Drug patch testing in Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review.

BACKGROUND: The data on patch testing (PT) to identify culprit medications in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are limited to scattered case reports and small case series, without analysis of overall trends to inform clinicians of its utility, methodology, and safety. OBJECTIVE: To conduct a systematic review of the practice of PT in SJS/TEN, quantify the positivity rate of common drug classes, and assess safety during testing. METHODS: PubMed was searched from inception to 2021. Search terms included "patch testing" AND "SJS" OR "TEN" OR "Stevens-Johnson syndrome" OR "toxic epidermal necrolysis" OR "Lyell's syndrome." RESULTS: There were 58 articles that met the inclusion criteria. In total, 82 patients underwent patch testing for SJS/TEN, resulting in 104 positive reactions to 49 unique medications. Antiepileptic drugs were responsible for 48.1% of the positive reactions; antibiotics, 28.8%; and nonsteroidal anti-inflammatory drugs, 6.7%. The positivity rates of antiepileptics, antibiotics, and nonsteroidal anti-inflammatory drugs were 33.1%, 13.1%, and 21.9%, respectively. When accounting for suspected causality, these rates increased to 54.3%, 78.4%, and 54.5%, respectively. Three patients (3.7%), 2 of whom had human immunodeficiency virus infection and active tuberculosis, experienced systemic reactions during PT, which required only conservative treatment. CONCLUSION: Published reports suggest that PT in SJS/TEN is useful and safe. Antiepileptic drugs have been tested most frequently and found to have the highest positivity rate. There is a critical need for large-scale studies with standardized methodology to obtain reproducible data on PT in SJS/TEN.

Safe administration of drug desensitizations in pediatric patients.

PURPOSE: Patients with certain types of allergic reactions to medication may safely receive the culprit medication through an elaborate allergy procedure called a drug desensitization. Nurses play a key role in this process which is only performed when a certain medication is absolutely indicated as optimal therapy. Nurses are instrumental in the planning stages of drug desensitizations for coordination of interdisciplinary care and anticipation of adverse effects. Thus, it is paramount that nurses performing this procedure understand the mechanism of desensitizations and have access to the resources needed to safely complete these procedures in pediatric patients. CONCLUSION: Excellence in nursing clinical acumen and a detailed order set are essential to patient safety during dug desensitization. With the following methodology and coordination by nursing, we have had great success at Children's Hospital Los Angeles in over one hundred drug desensitizations in pediatric patients which allowed them to received first line therapies. We have created order sets from published references and years of clinical experience. The nursing care of adult patients undergoing drug desensitization procedures is well described in the literature but few resources exist for pediatric nurses. There is paucity of published nursing resources for pediatric drug desensitizations. Repeated PubMed searches for "pediatric drug desensitizations" in 2019-2020, revealed only one recent reference geared toward physicians. PRACTICE IMPLICATIONS: With appropriate training, staffing, and coordination, drug desensitizations can be safely performed in pediatric patients with close observation by a multi-disciplinary team. The bedside nurse has a pivotal role as coordinator and clinician for these high-risk resource-intensive procedures.

Reimbursement patterns and user experiences in pediatric allergy home telehealth.

BACKGROUND: Telehealth use has been increasing during the last decade. Studies have found that patients have a positive attitude toward incorporating telehealth into their health care. Substantial uncertainty remains regarding reimbursement policies that vary widely between states and by payer. OBJECTIVE: To explore the clinical, operational, and financial feasibility of a home telehealth (HTH) program in a pediatric allergy and immunology clinic. METHODS: Allergy and immunology physicians defined use cases they deemed appropriate for HTH appointments. Established patients in the allergy and immunology clinic were approached to complete an attitudes and perception survey. Patients who met the use case definitions were asked to participate in the pilot program. After their HTH appointment took place, they completed a validated satisfaction survey. Our institution's revenue cycle management team provided reimbursement data. RESULTS: Patient attitudes toward HTH were generally favorable. A total of 51 HTH appointments were offered, and 46 appointments were made. Notably, 37 appointments were completed successfully among 32 unique patients. Patients were satisfied with the HTH experience. A total of 36 of 37 encounters were reimbursed by 19 different public and private payers. Payers on average reimbursed ±6% of the expected allowable for an equivalent in-person visit. CONCLUSION: Patients had reservations about HTH initially but were satisfied with their experience. Private and public payers reimbursed HTH the same as in-person appointments. Here, we report that HTH is well accepted by patients and is financially viable.

Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders.

PURPOSE OF REVIEW: This review presents the available data regarding efficacy of nutritional therapy, highlighting clinical decision points and a strategy for reintroduction of foods following an elemental diet for treatment of eosinophilic gastrointestinal disorders. RECENT FINDINGS: Elemental and empiric elimination diets are highly effective treatments for eosinophilic gastrointestinal diseases. Standardization in the reintroduction phase, after utilizing the diet for disease remission, is lacking. Clinicians are confronted with multiple challenges regarding the best practice for food reintroduction and identification of potential dietary triggers including order of foods being challenged and duration between endoscopic procedures. Individualization is required for preference and adherence to optimize quality of life and treatment success for this burdensome and life altering immune driven gastrointestinal disorder. Age specific concerns for children, teenagers, and adults should be assessed using a patient centric approach.

Mural Eosinophilic Gastrointestinal Disease in 2 Pediatric Patients Presenting as Focal Mass.

Eosinophilic gastrointestinal diseases (EGIDs) are a diverse group of intestinal diseases involving the infiltration of eosinophils into the bowel wall. EGID can present with a variety of clinical conditions, which are largely dependent on the location of eosinophils in the intestinal wall. We describe the first reported pediatric cases of EGID presenting with symptomatic partial bowel obstruction from intestinal masses due to isolated focal mural involvement. Both patients subsequently responded favorably to therapy with exclusive elemental nutrition in the first case and exclusive elemental nutrition with steroids in the second case. These cases reveal the wide-ranging clinical manifestations of EGID, expand on the differential diagnosis of focal intestinal masses, and provide guidance on the evaluation of ambiguous cases.

Utility of minor determinants for skin testing in inpatient penicillin allergy evaluation.

BACKGROUND: Most patients with a history of penicillin allergy can tolerate penicillin. Skin testing can identify tolerant patients, but not all known allergenic determinants are commercially available. Protocols exist that use only available reagents, but the sensitivity and safety of these protocols, particularly for hospitalized patients, are controversial. OBJECTIVE: To determine the number of hospitalized patients referred for penicillin skin testing who showed unique positivity to the minor determinants penicilloate and penilloate. METHODS: A retrospective chart review was conducted of all inpatients who underwent penicillin skin testing at 1 institution. Patients were referred by their treating physician. All patients underwent skin prick testing to benzylpenicilloyl polylysine (major determinant), penicillin G, penicilloate, penilloate (minor determinants), amoxicillin, and positive and negative controls. If the result was negative, then intradermal testing was done with the same penicillin determinants and the negative control. A 4-mm wheal with flare was considered a positive reaction. RESULTS: Inpatient penicillin skin testing was done in 528 subjects. Any positive test reaction was found in 107 subjects (20%). Three subjects (3%) reacted to penilloate only, 25 (23%) reacted to penicilloate only, 2 (2%) reacted to penicillin G only, and 8 (8%) reacted to amoxicillin only. Sixty-eight subjects (64%) reacted to a compound other than the major determinant. CONCLUSION: This study found a high rate of exclusively positive skin test reactions to the minor determinants penicilloate and penilloate. Because patients with positive test reactions are at increased risk of reaction to drug challenge, these data support the use of these reagents for penicillin skin testing in hospitalized patients.

Nursing Care of Patients Undergoing Chemotherapy Desensitization: Part II.

Chemotherapy desensitization protocols are safe, but labor-intensive, processes that allow patients with cancer to receive medications even if they initially experienced severe hypersensitivity reactions. Part I of this column discussed the pathophysiology of hypersensitivity reactions and described the development of desensitization protocols in oncology settings. Part II incorporates the experiences of an academic medical center and provides a practical guide for the nursing care of patients undergoing chemotherapy desensitization.
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Nursing Care of Patients Undergoing Chemotherapy Desensitization: Part I.

Hypersensitivity reactions to chemotherapeutic agents can cause the discontinuation of first-line therapies. Chemotherapy desensitization is a safe, but labor-intensive, process to administer these important medications. A desensitization protocol can enable a patient to receive the entire target dose of a medication, even if the patient has a history of severe infusion reactions. In this article, the authors explain the pathophysiology of hypersensitivity reactions and describe the recent development of desensitization protocols in oncology. In part II of this article, which will appear in the April 2016 issue of the Clinical Journal of Oncology Nursing, the authors will give a detailed account of how a desensitization protocol is performed at an academic medical center.
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Novel antioxidant approaches to the treatment of upper airway inflammation.

PURPOSE OF REVIEW: Current understanding of the role of oxidative stress in airway inflammation suggests that antioxidant therapy may be important to optimize the treatment. This review summarizes recent investigations of novel antioxidant agents for upper airway inflammation, with selected studies focused on lower airway disease as additional candidate therapeutics. RECENT FINDINGS: Recently investigated antioxidant therapies for airway inflammation may be broadly grouped into three categories: endogenous metabolic agents, vitamins/nutrients, and botanical extracts. Studies examining effects in upper airway inflammation are limited and primarily consist of in-vitro human and in-vivo animal models. More extensive studies have investigated the benefits of antioxidants in lower airway conditions such as allergic asthma. Existing evidence identifies antioxidant agents with potential therapeutic value, although human studies suggest that subpopulations affected by specific genetic, environmental, dietary factors, or all are most likely to benefit from antioxidant therapy. SUMMARY: Oxidative stress plays a causative role in upper airway inflammation, and novel strategies to mitigate cellular injury with antioxidant therapy may ameliorate disease in target populations. Preclinical studies demonstrate evidence of anti-inflammatory effects for a number of promising antioxidant agents. Well designed interventional human studies of the upper airway, which account for complex gene-environment-diet interactions, will be necessary to adequately examine the potential clinical benefit of antioxidant therapies for rhinosinusitis.