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Food allergy management in child care centers and schools is a controversial topic, for which evidence-based guidance is needed. Following the Grading of Recommendations Assessment, Development, and Evaluation approach, we conducted systematic literature reviews of the anticipated health effects of selected interventions for managing food allergy in child care centers and schools; we compiled data about the costs, feasibility, acceptability, and effects on health equity of the selected interventions; and we developed the following conditional recommendations: we suggest that child care centers and schools implement allergy training and action plans; we suggest that they use epinephrine (adrenaline) to treat suspected anaphylaxis; we suggest that they stock unassigned epinephrine autoinjectors, instead of requiring students to supply their own personal autoinjectors to be stored on site for designated at-school use; and we suggest that they do not implement site-wide food prohibitions (eg, "nut-free" schools) or allergen-restricted zones (eg, "milk-free" tables), except in the special circumstances identified in this document. The recommendations are labeled "conditional" due to the low quality of available evidence. More research is needed to determine with greater certainty which interventions are likely to be the most beneficial. Policymakers might need to adapt the recommendations to fit local circumstances.

Objective This study sought to evaluate available evidence of the safety of penicillin skin testing (PST), challenge, and desensitization in pregnancy, with efforts to improve perinatal care for patients with a penicillin allergy history and mitigate the negative sequelae of unverified penicillin allergy labels. Methods A systematic review of studies was conducted using Cochrane Library, Medline, EMBASE, and International Pharmaceutical Abstracts. Included were peer-reviewed studies without date restrictions, published in English or French, relating to PST, challenge, or desensitization in pregnancy. Editorials, opinion pieces, and letters were excluded. Review authors independently screened citations and full-text articles, extracted data, and conducted quality assessment. Given the heterogeneity of study designs, a narrative synthesis was conducted. Results The search identified 1195 references, of which 18 studies met inclusion criteria. In total there were 231 patients with varying histories of penicillin allergy, the majority requiring treatment for syphilis or group B streptococcal (GBS) disease during pregnancy. Of the 203 participants who underwent PST, 83.7% had negative test results. Allergy-related reactions were rare in PST (1.5%) and challenge (0%), and although these reactions were more common in desensitization (19.7%), most were benign. Among the 231 cases, only one adverse pregnancy outcome was reported (0.4%). Conclusion This review demonstrates that the known prevalence of true penicillin allergy extends to pregnant women. PST and desensitization can be safely applied during pregnancy and are tools that should be used more frequently. Further data on the safety of challenge during pregnancy are recommended.

Epinephrine is the first-line treatment for anaphylaxis. Despite this, there have been identified gaps in the management of anaphylaxis including infrequent or delayed use of epinephrine for acute allergic reactions, as well as inadequate epinephrine autoinjector (EAI) training, and prescription rates of these devices for patients at risk. This paper reviews new data, and new problems in recently published literature on EAIs. A database search was conducted for publications between January 2015 and February 2017 using keywords related to EAIs including their functionality and features, carriage, prescription rates, barriers, and side effects. Eligibility criteria included patients at risk for anaphylaxis, caregivers, and health care professionals. Experimental studies and observational studies were included. Of 1,737 potentially relevant articles, 19 were used for analysis. These articles addressed specific aspects of an EAI, including (1) information on features and functionality; (2) prescriptions; (3) training on their use; and (4) carriage and use at the time of reaction by patients, schools, camps, emergency departments, and paramedics. Our review highlights that existing gaps in anaphylaxis management remain unaddressed. Patient needs are largely unmet, and very few studies are being designed to clarify and instill best practice, and to determine how to increase adherence to existing anaphylaxis guidelines through integrated knowledge translation strategies.

Case A 41-year-old male presented with abdominal pain, diarrhea, weakness, and shock. He was diagnosed with cardiac tamponade, underwent pericardial drainage and initiation of broad-spectrum antibiotics. The patient had a recent admission with bilateral pleural effusions, with negative infectious and malignancy workup. Macrocytic anemia, increased white blood cells, incidental abdominal abscess and splenic infarcts were found during this admission. Investigations again demonstrated elevated white blood cells (53.8% neutrophils, 12.1% lymphocytes, 29.7% monocytes) and anemia. Autoimmune workup was unremarkable except for presence of atypical ANCA and lupus inhibitor. Bone marrow biopsy was non-specific. He had low IgM and IgG levels suggesting a diagnosis of Common Variable Immunodeficiency (CVID). He received intravenous Solumedrol after his respiratory status deteriorated. He improved and was transitioned to prednisone, but a pathogen was never found. His positive response to steroids with worsening symptoms with prednisone taper initiation suggested that this was an autoimmune process. He was started on Hydroxychloroquine and intravenous immunoglobulin by Rheumatology. However he was subsequently diagnosed with Chronic Myelomonocytic Leukemia (CMML) based on cytogenetic studies by Hematology. Current treatment includes hydroxyurea and prednisone. Discussion This patient demonstrates the challenge of diagnosing autoimmunity in a patient with low levels of immunoglobulins such as in CVID. How to interpret autoimmune antibody titres in autoimmune conditions is unknown. Most literature describes immunodeficiency being diagnosed after the autoimmune condition [1] and often after immunosuppressant use. Studies on systemic lupus erythematosus and CVID have shown low levels of autoantibodies after immunodeficiency diagnosis.

Background Treatment of Chronic Idiopathic Urticaria (CIU) may be challenging, as patients can be refractory to various treatments. This may be due to an autoimmune mechanism in its pathogenesis. CIU has been shown to be associated with autoantibodies to IgE or IgE receptor and with thyroid autoimmunity [1,2]. Treatments targeting this autoimmune pathogenesis are now being used, such as intravenous immunoglobulin (IVIG). We reviewed patients with CIU treated with IVIG to see if response to treatment correlated with presence of autoimmunity (antibodies to IgE/IgE receptor or Thyroidperoxidase (TPO) antibodies).

Background Wheat Dependent Exercise Induced Anaphylaxis (WDEIA) is a form of Food Dependent Exercise Induced Anaphylaxis. WDEIA occurs when there is an allergic reaction following the ingestion of wheat, coupled with exercise [1]. The suspected allergen that is responsible for WDEIA is omega5gliadin [2]. We report a series of adult clinical cases of WDEIA recorded between 2006-2009 at Health Sciences Centre (Winnipeg). The purpose of this study was to compare the results of Skin Prick Test (SPT) to commercial wheat extract and wheat flour in patients with WDEIA.

BackgroundThe natural history of Wheat Dependent ExerciseInduced Anaphylaxis (WDEIA) is not well defined. InIgE mediated, non exercise dependent, wheat allergy inchildren, the approximate age for resolution is 6.5 yearswith rare persistence into adolescence [1]. We report acase of resolution of WDEIA in an adult.Case reportA 62 year old male was assessed in 2006 with a 3-4 yearhistory of recurrent acute urticaria. A month prior toconsultation he developed anaphylaxis.No consistent trigger was identified, therefore a co-variable with food, such as exercise, was suspected.Skin prick testing (SPT) to foods ingested within 4hours of anaphylaxis was positive to wheat flour andnegative to wheat extract (WE) (Allergy Canada), pea-nut, egg, cow’s milk, cod, pickerel, salmon, whitefish,clam, and potato. Wheat products were tolerated daily,therefore WDEIA was suspected. Strict wheat avoidancewas advised and epinephrine autoinjector prescribed.4-6-12 months later he was asymptomatic with wheatavoidance. SPT was negative to oat, rye, corn flour.In 2008 and 2009 SPT was WE negative and flourpositive.In 2010 he reported eating wheat products, followedby exercise, with no reactions >6 months. SPT wasnegative to WE and flour.ResultsThis patient demonstrates WDEIA which resolved fouryears after diagnosis. The patient is asymptomatic despitewheat ingestion followed by exercise. SPT to wheat flour,which was positive previously, is now negative.ConclusionThis is the first case of WDEIA resolution reported.History plus SPT with wheat flour was used to diagnoseWDEIA, and to confirm its resolution.