David R. Stukus

Acceptability of an interactive asthma management mobile health application for children and adolescents

range, <20 IU/mL). Given the positive antimitochondrial and M2 antibody titer results, the patient underwent liver biopsy and was found to have granulomatous portal inflammation and bile duct inflammation that consisted of epithelioid cells, histiocytes, and rare giant cells consistent with primary biliary sclerosis stage 1 to 2. She was prescribed ursodeoxycholic acid and has maintained normal liver function test results and control of her urticaria and pruritus. The second patient is a male adolescent presenting at the age of 17 yearswith daily pruritus and urticaria that began 8months before this visit. His symptoms were unassociated with angioedema, abdominal pain, or respiratory symptoms, and the patient underwent autologous serum skin testing with appropriate positive and negative controls, which revealed a 20-mm wheal with associated flare. Thyroid function test and basophil histamine release assay results were negative. He was diagnosed as having CU and prescribed carbinoxamine, 4 mg twice daily, and ranitidine, 150 mg twice daily. Within a month, his urticarial resolved; however, he continued to have severe pruritus, so cyproheptadine, 4 mg twice daily, and hydroxyzine, 75mg twice daily, were also given during the next several months without resolution of his pruritus. Subsequently, liver function tests were performed. Aspartate aminotransferase and alanine transaminase levels were elevated at 101 U/L (reference range, 12e32 U/L) and 112 U/L (reference range, 8e46 U/L). The total bilirubin level was 1.6 mg/ dL (reference range, 0.2e1.1 mg/dL). The results of his hepatitis panel and cytomegalovirus and Epstein-Barr virus titers were all negative. His g-glutamyl transpeptidase level was elevated at 397 U/L (reference range, 15e85 U/L), and his alkaline phosphatase level was elevated at 485 U/L (reference range, 48e230 U/L). Because his liver function test results remained abnormal on subsequent testing, he underwent liver biopsy, which revealed marked bile duct proliferation, focal cholangitis, and advanced fibrosis consistent with autoimmune hepatitis and possible overlapping sclerosing cholangitis. Subsequent magnetic resonance cholangiopancreatography ruled out sclerosing cholangitis. He began taking daily prednisone, 60 mg, and azathioprine, 100 mg, with complete resolution of his urticaria, pruritus, and elevated liver function test results. His maintenance therapy now consists of azathioprine alone. Case reports in the medical literature are extremely limited regarding the presentation of autoimmune liver disease in patients presenting with CU and pruritus without additional clinical signs.5e7 Previous case reports cite clinical symptoms of arthralgias or fatigue in addition to chronic urticaria and pruritus or the development of

Deficits in allergy knowledge among physicians at academic medical centers

BACKGROUND Allergic conditions have high prevalence in the general population. Misconceptions regarding the diagnosis and management of allergic disease among physicians can lead to suboptimal clinical care. OBJECTIVE To determine the extent of allergy-related knowledge deficits among physicians. METHODS Pediatric and internal medicine resident and attending physicians from 2 separate academic medical centers were asked to answer an anonymous electronic survey. Survey questions addressed 7 different allergy content areas. RESULTS Four hundred eight physicians completed surveys (23.9% response rate). Respondents had few correct answers (mean ± SD 1.91 ± 1.43). Pediatric respondents had a larger number of correct answers compared with medicine-trained physicians (P < .001). No individual answered every survey question correctly, and 50 respondents (12.3%) had no correct answer. Three hundred seventy-eight respondents (92.6%) were unable to provide correct answers for at least 50% of survey questions. Level of residency training and prior rotation through an allergy and immunology elective correlated with a larger number of correct responses (P < .01). Only 1 survey question had an overall correct response rate higher than 50% (n = 261, 64%). Correct response rate was lower than 30% for 7 of the 9 possible questions. CONCLUSION There are significant knowledge deficits in many areas of allergy-related content among pediatric and internal medicine physicians and across all levels of training and specialty. Given the prevalence of allergic conditions, the potential implications of a negative impact on clinical care are staggering.

Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel

BackgroundFood allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy.ObjectivesPrompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy.ResultsThe addendum provides 3 separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider’s office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation.ConclusionsGuidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy.

Using Twitter to expand the reach and engagement of allergists.

Twitter is a social networking service that enables participants to send and read small messages, known as tweets. Most consider Twitter as a tool purely for social networking, but in recent years, its use has increased among academic physicians and professional medical societies. Twitter is free and easily accessible through its Web site and applications for mobile devices. Twitter profiles can display a picture as well as personal and/or professional affiliations. Twitter users see the tweets of those they follow in their personal timeline. Likewise, as one accumulates followers, their tweets are then automatically shared to their timelines, allowing for rapid dissemination of information. Twitter’s retweet feature permits reposting of someone else’s tweet, including commentary. Tweets can be saved to retweet or read at a later time by assigning a “favorite” status (see Figure E1 in this article’s Online Repository at www.jaci-inpractice.org). Within the 140-character limit per tweet, users can include pictures and links to Web sites and other social media outlets. In essence, Twitter provides another resource to extend one’s networking community and personal branding. Among academic and private practice physicians, Twitter is gaining traction as a method to rapidly share health-related information, cite articles, and even host virtual journal clubs. A hashtag is a word or phrase preceded by a hash or pound sign (#) used to identify messages on a specific topic. On Twitter, a hashtag turns any words that directly follow it into a searchable link. Over the last few years, there have been increasing reports of the use of Twitter hashtags at medical conferences. This allows conference participants to share up-to-date evidence-based information and anyone can follow along by searching the conference hashtag. In addition to posting daily communications for patients and physicians, the American Academy of Allergy, Asthma & Immunology (AAAAI) engages with Twitter during the annual meeting and through live Twitter chats. Twitter chats include allergists who discuss a topic using a predetermined hashtag, and then interact with the general public for real-time questions and answers. Symplur is an online resource that provides analytics for specific health careerelated hashtags. In 2015, the AAAAI registered and promoted #AAAAI15 through Symplur for annual meeting attendees to share tweets from the meeting. In addition, the AAAAI has used #allergyready for three 1-hour advertised Twitter chats during the period 2014 to 2015. Through the use of Symplur analytics, the last 4 AAAAI annual meetings and 3 chats were analyzed for trends in Twitter usage and dissemination. To standardize analysis during annual meetings, hashtags were analyzed for use during the day preceding through the day following meeting dates from 2012 to 2015. For the 2015 meeting, the hashtag #AAAAI15 was searched and the hashtag #AAAAI was used for all other meetings. Twitter chats were analyzed by use of the hashtag #allergyready from 1 hour before through 1 hour after completion of each of the 3 chat dates in 2014-2015. The number of tweets sent during AAAAI annual meetings increased by 547% between 2012 (n 1⁄4 1481) and 2015 (n 1⁄4 9584) (Figure 1). Even more impressive is a 790% increase in the number of participants using the Twitter hashtag at 2015 AAAAI annual meeting (n 1⁄4 1211) compared with 2012 (n 1⁄4 136). The largest year-to-year increase in Twitter usage was noted between 2014 and 2015 (Figure 1), which is likely related to 2015 marking the first time that an official hashtag #AAAAI15 was promoted before and during the annual meeting. One way to evaluate dissemination through Twitter is through impressions, which are the number of times a tweet is directed to a unique user’s timeline, but not necessarily read. Impressions are influenced by the number of tweets and followers. As such, an increase in the number of followers will dramatically increase the number of impressions for the same number of tweets. In 2012, there were 1,878,725 impressions during the AAAAI annual meeting. In 2015, this increased to 14,754,483 impressions, a 7fold increase in 3 years. During the 2015 annual AAAAI meeting, the results of the landmark Learning Early About Peanut Introduction study were released during a Cutting Edge Keynote Session on February 23, 2015, at 3:30 pm CST. This coincided with publication that day in the New England Journal of Medicine. As an example of the reach of Twitter, during this 1-hour session, there were 753 tweets using #AAAAI15, which originated from 185 unique accounts and garnered almost 2.5 million impressions. Of note, 3 of the top 4 accounts with the highest number of tweets during this hour originated from laypeople not in attendance at the meeting. The 3 live Twitter chats garnered 2365 total tweets from 412 participants, with almost 28 million total impressions (Table I). Participants included AAAAI members, representatives from trade organizations, and the general public. As the use of Twitter increases among physicians, it will become ever more important to use common hashtags to allow for maximal reach of information to other health care providers and the general public. Hashtags should be kept short as the characters count toward the limit for each tweet. Organizers of medical meetings should register their hashtag with an online platform to allow for increased exposure, as well as analytics to review performance. Limitations of this data set include the potential for exclusion of tweets that did not use the common hashtag in the Twitter streams. However, this would only underestimate dissemination. Current analytics do not allow for categorization of user profiles to determine personal and/or professional affiliations. Many physicians have yet to embrace social media for professional use. Some are not familiar, whereas others may fear

LEAPing through the looking glass: secondary analysis of the effect of skin test size and age of introduction on peanut tolerance after early peanut introduction

In the Learning Early About Peanut Allergy (LEAP) study, early peanut introduction in high‐risk 4‐ to 11‐month‐olds was associated with a significantly decreased risk of developing peanut allergy. However, the influences of key baseline high‐risk factors on peanut tolerance are poorly understood.

Social Media and the 21st-Century Scholar: How You Can Harness Social Media to Amplify Your Career

To many physicians and professionals, social media seems to be a risky business. However, recent literature has shown that there is potential to enhance your scholarly brand by engaging your stakeholders online. In this article, we discuss the opportunities presented to modern scholars by social media. Using case studies, we highlight two success stories around how scientists and scholars might use social media to enhance their careers. We also outline five key steps you can follow to build and manage your scholarly presence online.

Addendum guidelines for the prevention of peanut allergy in the United States.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Allergy and Infectious Diseases In 2015, findings from the landmark Learning Early About Peanut Allergy (LEAP) study—the first randomized trial to study early allergen introduction as a preventive strategy—showed that early introduction of peanut-containing foods to infants at high risk of developing peanut allergy was safe and led to an 81 percent relative reduction in the subsequent development of peanut allergy.

Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel

BackgroundFood allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy.ObjectivesPrompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy.ResultsThe addendum provides 3 separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider’s office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation.ConclusionsGuidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy.

Pearls and Pitfalls in Diagnosing IgE-Mediated Food Allergy.

The term “food allergy” is used by many patients and clinicians to describe a range of symptoms that occur after ingestion of specific foods. However, not all symptoms occurring after food exposure are due to an allergic, or immunologic, response. It is important to properly evaluate and diagnose immunoglobulin E (IgE)-mediated food allergy as this results in reproducible, immediate onset, allergic reactions that can progress toward life-threatening anaphylaxis. Proper diagnosis requires understanding of the common foods that cause these reactions in addition to key historical elements such as symptoms, timing and duration of reaction, and risk factors that may predispose to development of IgE-mediated food allergy. Diagnostic testing for food-specific IgE can greatly aid the diagnosis. However, false-positive test results are very common and can lead to overinterpretation, misdiagnosis, and unnecessary dietary elimination. This review discusses important aspects to consider during evaluation of a patient for suspected IgE-mediated food allergy.

Food allergy prevalence and management at an overnight summer camp.

BACKGROUND In recent years, increased awareness of food allergy management has focused on the school setting. A lack of awareness and relevant literature prompted evaluation of the camp experience. OBJECTIVE To characterize the prevalence of food allergies among children attending an overnight summer camp and to evaluate the knowledge and comfort of camp personnel before and after a training session. METHODS The database for the 2014 season at Flying Horse Farms was reviewed for information pertaining to food allergies and provision of epinephrine and treatment plans. Camp personnel completed surveys regarding food allergy knowledge and comfort. Surveys were redistributed 30 days after the training session. RESULTS Among 445 campers, 15% reported at least one food allergy, with 8.5% reporting allergy to 1 of the top 8 food allergens. Only 32% of campers with food allergy supplied an epinephrine autoinjector, and 0% provided written treatment plans. Before training, 84% of personnel desired additional information about food allergies. Knowledge of food allergies among personnel was high at baseline but increased after training in regard to epinephrine use for anaphylaxis and postepinephrine management. Staffers who reported feeling very comfortable caring for campers with food allergy increased from 16% to 46% after the training session; comfort in treating a food allergy emergency increased from 2% to 29%. CONCLUSION Management of food allergies at overnight summer camps warrants similar education and preparation strategies as those implemented in schools. Camp personnel should receive annual training regarding food allergies and anaphylaxis.