of severe and/or fatal anaphylaxis and patient co-factors that amplify anaphylactic episodes is presented and new information about anaphylaxis triggers and confirmation of triggers to facilitate specific trigger avoidance and immunomodulation is reviewed. The update includes tables summarizing important advances in anaphylaxis research.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2014

This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2014. Studies on food allergy suggest worrisomely high rates of peanut allergy and food-induced anaphylaxis-related hospitalizations. Evidence is mounting to support the theory that environmental exposure to peanut, such as in house dust, especially with an impaired skin barrier attributed to atopic dermatitis (AD) and loss of function mutations in the filaggrin gene, is a risk factor for sensitization and allergy. Diagnostic tests are improving, with early studies suggesting the possibility of developing novel cellular tests with increased diagnostic utility. Treatment trials continue to show the promise and limitations of oral immunotherapy, and mechanistic studies are elucidating pathways that might define the degree of efficacy of this treatment. Studies have also provided insights into the prevalence and characteristics of anaphylaxis and insect venom allergy, such as suggesting that baseline platelet-activating factor acetylhydrolase activity levels are related to the severity of reactions. Advances in drug allergy include identification of HLA associations for penicillin allergy and a microRNA biomarker/mechanism for toxic epidermal necrolysis. Research identifying critical events leading to skin barrier dysfunction and the polarized immune pathways that drive AD have led to new therapeutic approaches in the prevention and management of AD.

Vaccination in children with allergy to non active vaccine components

Childhood immunisation is one of the greatest public health successes of the last century. Vaccines contain an active component (the antigen) which induces the immune response. They may also contain additional components such as preservatives, additives, adjuvants and traces of other substances. This review provides information about risks of hypersensitivity reactions to components of vaccines. Furthermore, recommendations to avoid or reduce reactions to vaccine components have been detailed.