CME suggestions for pediatricians, allergists, and dermatologists, directed by an online survey on urticaria knowledge.

BACKGROUND: The Mexican Guidelines for the diagnosis and treatment of urticaria have been published. Just before their launch, physicians' knowledge was explored relating to key issues of the guidelines. OBJECTIVE: The aim of this study was to investigate the opinion of medical specialists concerning urticaria management. METHODS: A SurveyMonkey® survey was sent out to board-certified physicians of three medical specialties treating urticaria. Replies were analyzed per specialty against the evidence-based recommendations. RESULTS: Sixty-five allergists (ALLERG), 24 dermatologists (DERM), and 120 pediatricians (PED) sent their replies. As for diagnosis: ALERG 42% and PED 76% believe cutaneous mastocytosis, urticarial vasculitis, and hereditary angioedema are forms of urticaria, versus DERM 29% (P < 0.005). Most of the specialties find that the clinical history and physical examination are enough to diagnose acute urticaria, except DERM 45% (P < 0.01). DERM 45% believe laboratory-tests are necessary, as opposed to <15% ALLERG-PED (P < 0.005). However, PED 69% did not know that the most frequent cause of acute urticaria in children is infections, versus ALLERG-DERM 30% (P < 0.005). Many erroneously do laboratory testing in physical urticaria and ALLERG 51%, DERM 59%, and PED 37% do extensive laboratory testing in chronic spontaneous urticaria (CSU); many more PED 59% take Immunoglobulin G (IgG) against foods (P < 0.005). More than half of non-allergists do not know about autologous serum testing nor autoimmunity (P < 0.05). As for treatment, there were a few major gaps: when CSU was controlled, >75% prescribed antihistamines pro re nata, and >85% gave first-generation antiH1 for insomnia. Finally, >40% of DERM did not know that cyclosporine A, omalizumab, or other immunosuppressants could be used in recalcitrant cases. CONCLUSION: Specialty-specific continuous medical education might enhance urticaria management.

Hymenoptera venom allergy among children in Italy: time for pediatricians to take action.

Hymenoptera venom allergy (HVA) is one of the most frequent causes of anaphylaxis following a bee, vespid or ant sting. Real-life data regarding the management of HVA in children are lacking. To address this unmet need, we carried out a survey defining the current management of HVA in children among pediatric allergists in Italy. Educational investments on the improvement of the management of pediatric patients with HVA are urgently needed, and our analysis represents a relevant instrument in targeting a roadmap with this aim. The time for pediatric allergists to take action has come, and a task force from the Rare Allergic Diseases Commission of the Italian Society of Pediatric Allergy and Immunology is working on the topic to improve pediatricians' knowledge and optimize the care of these patients.

Family Caregiver Marginalization is Associated With Decreased Primary and Subspecialty Asthma Care in Head Start Children.

BACKGROUND: Urban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma. METHODS: The Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months. RESULTS: Three hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes. CONCLUSIONS: Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.

Allergen immunotherapy at university health services and allergist's reasons for guidelines nonadherence.

BACKGROUND: Our previous pilot study conducted at the University of Michigan Health Services showed that fewer than 25% of the non-university allergen immunotherapy (AIT) prescribers adhered to AIT labeling guidelines which impacted both patients and healthcare personnel involved in AIT administration. OBJECTIVES: We expand our study to characterize AIT labeling compliance and impact of practice variability at the "Big 10" University Health Services, and investigate prescribers motives for nonadherence to practice parameter guidelines. METHODS: Three online surveys were distributed: AIT Administrator and Manager surveys for healthcare personnel at the "Big 10"; University Health Services and Physician Survey for physician members of the AAAAI. Data were analyzed using frequency/bivariate analysis and logistic regression. RESULTS: 21 AIT administrators from 10 University Health Services responded. 90.4% (20/21) felt labels containing all recommended practice parameter guidelines, components would decrease error; and standardization of labels, buildup and missed dose schedules would increase workflow efficiency (76%; 16/21). 90% (17/19) felt standardized protocols for treatment of systemic reactions would increase patient safety, workflow efficiency and comfort level of administrators. Only 28.6% of AIT extract vial labels at University Health Services were in accordance with practice parameter guidelines. Despite familiarity with the guidelines (91.5%; 697/762), only 64% (488/762) of surveyed physicians had practice parameter adherent AIT extracts labels with higher odds of a complete label when physicians were in group practice (odds ratio 1.51; [95% confidence interval, 1.06-2.15]; P=0.02). Reasons for nonadherence included having personalized labeling systems (55.4%, 174/314), unfamiliarity (14%, 44/314) and disagreement (9%, 29/314) with practice parameter guidelines. CONCLUSION: Poor adherence with AIT practice parameters labeling guidelines is an important concern in nonallergy offices. It is imperative that allergists comply with the highest recommended standards to provide the best clinical outcomes and ensure excellent and efficient care in both allergy and non-allergy offices.

Management of chronic spontaneous urticaria in routine clinical practice: A Delphi-method questionnaire among specialists to test agreement with current European guidelines statements.

BACKGROUND: Chronic spontaneous urticaria (CSU) is a frequent clinical entity that often presents a diagnostic and therapeutic challenge. OBJECTIVE: To explore the degree of agreement that exists among the experts caring for patients with CSU diagnosis, evaluation, and management. METHODS: An online survey was conducted to explore the opinions of experts in CSU, address controversial issues, and provide recommendations regarding its definition, natural history, diagnosis, and treatment. A modified Delphi method was used for the consensus. RESULTS: The questionnaire was answered by 68 experts (dermatologists, allergologists, and primary care physicians). A consensus was reached on 54 of the 65 items posed (96.4%). The experts concluded that CSU is a difficult-to-control disease of unpredictable evolution. Diagnostic tests should be limited and based on clinical history and should not be indiscriminate. Autoinflammatory syndromes and urticarial vasculitis must be ruled out in the differential diagnosis. A cutaneous biopsy is only recommended when wheals last more than 24h, to rule out urticarial vasculitis. The use of specific scales to assess the severity of the disease and the quality of life is recommended. In patients with severe and resistant CSU, second-generation H1-antihistamines could be used at doses up to four times the standard dose before giving second-line treatments. Omalizumab is a safe and effective treatment for CSU that is refractory to H1-antihistamines treatment. In general, diagnosis and treatment recommendations given for adults could be extrapolated to children. CONCLUSIONS: This work offers consensus recommendations that may be useful in the management of CSU.

Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists.

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.

Managing simple food allergy in community settings: A pilot study investigating a new model of care.

AIM: The prevalence of food allergy in Australia has increased, paralleled by an increase in waiting time to access tertiary paediatric allergy care. We aimed to test whether a new model of care, based on serum specific IgE testing, was feasible and acceptable to Australian families. METHODS: A prospective pilot intervention study was conducted in community paediatric practices within 20-40 km of The Royal Children's Hospital, Melbourne. Children ≤7 years with likely food allergy referred to the Department of Allergy and Immunology at RCH were included; children with anaphylaxis, drug allergy or complex food allergy (>three food groups) were excluded. Community general paediatricians, recruited through the Australian Paediatric Research Network, were trained via webinars on the management of four common food allergy-related scenarios. Paediatrician and child and family parameters were assessed at baseline and 3 months, including safety. RESULTS: 34/45 (76%) eligible families and 10/12 (83%) paediatricians participated. Paediatricians managed 27/34 (80%) of children independently, with 7/34 (20%) requiring referral to an allergist for more complex food allergy. Paediatricians reported improved knowledge and competency in managing food allergy: (mean (standard deviation) scores pre = 35 (5.3) and post = 43.3 (3.9) training). The majority of children received appropriate management; there were no anaphylaxis episodes. There was no significant change in child quality of life or parent mental health. CONCLUSIONS: Management of simple food allergy by community paediatricians appears feasible and acceptable to paediatricians and families alike. Future research will evaluate this approach in an adequately powered and controlled trial.