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Raju M, Sagar M, Bush A, Quaye E, Ghamande S, Malhotra S, Arroliga ME. The role of supervised school therapy in poorly controlled asthma in children. Proc AMIA Symp 2023; 36:448-452. [PMID: 37334099 PMCID: PMC10269411 DOI: 10.1080/08998280.2023.2204522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 06/20/2023] Open
Abstract
Background In children, nonadherence to inhaled corticosteroid (ICS) therapy leads to poor asthma control and complications. Methods We evaluated the benefit from initiation of ICS administration once daily at school. We retrospectively chose patients from our pediatric pulmonary clinic who had poorly controlled asthma and prescribed ICS daily. For the study period, we examined the number of corticosteroid courses, emergency room visits, hospital admissions, symptom history, and pulmonary function tests. Results Thirty-four patients who satisfied the inclusion criteria began the intervention. Preintervention, there were a mean number of 2.6 oral corticosteroid courses compared to 2 courses in the year following intervention (P = 0.8). Postintervention emergency department visits decreased from a mean of 1.4 to 1.0 (P = 0.71), and hospital admissions decreased from 1.23 to 0.57 (P = 0.04). There was also a significant increase in forced expiratory volume in 1 second (1.69 vs 1.4 L/sec, P = 0.02), a decrease in systemic steroid-free days in a year (96 vs 141 days, P = 0.03), and an increase in symptom-free days postintervention (28 vs 26 days, P = 0.325). Conclusion These findings suggest that ICS administration in schools may help reduce hospital admissions and improve lung function in patients with poorly controlled asthma.
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Affiliation(s)
- Muppala Raju
- Department of Pediatrics, Baylor Research Institute, Temple, Texas
| | - Malvika Sagar
- Division of Pediatric Pulmonology, Department of Pediatrics, Baylor Scott and White McLane Children’s Medical Center, Temple, Texas
| | - Andrew Bush
- Department of Paediatrics, Imperial College London, London, UK
| | - Eugene Quaye
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Shekhar Ghamande
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Sonal Malhotra
- Pulmonary and Sleep Medicine Services, Baylor College of Medicine, Houston, Texas
| | - Mercedes E. Arroliga
- Division of Allergy and Clinical Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas
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Angirekula A, Estrada VA, Sagar M, Arroliga ME. Hypersensitivity reactions to multiple biologicals in a pediatric patient with severe persistent asthma. Proc AMIA Symp 2022; 36:66-67. [PMID: 36578600 PMCID: PMC9762826 DOI: 10.1080/08998280.2022.2116692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Asthma is a common chronic pediatric disease that negatively impacts the quality of patients' lives. While most cases can be effectively managed with a regimen of inhaled corticosteroids, severe cases require prolonged or frequent courses of oral corticosteroids or the addition of biologic therapies and allergen immunotherapy. Biologics are well tolerated with few side effects; however, reactions as severe as anaphylaxis have been reported. We present a pediatric patient with severe persistent asthma who developed hypersensitivity reactions to three different biologic agents.
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Affiliation(s)
| | - Victor A. Estrada
- Division of Allergy and Clinic Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas
| | - Malvika Sagar
- Department of Pediatrics, Baylor Scott and White McLane Children’s Medical Center, Temple, Texas
| | - Mercedes E. Arroliga
- Division of Allergy and Clinic Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas,Corresponding author: Mercedes E. Arroliga, MD, Baylor Scott and White Center for Diagnostic Medicine, 1605 S. 31st St., Temple, TX76508 (e-mail: )
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Arroliga ME, Dhanani K, Arroliga AC, Huddleston PS, Trahan J, Aguilar T, Weldon D. Allergic reactions and adverse events associated with administration of mRNA-based vaccines. A health-care system experience. Allergy Asthma Proc 2021; 42:395-399. [PMID: 34474708 DOI: 10.2500/aap.2021.42.210069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Adverse reactions, including anaphylaxis, to messenger RNA coronavirus disease 2019 (COVID-19) vaccines rarely occur. Because of the need to administer a timely second dose in subjects who reported a reaction to their first dose, a panel of health-care professionals developed a safe triage of the employees and health care providers (EHCP) at a large health-care system to consider administration of future dosing. Methods: There were 28,544 EHCPs who received their first dose of COVID-19 vaccines between December 15, 2020, and March 8, 2021. The EHCPs self-reported adverse reactions to a centralized COVID-19 command center (CCC). The CCC screened and collected information on the quality of reaction, symptoms, and timing of the onset of the reaction. Results: Of 1253 calls to the CCC, 113 were identified as requiring consideration by a panel of three (American Board of Allergy and Immunology) ABAI-certified allergists for future dosing or formal in-person assessment. Of the 113 EHCPs, 94 (83.2%) were recommended to get their second dose. Eighty of 94 received their second planned dose without a severe or immediate reaction. Of the 14 of 113 identified as needing further evaluation, 6 were evaluated by a physician and subsequently received their second dose without a serious adverse reaction. Eight of 14 did not receive their second dose. Only 5 of the 113 EHCPs reported reactions (4.4%) were recommended to not take the second dose: 3 (2.6%) because of symptoms consistent with anaphylaxis, and 2 because of neurologic complications (seizure, stroke). Conclusion: The panel demonstrated that, by consideration of reaction history alone, the ECHPs could be appropriately triaged to receive scheduled second dosing of COVID-19 vaccines without delays for in-person evaluation and allergy testing.
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Arroliga ME, Vazquez-Sandoval A, Dvoracek J, Arroliga AC. Penicillin skin testing is a safe method to guide β-lactam administration in the intensive care unit. Ann Allergy Asthma Immunol 2015; 116:86-7. [PMID: 26596409 DOI: 10.1016/j.anai.2015.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/13/2015] [Accepted: 10/18/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mercedes E Arroliga
- Division of Allergy and Immunology, Baylor Scott and White Health, Temple, Texas.
| | - Alfredo Vazquez-Sandoval
- Division of Pulmonary/Critical Care/Sleep Medicine, Baylor Scott and White Health, Temple, Texas
| | - John Dvoracek
- Division of Allergy and Immunology, Baylor Scott and White Health, Temple, Texas
| | - Alejandro C Arroliga
- Division of Pulmonary/Critical Care/Sleep Medicine, Baylor Scott and White Health, Temple, Texas
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Philipson EH, Lang DM, Gordon SJ, Burlingame JM, Emery SP, Arroliga ME. Management of group B Streptococcus in pregnant women with penicillin allergy. J Reprod Med 2007; 52:480-4. [PMID: 17694964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To determine whether group B Streptococcus (GBS)-colonized pregnant women who report a history of penicillin allergy can safely undergo diagnostic evaluation to rule out or confirm the potential for an IgE-mediated (allergic) reaction to penicillin. STUDY DESIGN Over 18 months, all pregnant women with GBS-positive vaginal/rectal cultures and a history of penicillin allergy were referred to the Department of Allergy and Immunology for a history and possible skin testing. Patients who had experienced anaphylaxis were advised to continue avoiding penicillin and were not skin tested. Women without such a history underwent immediate hypersensitivity (percutaneous and intradermal) testing using 2 penicillin reagents with controls. If skin testing was negative, intrapartum antimicrobial prophylaxis with intravenous penicillin was administered. RESULTS Of 28 patients with both GBS colonization and "penicillin allergy," 25 (89%) had negative skin testing to penicillin and received intrapartum penicillin for GBS prophylaxis without adverse reactions. Skin testing was positive in 2 patients, and intrapartum penicillin was not administered. Penicillin skin testing was not performed on 1 patient due to a history of anaphylaxis from penicillin. CONCLUSION These results indicate that most pregnant women reporting penicillin allergy undergo negative skin tests and are able to safely receive intrapartum penicillin GBS prophylaxis.
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Affiliation(s)
- Elliot H Philipson
- Department of Obstetrics and Gynecology, Hillcrest Hospital, Cleveland Clinic Foundation, 6770 Mayfield Road, Suite 336, Mayfield Heights, OH 44124 , USA.
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del Real GA, Rose ME, Ramirez-Atamoros MT, Hammel J, Gordon SM, Arroliga AC, Arroliga ME. Penicillin skin testing in patients with a history of beta-lactam allergy. Ann Allergy Asthma Immunol 2007; 98:355-9. [PMID: 17458432 DOI: 10.1016/s1081-1206(10)60882-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Vancomycin and fluoroquinolones are commonly used in patients with a history of penicillin allergy. OBJECTIVE To determine the safety and utility of penicillin skin testing (PST). METHODS Retrospective study of patients with a history of penicillin allergy between April 1, 1999, and September 30, 2004. Penicillin skin testing was performed by means of standard methods using benzylpenicilloyl-polysine, penicillin G, and histamine and saline controls. RESULTS Of 596 patients studied, 25.3% were outpatients, 50.3% were inpatients, and 24.3% were intensive care unit patients. The most common antibiotics used during the time of PST were vancomycin and fluoroquinolones. Results of PST were negative in 88.4% of patients, positive in 8.2%, and indeterminate in 3.4%. One patient (0.17%) developed urticaria immediately after PST. Fifty-five percent of patients with negative PST results were changed to a beta-lactam drug, more frequently in the intensive care unit vs the outpatient setting (70.3% vs 8.6%; P < .001) and in adults vs patients younger than 18 years (58.6% vs 8.1%; P < .001). A beta-lactam antibiotic was used in 290 patients with negative PST results. Of the patients given beta-lactam antibiotics, 5 (1.7%) had adverse reactions: 2 had hives after 16 and 20 days of therapy, 1 had a nonspecific rash after 17 days of therapy, 1 had flushing and urticaria 3 hours after a test dose of piperacillin-tazobactam, and 1 had a pruritic rash after 12 hours of therapy. CONCLUSIONS Patients with a history of penicillin allergy can safely use beta-lactam drugs if negative PST results.
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Affiliation(s)
- Gonzalo Alvarez del Real
- Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic, Cleveland, Ohio 44195, USA
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Arroliga ME, Radojicic C, Gordon SM, Popovich MJ, Bashour CA, Melton AL, Arroliga AC. A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit. Infect Control Hosp Epidemiol 2003; 24:347-50. [PMID: 12785408 DOI: 10.1086/502212] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients with penicillin allergy admitted to the intensive care unit (ICU) frequently receive non-beta-lactam antimicrobials for the treatment of infection. The use of these antimicrobials, more commonly vancomycin and fluoroquinolones, is associated with the emergence of multidrug-resistant infections. The penicillin skin test (PST) can help detect patients at risk of developing an immediate allergic reaction to penicillin and those patients with a negative PST may be able to use a penicillin antibiotic safely. METHODS We determined the incidence of true penicillin allergy, the percentage of patients changed to a beta-lactam antimicrobial when the test was negative, the safety of the test, and the safety of administration of beta-lactam antimicrobials in patients with a negative test. Skin testing was performed using standard methodology. RESULTS One hundred patients admitted to 4 ICUs were prospectively studied; 58 of them were male. The mean age was 63 years. Ninety-six patients had the PST: one was positive (1.04%), 10 (10.4%) were nondiagnostic, and 85 (88.5%) were negative. Of the 38 patients who received antimicrobials for therapeutic reasons, 31(81.5%) had the antibiotic changed to a beta-lactam antimicrobial after a negative reading versus 7 patients of the 57 (12%) who had received a prophylactic antimicrobial (P < .001). No adverse effects were reported after the PST or after antimicrobial administration. CONCLUSIONS The PST is a safe, reliable, and effective strategy to reduce the use of non-beta-lactam antimicrobials in patients who are labeled as penicillin allergic and admitted to the ICU.
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Abstract
A history of allergy to penicillin does not necessarily rule out using penicillin again. With skin testing and, in some cases, desensitization, most patients with a history of penicillin allergy can safely receive the drug.
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Affiliation(s)
- Mercedes E Arroliga
- Section of Allergy and Immunology, Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic, Cleveland Clinic Foundation, OH 44195, USA.
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Uetani K, Arroliga ME, Erzurum SC. Double-stranded rna dependence of nitric oxide synthase 2 expression in human bronchial epithelial cell lines BET-1A and BEAS-2B. Am J Respir Cell Mol Biol 2001; 24:720-6. [PMID: 11415937 DOI: 10.1165/ajrcmb.24.6.4297] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The human airway epithelium expresses abundant nitric oxide synthase 2 (NOS2) in vivo. Although NOS2 is easily induced by cytokines in primary cultured human airway epithelial cells and lung adenocarcinoma cell line A549, the human bronchial epithelial cell lines BEAS-2B and BET-1A do not express NOS2 in response to cytokines. Mechanisms regulating NOS2 expression in human respiratory epithelial cells are complex, but we have recently shown that NOS2 expression in primary human airway epithelial cells occurs in response to double-stranded RNA (dsRNA) through activation of signaling proteins including nuclear factor (NF)-kappaB and interferon (IFN) regulatory factor (IRF)-1. In this context, we hypothesized that BEAS-2B and BET-1A cells may express NOS2 in response to dsRNA. Here, we show that although cytokines (IFN-gamma, tumor necrosis factor-alpha and interleukin-1beta) do not induce NOS2 expression in BEAS-2B or BET-1A cells, addition of dsRNA to this cytokine mix enables BEAS-2B cells to express NOS2. IFN-gamma and dsRNA induction of NOS2 in BET-1A cells occurs in a serum concentration-dependent manner, with a minimum of 3 d of serum treatment necessary for BET-1A cells to acquire the potential to induce NOS2. Importantly, dsRNA strongly activates NF-kappaB and IRF-1 in BEAS-2B cells, transcription factors essential for NOS2 gene expression in other cell lines. On the basis of these results, dsRNA-activated signaling pathways are clearly important for NOS2 expression in human respiratory epithelial cells. With conditions for NOS2 expression characterized, these cell lines are a convenient in vitro system to investigate the mechanisms regulating NOS2 expression in human respiratory epithelial cells.
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Affiliation(s)
- K Uetani
- Department of Pulmonary, Critical Care Medicine and Allergy, Cleveland Clinic Foundation, Lerner Research Institute, Cleveland, Ohio, USA
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Arroliga ME, Wagner W, Bobek MB, Hoffman-Hogg L, Gordon SM, Arroliga AC. A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to a medical ICU. Chest 2000; 118:1106-8. [PMID: 11035685 DOI: 10.1378/chest.118.4.1106] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Penicillin skin testing is an accurate method to determine whether a person with a history of penicillin allergy is at risk of having an immediate reaction to penicillin. A patient with a negative reaction to a skin test may be able to use a penicillin compound safely, which could reduce the use of broad-spectrum antibiotics in this patient population. METHODS We prospectively studied all patients with histories of penicillin allergy who were admitted to a medical ICU during a 3-month period and who received antibiotics. Skin testing was performed with benzylpenicilloyl polylysine and penicillin G. We determined the incidence of true allergy, the percentage of patients in whom antibiotic coverage was modified, and the safety of the test. RESULTS Two hundred fifty-seven patients were admitted to the medical ICU of The Cleveland Clinic Foundation during the study period. Twenty-four patients (9%), labeled as penicillin allergic and receiving antibiotics, were enrolled. Three patients (13%, 3 of 21) gave histories of type I reaction to penicillin and were not skin tested. Twenty patients (95%, 20 of 21) had negative skin test reactions to penicillin and positive skin test reactions to histamine control. One patient (4%, 1 of 21) with negative skin test reactions to both penicillin and histamine control had a test dose challenge with piperacillin that was well tolerated. There were no adverse events. Antibiotic coverage was changed in 10 patients (48%) as a result of skin testing. CONCLUSION Most patients with histories of allergy to penicillin have negative reactions to skin tests and may receive penicillin safely. Penicillin skin testing can be utilized as a safe and effective strategy to reduce the use of broad-spectrum antibiotics.
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Affiliation(s)
- M E Arroliga
- Section of Allergy and Immunology, The Cleveland Clinic Foundation, Cleveland Clinic Foundation, OH, USA.
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