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Importance: The optimal inhaled reliever therapy for asthma remains unclear., Objective: To compare short-acting β agonists (SABA) alone with SABA combined with inhaled corticosteroids (ICS) and with the fast-onset, long-acting β agonist formoterol combined with ICS for asthma., Data Sources: The MEDLINE, Embase, and CENTRAL databases were searched from January 1, 2020, to September 27, 2024, without language restrictions., Study Selection: Pairs of reviewers independently selected randomized clinical trials evaluating (1) SABA alone, (2) ICS with formoterol, and (3) ICS with SABA (combined or separate inhalers)., Data Extraction and Synthesis: Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analyses synthesized outcomes. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the certainty of evidence., Main Outcomes and Measures: Asthma symptom control (5-item Asthma Control Questionnaire; range, 0-6, lower scores indicate better asthma control; minimum important difference [MID], 0.5 points), asthma-related quality of life (Asthma Quality of Life Questionnaire; range, 1-7, higher scores indicate better quality of life; MID, 0.5 points), risk of severe exacerbations, and risk of serious adverse events., Results: A total of 27 randomized clinical trials (N = 50 496 adult and pediatric patients; mean age, 41.0 years; 20 288 male [40%]) were included. Compared with SABA alone, both ICS-containing relievers were associated with fewer severe exacerbations (ICS-formoterol risk ratio [RR], 0.65 [95% CI, 0.60-0.72]; risk difference [RD], -10.3% [95% CI, -11.8% to -8.3%]; ICS-SABA RR, 0.84 [95% CI, 0.73-0.95]; RD, -4.7% [95% CI, -8.0% to -1.5%]) with high certainty. Compared with SABA alone, both ICS-containing relievers were associated with improved asthma control (ICS-formoterol RR improvement [MID] in total score, 1.07 [95% CI, 1.04-1.10]; RD, 4.1% [95% CI, 2.3%-5.9%]; ICS-SABA RR, 1.09 [95% CI, 1.03-1.15]; RD, 5.4% [95% CI, 1.8%-8.5%]) with high certainty. In an indirect comparison with ICS-SABA, ICS-formoterol was associated with fewer severe exacerbations (RR, 0.78 [95% CI, 0.66-0.92]; RD, -5.5% [95% CI, -8.4% to -2.0%]) with moderate certainty. Compared with SABA alone, ICS-formoterol (RD, -0.6% [95% CI, -1.3% to 0%]) was not associated with increased risk of serious adverse events (high certainty) and ICS-SABA (RD, 0% [95% CI, -1.1% to 1.2%]) was not associated with increased risk of serious adverse events (moderate certainty)., Conclusions and Relevance: In this network meta-analysis of patients with asthma, ICS combined with formoterol and ICS combined with SABA were each associated with reduced asthma exacerbations and improved asthma control compared with SABA alone.

Objective: To evaluate the comparative effectiveness of allergy specialist care for children with asthma enrolled in the Arkansas Medicaid program., Study Design: We used the Arkansas All-Payers Claims Database (APCD) to identify Medicaid-enrolled children with asthma who had an allergy specialist visit in 2018. These children were propensity score matched to children without an allergy specialist visit to evaluate differences in asthma-related adverse events (AAE), specifically emergency department visits and/or hospitalizations in 2019. Multivariable logistic regression was used to assess the association between allergy specialist care in 2018 and AAEs in 2019., Results: Prior to matching, a higher percentage of children with an allergy specialist visit had persistent asthma, were atopic, and received influenza vaccination. In the matched sample, 10.1% of identified patients experienced an AAE in 2019. Adjusted analysis showed 21.0% lower odds of AAEs (aOR: 0.79; 95%CI: 0.63, 0.98) in 2019 for children with an allergy specialist visit (n=2,964) in 2018 compared with those without an allergy specialist visit (ME: 9.1% vs 11.0%; p=0.04)., Conclusions: Children with asthma enrolled in Arkansas Medicaid who saw an allergy specialist were less likely to have an AAE. Asthma quality metrics developed using guideline-based recommendations for allergy specialist care should be considered for asthma health management programs., (Copyright © 2024. Published by Elsevier Inc.)

Background: The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in March 2020 led to the implementation of nonpharmaceutical interventions (NPIs) to curb its spread. Studies have shown that adult asthma exacerbations and viral infections decreased during NPI use. However, few studies have shown the effects of NPIs on pediatric asthma exacerbations and infections during and after the pandemic., Objective: This study aimed to understand the impact of NPIs on asthma exacerbations and viral respiratory infections in pediatric patients at our institution from March 2018 to December 2022., Methods: The medical record numbers of children with asthma exacerbations seen at our institution between March 2018 and December 2022 were analyzed. Subjects were categorized on the basis of timing of their exacerbation in relation to NPI enforcement. We used the results from clinical testing with the BioFire Respiratory Panel (BRP) to detect up to 22 respiratory pathogens and then correlated these results with asthma exacerbation severity., Results: There were 5,758 asthma exacerbations recorded, with a 50% decline in average weekly exacerbations during NPI enforcement. Of the 70,682 BRP tests performed, 87% returned a positive result for at least 1 pathogen. Several viruses (respiratory syncytial virus, parainfluenza, and influenza) had a decrease in positivity rate with NPIs, whereas rhinovirus/enterovirus positivity rates were unchanged throughout the pandemic. Asthma exacerbations with a positive BRP result required higher clinical levels of care during the admission., Conclusion: NPIs were associated with significantly reduced numbers of asthma exacerbations and respiratory viral infections. The post-NPI period saw a return to prepandemic levels of asthma exacerbations and an unusual surge in respiratory syncytial virus infections, emphasizing the need for continuous monitoring and adaptive strategies in the postpandemic landscape., Competing Interests: Supported by the Center for Translational Pediatric Research (10.13039/100000002National Institutes of Health/10.13039/100000057National Institute of General Medical Sciences [P20GM121293 Team Science and COVID-19 Variant Sequencing supplements (to J.L.K., S.H., G.T., A.I., and D.F.)]), the 10.13039/501100020492Translational Research Institute (National Institutes of Health/National Center for Advancing Translational Sciences [grant UL1TR003107 (to J.L.K.)]), the Arkansas Children’s Research Institute (to J.L.K.), the 10.13039/100008231Arkansas Biosciences Institute (to J.L.K.), NIH/NHLBI R01HL173573 (to J.K.L.) and the National Center For Advancing Translational Sciences of the National Institutes of Health (awards KL2 TR003108 and UL1 TR003107 [to A.A.J.]). Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest., (© 2024 The Authors.)

Objective: To test the effectiveness of a telemedicine-based program in reducing asthma morbidity among children who present to the emergency department (ED) for asthma, by facilitating primary care follow-up and promoting delivery of guideline-based care., Study Design: We included children (3-12 years of age) with persistent asthma who presented to the ED for asthma, who were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced usual care. TEAM-ED included (1) school-based telemedicine follow-ups, completed by a primary care provider, (2) point-of-care prompting to promote guideline-based care, and 3) an opportunity for 2 additional telemedicine follow-ups. The primary outcome was the mean number of symptom-free days (SFDs) over 2 weeks at 3, 6, 9, and 12 months., Results: We included 373 children from 2016 through 2021 (participation rate 68%; 54% Black, 32% Hispanic, 77% public insurance; mean age, 6.4 years). Demographic characteristics and asthma severity were similar between groups at baseline. Most (91%) TEAM-ED children had ≥1 telemedicine visit and 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66% vs 48%; aOR, 2.07; 95% CI, 1.28-3.33), preventive asthma medication actions (90% vs 79%; aOR, 3.28; 95% CI, 1.56-6.89), and use of a preventive medication (82% vs 69%; aOR, 2.716; 95% CI, 1.45-5.08), compared with enhanced usual care. There was no difference between groups in medication adherence or asthma morbidity. When only prepandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED vs enhanced usual care., Conclusions: TEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with prepandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support., Trial Registration: NCT02752165., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest. Funded by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health (R01HL091835). The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Previous machine learning approaches fail to consider race and ethnicity and social determinants of health (SDOH) to predict childhood asthma exacerbations. A predictive model for asthma exacerbations in children is developed to explore the importance of race and ethnicity, rural-urban commuting area (RUCA) codes, the Child Opportunity Index (COI), and other ICD-10 SDOH in predicting asthma outcomes., Methods: Insurance and coverage claims data from the Arkansas All-Payer Claims Database were used to capture risk factors. We identified a cohort of 22,631 children with asthma aged 5-18 years with 2 years of continuous Medicaid enrollment and at least one asthma diagnosis in 2018. The goal was to predict asthma-related hospitalizations and asthma-related emergency department (ED) visits in 2019. The analytic sample was 59% age 5-11 years, 39% White, 33% Black, and 6% Hispanic. Conditional random forest models were used to train the model., Results: The model yielded an area under the curve (AUC) of 72%, sensitivity of 55% and specificity of 78% in the OOB samples and AUC of 73%, sensitivity of 58% and specificity of 77% in the training samples. Consistent with previous literature, asthma-related hospitalization or ED visits in the previous year (2018) were the two most important variables in predicting hospital or ED use in the following year (2019), followed by the total number of reliever and controller medications., Conclusions: Predictive models for asthma-related exacerbation achieved moderate accuracy, but race and ethnicity, ICD-10 SDOH, RUCA codes, and COI measures were not important in improving model accuracy.

Food security encompassess the concept of access by all people at all times to enough food for an active, healthy life. Conversely, food insecurity (FI) refers to household-level economic and social conditions of limited or uncertain access to adequate food. FI is a key social determinant of health that can negatively affect nutrition and health outcomes, as it is estimated that 10.2% of the US population meets criteria for FI. Recognizing the impact of FI on our patients and families is critical to promote health equity and optimize health outcomes. This review focuses on FI and allergic disease from the perspective of key multisector stakeholders within the field of allergy and immunology as well as from the larger health care arena, highlighting key resources and initiatives important to patients. Collectively, as specialists in allergy and immunology, and within the medical field more broadly, we must leverage our unique roles as we interface with patients and families and serve as committed advocates for change. Developing innovative strategies to promote health equity can provide a pathway forward for all children, adults, and families to gain access to healthy, nutritious food as part of their routine lifestyle. This is a call to action., Competing Interests: Disclosure Statement A.A.J. received funding from the NIH National Center for Advancing Translational Sciences (NCATS) (awards KL2 TR003108 and UL1 TR003107). Disclosure of potential conflict of interest: S. M. Jones reports grants to her institution from the National Institute of Allergy and Infectious Diseases (NIAID) and from FARE; clinical trials funding to her institution from Aimmune Therapeutics, DBV Technologies, Regeneron Pharmaceuticals, Astellas Pharma, Genentech, Aravax, PTY, ALK-Albello, and Novartis; and personal fees from Aimmune Therapeutics as a member of the scientific advisory board from Regeneron Pharmaceuticals as a research advisory consultant, and from Astellas Pharma as scientific advisory consultant. S. Anvari reports grants to her institution from NIAID; clinical trials funding from DBV Technologies; and personal fees from DBV Technologies as a member of the scientific advisory board. R. D. Pesek reports a grant to his institution from the NCATS in partnership with NIAID and the National Institute of Diabetes and Digestive and Kidney Diseases. He has clinical trials funding to his institution from AstraZeneca and Regeneron Pharmaceuticals. He is a research advisory consultation for Regeneron Pharmaceuticals. K. M. Kloepfer reports grants from the National Heart, Lung, and Blood Institute and NIAID; and payments for disease state awareness lectures for Regeneron. T. T. Perry reports grants to her institution from the National Institute of Nursing Research, the National Heart, Lung, and Blood Institute, NIAID, and the NIH Office of the Director. She is an at-large member of the American Academy of Allergy, Asthma & Immunology board of directors. A. Andres reports grants to her institution from NIH and the US Department of Agriculture Agricultural Research Services. M. Doderer serves as president and CEO of Arkansas Children’s. A. M. Scurlock reports grants to her institution from NIAID and FARE; clinical trials funding to her institution from Aimmune Therapeutics, DBV Technologies, Regeneron Pharmaceuticals, Astellas Pharma, Genentech, Aravax, PTY, ALK-Albello, Novartis, and Siolta Therapeutics; and personal fees from DBV Technologies as a medical advisory board consultant. The rest of the authors declare that they have no relevant conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Schools are in a unique position to address social determinants of health (SDOHs) in pediatric asthma management because of their potential to provide resources and facilitate collaboration with health care providers and services for children at risk within their community. SDOHs include economic factors, educational attainment and health literacy, neighborhood factors and the built environment, social and community aspects including discrimination and racism, and health care access and quality. These factors have a significant impact on asthma health in children, and certain populations such as minoritzed populations and those living in high-poverty environments have been shown to be at greater risk for adverse effects of SDOHs on asthma outcomes. School-based asthma programs address several SDOHs including health literacy, the built environment, and health care quality and access and have been shown to improve asthma outcomes. Key components include connection between the school and the health care team, self-management education, and directly observed therapy. School nurses play a key role in directing and managing effective programs because they can evaluate and support a student's health while considering the effect of SDOHs at interpersonal, institutional, community, and policy levels., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Children with asthma and obesity are more likely to have lower vitamin D levels, but the optimal replacement dose is unknown in this population. The objective of this study is identifying a vitamin D dose in children with obesity-related asthma that safely achieves serum vitamin D levels of ≥ 40 ng/mL. This prospective multisite randomized controlled trial recruited children/adolescents with asthma and body mass index ≥ 85% for age/sex. Part 1 (dose finding), evaluated 4 oral vitamin D regimens for 16 weeks to identify a replacement dose that achieved serum vitamin D levels ≥ 40 ng/mL. Part 2 compared the replacement dose calculated from part 1 (50,000 IU loading dose with 8,000 IU daily) to standard of care (SOC) for 16 weeks to identify the proportion of children achieving target serum 25(OH)D level. Part 1 included 48 randomized participants. Part 2 included 64 participants. In Part 1, no SOC participants achieved target serum level, but 50-72.7% of participants in cohorts A-C achieved the target serum level. In part 2, 78.6% of replacement dose participants achieved target serum level compared with none in the SOC arm. No related serious adverse events were reported. This trial confirmed a 50,000 IU loading dose plus 8,000 IU daily oral vitamin D as safe and effective in increasing serum 25(OH)D levels in children/adolescents with overweight/obesity to levels ≥ 40 ng/mL. Given the critical role of vitamin D in many conditions complicating childhood obesity, these data close a critical gap in our understanding of vitamin D dosing in children., (© 2023 The Authors. Clinical Pharmacology & Therapeutics published by Wiley Periodicals LLC on behalf of American Society for Clinical Pharmacology and Therapeutics.)

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly affected by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including health care access and quality, diagnosis, management, education, and disease prevalence and outcomes. Ongoing research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on health care disparities and outcomes among patients with allergic and immunologic diseases., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Rationale: Metformin is a commonly used antidiabetes medication with suggested anti-inflammatory and antioxidative effects. Metformin use has been associated with lower risk of asthma exacerbations and hospitalizations in adults. Here, we aimed to evaluate how asthma exacerbation rates changed after adolescents and young adults were prescribed metformin, and to learn if those changes were related to metformin prescription adherence., Methods: Using secondary data of patients between 12 and 20 years old with asthma diagnosis and a metformin prescription from the Arkansas All Payers Claim Database and Arkansas School body mass index (BMI) database, we estimated the change in annualized asthma exacerbation rates after metformin prescription. We also evaluated the association of prescription adherence to the changes in those rates using univariate and multivariate regression models., Results: A total of 464 patients met inclusion criteria. Outpatient exacerbation rates decreased after metformin prescription (13.4% only before vs. 7.8% only after, p = .009), and the annualized rate decreased more after metformin prescription as adherence increased (rank r = -.165, p < .001). After adjusting for potential confounders-age, sex, BMI, and inhaled corticoid steroid use-the strength of the association was attenuated., Conclusions: Asthma exacerbation rates decreased after metformin prescription, but a larger sample of patients who have experienced exacerbations and including patients with asthma who have not been prescribed metformin is needed to better know whether these decreases are driven by metformin use., (© 2023 Wiley Periodicals LLC.)

Introduction: Difficult communication environments are common in military settings, and effective voice use can be critical to mission success. This study aimed to estimate the prevalence of self-reported voice disorders among U.S. military service members and to identify factors that contribute to their voice concerns., Method: A nonclinical sample of 4,123 active-duty service members was recruited across Department of Defense hearing conservation clinics. During their required annual hearing evaluation, volunteers provided responses to voice-related questions including a slightly adapted version of the Voice Handicap Index-10 (VHI-10) as part of a larger survey about communication issues. Changepoint detection was applied to age and years of service to explore cohort effects in the reporting of voice concerns. Logistic regression analyses examined multiple available factors related to communication to identify factors associated with abnormal results on the VHI-10., Results: Among the respondents, 41% reported experiencing vocal hoarseness or fatigue at least several times per year, and 8.2% ( n = 336) scored above the recommended abnormal cut-point value of 11 on the VHI-10. Factors independently associated with the greatest risk for self-reported voice concerns were sex (female), cadmium exposure, vocal demands (the need for a strong, clear voice), and auditory health measures (frequency of experiencing temporary threshold shifts; self-reported hearing difficulties)., Conclusions: Based on self-reported voice concerns and false negative rates reported in the literature, the prevalence of dysphonia in a large sample of active-duty service members is estimated to be 11.7%, which is higher than that in the general population. Certain predictors for voice concerns were expected based on previous literature, like female sex and voice use, but frequency of temporary threshold shifts and exposure to cadmium were surprising. The strong link between voice and auditory problems has particular implications regarding the need for effective communication in high-noise military and other occupational environments.

Objectives: To determine the association between the asthma medication ratio (AMR) quality measure and adverse outcomes among Medicaid-enrolled children with asthma in Arkansas, given concerns regarding the utility of the AMR in evaluating pediatric risk of asthma-related adverse events (AAEs)., Methods: We used the Arkansas All-Payer Claims Database to identify Medicaid-enrolled children with asthma using a nonrestrictive case definition and additionally using the standard Healthcare Effectiveness Data and Information Set (HEDIS) persistent asthma definition. We assessed the AMR using the traditional dichotomous HEDIS AMR categorization and across 4 expanded AMR categories. Regression models assessed associations between AMR and AAE including hospitalization and emergency department utilization, with models conducted overall and by race and ethnicity., Results: Of the 22 788 children in the analysis, 9.0% had an AAE (6.7% asthma-related emergency department visits; 3.0% asthma-related hospitalizations). We found poor correlation between AMR and AAE, with higher rates of AAE (10.5%) among children with AMR ≥0.5 compared with AMR <0.5 (8.5%; P < .001), and similar patterns stratified by racial and ethnic subgroups. Expanded AMR categorization revealed notable differences in associations between AMR and AAEs, compared with traditional dichotomous categorization, with worse performance in Black children., Conclusions: The AMR performed poorly in identifying risk of adverse outcomes among Medicaid-enrolled children with asthma. These findings underscore concerns of the utility of the AMR in population health management and reliance on restrictive HEDIS definitions. New population health frameworks incorporating broader considerations that accurately identify at-risk children are needed to improve equity in asthma management and outcomes., (Copyright © 2023 by the American Academy of Pediatrics.)

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Secondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Although viral infection is known to be associated with asthma exacerbations, prior research has not identified reliable predictors of acute symptom severity in virus-related asthma exacerbations (VRAEs)., Objective: To determine the effect of asthma control and viral infection on the severity of current illness and evaluate biomarkers related to acute symptoms during asthma exacerbations., Methods: We prospectively enrolled 120 children with physician-diagnosed asthma and current wheezing who presented to Arkansas Children's Hospital emergency department. The asthma control test (ACT) stratified controlled (ACT > 19) and uncontrolled (ACT ≤ 19) asthma, whereas pediatric respiratory symptom scores evaluated symptoms. Nasopharyngeal swabs were obtained for viral analysis, and inflammatory mediators were evaluated by nasal filter paper and Luminex assays., Results: There were 33 children with controlled asthma and 87 children with uncontrolled asthma. In those with uncontrolled asthma, 77% were infected with viruses during VRAE compared with 58% of those with controlled asthma. Uncontrolled subjects with VRAE had more acute symptoms compared with the controlled subjects with VRAE or uncontrolled subjects without a virus. The uncontrolled subjects with VRAE and allergy had the highest acute symptom scores (3.363 point pediatric respiratory symptom; P = .04). Children with asthma with higher symptom scores had more periostin (P = .02)., Conclusion: Detection of respiratory viruses is frequent in those with uncontrolled asthma. Uncontrolled subjects with viruses have more acute symptoms during exacerbations, especially in those with allergy. Periostin was highest in subjects with the most acute symptoms, regardless of control status. Taken together, these data imply synergy between viral infection and allergy in subjects with uncontrolled asthma when considering acute asthma symptoms and nasal inflammation during an exacerbation of asthma., (Copyright © 2022 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: Self-adjustment of hearing aid amplification enables wearers to customize the hearing aid output to match their preferences and could become an important tool for programming direct-to-consumer devices for people with mild-to-moderate hearing loss. One risk is that user-selected settings may provide inadequate audibility. This study assessed that risk by quantifying relationships between self-adjusted settings, subjective preferences, and speech recognition performance using speech at low levels in quiet, where achieving high speech audibility requires sufficient amplification., Method: Fifteen people with symmetric, mild-to-moderate sensorineural hearing loss self-adjusted hearing aid amplification while listening to speech in quiet at 45, 55, and 65 dBA. After self-adjustment, 11 participants made blinded ratings of their self-adjusted fit, their NAL-NL2 prescriptive fit, and experimenter-created fits with reduced gain. Participants completed blinded paired comparisons and sentence recognition assessments using these settings., Results: The gain of self-adjusted fits showed a large range of variability between participants. On average, self-adjusted gain was similar to NAL-NL2 prescribed gain for input signals of 55 dBA and slightly greater than prescribed gain for 45-dBA signals. Speech recognition scores for NAL-NL2 fits were consistently high, and differences in speech recognition results were strongly correlated with the overall preferences obtained from paired comparisons., Conclusions: Self-adjusted fits are highly variable between individuals for low-audibility conditions. Nonetheless, self-adjusted fits are at least as satisfactory as NAL-NL2 fits, and listeners tend to disfavor settings that result in poorer speech recognition. The findings argue against concerns that self-adjustment will result in inadequate audibility compared to prescribed settings.

Although the behavioral pure-tone threshold audiogram is considered the gold standard for quantifying hearing loss, assessment of speech understanding, especially in noise, is more relevant to quality of life but is only partly related to the audiogram. Metrics of speech understanding in noise are therefore an attractive target for assessing hearing over time. However, speech-in-noise assessments have more potential sources of variability than pure-tone threshold measures, making it a challenge to obtain results reliable enough to detect small changes in performance. This review examines the benefits and limitations of speech-understanding metrics and their application to longitudinal hearing assessment, and identifies potential sources of variability, including learning effects, differences in item difficulty, and between- and within-individual variations in effort and motivation. We conclude by recommending the integration of non-speech auditory tests, which provide information about aspects of auditory health that have reduced variability and fewer central influences than speech tests, in parallel with the traditional audiogram and speech-based assessments.

Health disparities disproportionately affect patients in racial and ethnic minority groups, and these disparities are linked to economic, environmental, and social disadvantage. It is widely known that health disparities impact patients with allergic and immunologic conditions, yet universal and comprehensive training in health disparities is lacking. More robust educational opportunities are needed to fully equip trainees with tools to recognize and develop effective strategies to reduce the burden of health disparities. Also, there are no universal standards or requirements for professional medical boards in their respective maintenance of certification programs that will ensure ongoing training for practicing providers that will help them identify and manage individual or societal issues such as social determinants that contribute to health disparities. Further, the long-term impact of systematic discrimination, implicit and overt bias, and medical mistrust among populations most often affected by disparities compounds the complexity of the methods and types of training that is desperately needed to overcome health disparities. We provide a commentary on important topics that should be addressed during allergy and immunology training and beyond. We further highlight strategies and tools that should be used to tackle this important issue affecting millions of patients under our specialty care. It is past time for us to go beyond the bedside and comprehensively integrate health disparities training in our fellowship programs and in our practices., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Race is a social construct. It is used in medical diagnostic algorithms to adjust the readout for spirometry and other diagnostic tests. The authors review historic evidence about the origins of race adjustment in spirometry, and recent attention to the lack of scientific evidence for their continued use. Existing reference values imply that White patients have better lung function than non-White patients. They perpetuate the historical assumptions that human biological functions of the lung should be calculated differently on the basis of racial-skin color without considering the difficulty of using self-identified race. More importantly, they fail to consider the important effects of environmental exposures, socioeconomic differences, health care access, and prenatal factors on lung function. In addition, the use of "race adjustment" implies a White standard to which other non-White values need "adjustment." Because of the spirometric guidelines in place, the current diagnostic prediction adjustment practice may have untoward effects on patients not categorized as "White," including underdiagnosis in asthma and restrictive lung disease, undertreatment with lung transplant, undercompensation in workers compensation cases, and other unintended consequences. Individuals, institutions, national organizations, and policymakers should carefully consider the historic basis, and reconsider the current role of an automated, race-based adjustment in spirometry., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objectives: Many individuals with noise-related hearing loss continue working in environments where they are periodically exposed to high levels of noise, which increases their risk for further hearing loss. These individuals often must remove their hearing aids in operational environments because of incompatibility with the mandated personal protective equipment, thus reducing situational awareness. Extended-wear hearing aids might provide a solution for these individuals because they can be worn for weeks or months at a time, protect users from high-level noise exposures, and are compatible with communication headsets, earmuffs, and other types of personal protective equipment. The purpose of this study was to evaluate localization ability and speech understanding, feasibility of fitting and use, and acceptability in terms of comfort in a population of noise-exposed, active duty Service members., Design: Participants in the study were active duty Service members who were experienced hearing aid users and were currently using standard hearing aids bilaterally. Participants were fitted with extended-wear hearing aids for up to 14 weeks. Laboratory measures included functional gain, sound localization, and speech recognition (in quiet and in noise). Performance was compared between unaided, standard hearing aids, extended-wear hearing aids, and extended-wear hearing aids combined with a tactical communication device (3M Peltor ComTac). In addition, self-perceived benefit between extended-wear hearing aids and standard hearing aids was compared., Results: The extended-wear hearing aids provided more attenuation of external sound when turned off compared to standard hearing aids. Speech understanding in quiet and in noise was comparable between extended-wear hearing aids and standard hearing aids and was better when a tactical communication device was worn in addition to extended-wear hearing aids. Localization with extended-wear hearing aids was the worst, intermediate with the standard hearing aids, and the best when the ears were unaided. The extended-wear hearing aids and standard hearing aids provided similar self-perceived communication benefits relative to unaided ears. Device failure and issues with extended-wear hearing aids fit and comfort contributed to a high participant withdrawal rate., Conclusions: Overall, the hearing benefits of extended-wear hearing aids for Service members with hearing loss were comparable to those obtained with standard hearing aids, except for sound localization, which was poorer with extended-wear hearing aids. Extended-wear hearing aids provide the additional benefits of protecting the ears from high-level impulsive noise and being compatible with tactical communication and protection systems and other existing personal protective equipment and communication gear. The withdrawal rate in this study, however, suggests that extended-wear hearing aids may not be suitable for active duty Service members in locations where properly trained hearing professionals are not available to replace or re-insert extended-wear hearing aids when needed due to discomfort or device failure., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Health disparities are health differences linked with economic, social, and environmental disadvantage. They adversely affect groups that have systematically experienced greater social or economic obstacles to health. Renewed efforts are needed to reduced health disparities in the United States, highlighted by the disparate impact on racial minorities during the coronavirus pandemic. Institutional or systemic patterns of racism are promoted and legitimated through accepted societal standards, and organizational processes within the field of medicine, and contribute to health disparities. Herein, we review current evidence regarding health disparities in allergic rhinitis, asthma, atopic dermatitis, food allergy, drug allergy, and primary immune deficiency disease in racial and ethnic underserved populations. Best practices to address these disparities involve addressing social determinants of health and adopting policies to improve access to specialty care and treatment for the underserved through telemedicine and community partnerships, cross-cultural provider training to reduce implicit bias, inclusion of underserved patients in research, implementation of culturally competent patient education, and recruitment and training of health care providers from underserved communities. Addressing health disparities requires a multilevel approach involving patients, health providers, local agencies, professional societies, and national governmental agencies., (Copyright © 2021. Published by Elsevier Inc.)

Risk is a concept inherent in every medical procedure. It can be defined as the probability of an adverse event in a defined population over a specified period of time. In the frame of food allergy management, it might be related to a diagnostic procedure, a treatment, or the consumption of foods. The risk of an adverse event can also be augmented by individual factors. This rostrum article discusses various aspects faced by children with food allergies in the light of risk, and their practical implications. Identifying personal risks for severe reaction, such as unstable asthma, and correcting them whenever possible also contribute to a reduction of the risk inherent to food allergy. Among the facets discussed, oral food challenges (OFC) are the most common diagnostic procedures implying an inherent risk. The risk of OFCs can be minimized by correct indication and timing of the test, a safe setting, as well as by ensuring that the patient is otherwise well without potential stressor potentially increasing the risk of a more severe reaction. Oral immunotherapy (OIT) has been studied as a potential treatment for increasing the threshold dose for reaction, and thus reducing the risk of accidental reaction. Nevertheless, the procedure is not devoid of risk as the patients may and do often react during the course of the procedure. Ingestion of trace amounts in processed foods, mainly in community settings such as restaurants, schools, or day care, represents a potential risk of reactions, although for a minority of patients. Precautionary allergen labeling (PAL) is a widespread strategy to reduce the potential risk of reactions due to traces. However, PAL is currently inefficient due to inconsistent labeling, also not indicating a clear maximum amount possibly present in the manufactured food. Finally, cost-effectiveness needs to be considered in risk management, as many risk reduction procedures are clearly not cost-effective., (© 2021 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background: While desensitization and sustained unresponsiveness (SU) have been shown with egg oral immunotherapy (OIT), the benefits of baked egg (BE) therapy for egg allergy have not been well studied., Objectives: This study sought to evaluate the safety and efficacy of BE ingestion compared with egg OIT in participants allergic to unbaked egg but tolerant to BE., Methods: Children who are BE-tolerant but unbaked egg reactive ages 3 to 16 years were randomized to 2 years of treatment with either BE or egg OIT. Double-blind, placebo-controlled food challenges were conducted after 1 and 2 years of treatment to assess for desensitization, and after 2 years of treatment followed by 8 to 10 weeks off of treatment to assess for SU. Mechanistic studies were conducted to assess for immune modulation. A cohort of participants who are BE-reactive underwent egg OIT and identical double-blind, placebo-controlled food challenges as a comparator group., Results: Fifty participants (median age 7.3 years) were randomized and initiated treatment. SU was achieved in 3 of 27 participants assigned to BE (11.1%) versus 10 of 23 participants assigned to egg OIT (43.5%) (P = .009). In the BE-reactive comparator group, 7 of 39 participants (17.9%) achieved SU. More participants who are BE-tolerant withdrew from BE versus from egg OIT (29.6% vs 13%). Dosing symptom frequency in participants who are BE-tolerant was similar with BE and egg OIT, but more frequent in participants who are BE-reactive. Egg white-specific IgE, skin testing, and basophil activation decreased similarly after BE and egg OIT., Conclusions: Among children allergic to unbaked egg but tolerant to BE, those treated with egg OIT were significantly more likely to achieve SU than were children ingesting BE., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Pediatric patients with uncontrolled asthma often live in underserved areas such as rural communities where few pediatric asthma specialists exist. There are significant costs associated with acute asthma exacerbations, which are increasingly prevalent in these high-risk populations. Telemedicine is a viable option when addressing barriers in access to care and cost-efficiency. Implementing telemedicine in schools and other local community settings, as well as implementing innovative technology such as smartphone applications, can reduce the burden of asthma; increase patient satisfaction; and, most importantly, improve pediatric asthma outcomes., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Prognostication of peanut allergy (PNA) is relevant for early interventions. We aimed to determine baseline parameters associated with the development of PNA in 3- to 15-month-olds with likely egg and/or milk allergy, and/or moderate to severe atopic dermatitis (AD) and a positive egg/milk skin prick test (SPT), but no known PNA., Methods: The primary endpoint was PNA [confirmed/convincing diagnosis or last classified as serologic PNA (<2 years, ≥5 kUA/L, otherwise ≥14 kUA/L, peanut IgE)] among 511 participants (median follow-up, 7.3 years). Associations were explored with univariate logistic regression; factors with P < 0.15 were analyzed by stepwise multiple logistic regression, using data stratified by PNA status and randomly assigned to development and validation datasets., Results: 205/511 (40.1%) had PNA. Univariate factors associated with PNA (P < 0.01) included increased AD severity, larger egg and peanut SPT, greater egg, milk, peanut, Ara h1-h3 IgE, higher peanut IgG and IgG4, and increased pregnancy peanut consumption. P-values were between 0.01 and 0.05 for younger age, non-white race, lack of breastfeeding, and increased lactation peanut consumption. Using a development dataset, the multivariate model identified younger age at enrollment, greater peanut and Ara h2 IgE, and lack of breastfeeding as prognosticators. The final model predicted 79% in the development and 75% in the validation dataset (AUC = 0.83 for both). Models using stricter or less strict PNA criteria both found Ara h2 as predictive., Conclusions: Key factors associated with PNA in this high-risk population included lack of breastfeeding, age, and greater Ara h2 and peanut-specific IgE, which can be used to prognosticate outcomes., (© 2019 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Food insecurity (FI), limited availability of or access to nutritional foods, is linked to poor child/caregiver health. We examined FI in food-allergic and non-food-allergic children to determine whether dietary limitations associated with food allergy increases risk of FI., Methods: Food-allergic and non-food-allergic children (1-17 years) were recruited from Arkansas Children's Hospital allergy/asthma clinics. The USDA Food Security Survey, the Newest Vital Sign Health Literacy (HL) questionnaire, and the Food Allergy Impact Scale QOL survey were administered. Logistic regression and analysis of covariance models were utilized for data analysis., Results: Subjects (n = 650) included 325 food-allergic and 325 non-food-allergic children. Overall rate of FI was 21.5% (food allergic 22.2% and non-food allergic 20.9%) with no significant difference in the prevalence of FI between groups (OR = 1.30; 95% CI 0.86-1.96; P = 0.21). FI was increased in households of children with both milk and egg allergy when compared to those without food allergy and those with single food allergy (OR = 2.5; 95% CI 1.4-4.6; P = 0.003). Mean HL rates were higher in the food-secure vs food-insecure groups (mean diff = 0.31; 95% CI 0.03-0.59; P = 0.03). Among food-allergic children, QOL was better in the food-secure vs food-insecure group (mean diff = 0.61; 95% CI 0.002-1.23; P = 0.049)., Conclusion: Food allergy to milk and egg was associated with increased risk of household FI. Food-insecure participants had lower HL than their food-secure counterparts. Further work is needed to define risks associated with FI among food-allergic children to improve screening and management strategies., (© 2019 EAACI and John Wiley and Sons A/S. Published by John Wiley & Sons Ltd.)

Self-adjustment of hearing aid gain can provide valuable information about the gain preferences of individual listeners, but these preferences are not well understood. Listeners with mild-to-moderate hearing loss used self-adjustment to select amplification gain and compression parameters in real time on a portable touch screen device while listening in quiet and noisy backgrounds. Adjustments to gain prescribed by the National Acoustics Laboratories' non-linear fitting procedure (NAL-NL2) showed large between-subject variability. Known listener characteristics (age, gender, hearing thresholds, hearing aid experience, acceptable noise level, and external ear characteristics) and listener engagement with the self-adjustment software were examined as potential predictors of this variability. Neither listener characteristics nor time spent adjusting gain were robust predictors of gain change from NAL-NL2. Listeners with less than 2 years of hearing aid experience and who also had better hearing thresholds tended to select less gain, relative to NAL-NL2, than experienced hearing aid users who had poorer thresholds. Listener factors explained no more than 10% of the between-subject variance in deviation from NAL-NL2, suggesting that modifying prescriptive fitting formulae based on the factors examined here would be unlikely to result in amplification parameters that are similar to user-customized settings. Self-adjustment typically took less than 3 min, indicating that listeners could use comparable technology without a substantial time commitment.

Background/aims: Engaging underserved populations in research requires substantial effort for recruitment and retention. The objective of this study is to describe the effort needed to recruit and retain urban participants in pediatric asthma studies and to characterize the Hardest-to-Reach group by demographics and asthma severity., Methods: We included 311 children (3-10 years) with persistent asthma enrolled in two school-based asthma interventions in Rochester, NY. Contact logs were collected at four time points (baseline, 2 month, 4 month, 6 month). We defined "Hardest-to-Reach" (vs "Easier-to-Reach") as being unable to reach a family by telephone at any given contact attempt due to disconnected or wrong numbers. Chi-square and Mann-Whitney tests were used to compare groups., Results: Overall, we enrolled 311 children (60% Black, 29% Hispanic, 70% Medicaid, response rate 70%). On average, 3.1 contact attempts were required for recruitment (range 1-15), and 35% required rescheduling at least once for the enrollment visit. All but 12 participants completed each follow-up (retention rate = 96%). Completion of follow-ups required an average of 7.6 attempts; we considered 38% of caregivers "Hardest-to-Reach." Caregivers in the Hardest-to-Reach group were slightly younger (33 vs 36 years, p = 0.007) with more depressive symptoms (41% vs 29%, p = 0.035) and smokers in the home (59% vs 48%, p = 0.048). Furthermore, more of the Hardest-to-Reach children had moderate-severe versus mild persistent asthma (64% vs 52%, p = 0.045). Importantly, even the Easier-to-Reach families required many contact attempts, with 52% having >5 attempts for at least one follow-up., Conclusion: In conclusion, we found that among an already vulnerable population, the Hardest-to-Reach families demonstrated higher risk and had children with significantly worse asthma. This study highlights the importance of persistence in reaching those in greatest need.

Background: Asthma morbidity is high in low-income children living in rural US regions, yet few interventions have been designed to decrease the asthma burden in rural populations., Objective: To examine the effect of a school-based asthma education program delivered by telemedicine in children living in an impoverished rural region., Methods: We conducted a cluster randomized trial with rural children 7 to 14 years old by comparing a school-based telemedicine asthma education intervention with usual care. The intervention provided comprehensive asthma education by telemedicine to participants and provided evidence-based treatment recommendations to primary care providers., Results: Of the 393 enrolled children, median age was 9.6 years, 81% were African American, and 47% lived in households with an annual income less than $14,999. At enrollment, 88% of children reported uncontrolled asthma symptoms. At the end of the intervention, there were no statistically significant differences in reported symptom-free days (primary outcome) for the intervention or usual-care group. Participants in the intervention group reported significantly higher use of peak flow meters to monitor asthma and reported taking their asthma medications as prescribed more frequently compared with the usual-care group. There were no changes in other outcome measures, including quality of life, self-efficacy, asthma knowledge, or lung function, between groups., Conclusion: Although there was some evidence of behavior change among intervention participants, these changes were inadequate to overcome the significant morbidity experienced by this highly symptomatic rural impoverished population. Future interventions should be designed with a multifaceted approach that considers caregiver engagement, distance barriers, and inadequate access to asthma providers in rural regions., Trial Registration: ClinicalTrials.gov Identifier: NCT01167855., (Copyright © 2018 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Importance: Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care., Objective: To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma., Design, Setting, and Participants: In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses., Interventions: Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration., Main Outcomes and Measures: The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews., Results: Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84)., Conclusions and Relevance: The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children., Trial Registration: clinicaltrials.gov Identifier: NCT01650844.

The current study used the self-fitting algorithm to allow listeners to self-adjust hearing-aid gain or compression parameters to select gain for speech understanding in a variety of quiet and noise conditions. Thirty listeners with mild to moderate sensorineural hearing loss adjusted gain parameters in quiet and in several types of noise. Outcomes from self-adjusted gain and audiologist-fit gain indicated consistent within-subject performance but a great deal of between-subject variability. Gain selection did not strongly affect intelligibility within the range of signal-to-noise ratios tested. Implications from the findings are that individual listeners have consistent preferences for gain and may prefer gain configurations that differ greatly from National Acoustic Laboratories-based prescriptions in quiet and in noise.

Background: In children with eosinophilic esophagitis (EoE) foods are the most common disease triggers, but environmental allergens are also suspected culprits., Objective: To determine the effects of environmental allergen sensitization on response to treatment in children with EoE in the southeastern United States., Methods: Patients 2 to 18 years old who were referred to the Arkansas Children's Hospital Eosinophilic Gastrointestinal Disorders Clinic from January 2012 to January 2016 were enrolled in a prospective, longitudinal cohort study with collection of demographics, clinical symptoms, medical history, allergy sensitization profiles, and response to treatment over time. Comparisons were made between complete responders (peak esophageal eosinophil count <15 per high-power field [HPF]) and nonresponders (>25 eosinophils per HPF) after treatment with diet elimination alone, swallowed corticosteroids alone, or diet elimination and swallowed corticosteroids. Sensitization patterns to environmental allergens found in the southeastern United States were analyzed for the effect on treatment response., Results: A total of 223 individuals were enrolled. Of these, 182 had environmental allergy profiling and at least one endoscopy while receiving proton pump inhibitor (PPI) therapy. Twenty-nine individuals had PPI-responsive EoE and were excluded from further analysis, leaving 123 individuals with non-PPI-responsive EoE who were further analyzed; 72 (58.5%) were complete responders and 33 (26.8%) were nonresponders. Seventeen individuals (13.8%) were partial responders (≥1 but ≤25 eosinophils per HPF) and excluded from further analysis. Nonresponders were more likely to be sensitized to perennial allergens (P = .02). There was no significant difference in response based on seasonal allergen sensitization. Individuals with mold or cockroach sensitization were more likely to fail combination diet and swallowed corticosteroid treatment (P = .02 and P = .002)., Conclusion: Perennial allergen and mold sensitization may lead to nonresponse to EoE treatment in some patients. Additional studies are needed to further understand the effect of environmental allergens on EoE., Trial Registration: ClinicalTrials.gov identifier: NCT01779154., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the 'School-Based Telemedicine Enhanced Asthma Management' program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Smart wearables such as the Fitbit wristband provide the opportunity to monitor patients more comprehensively, to track patients in a fashion that more closely follows the contours of their lives, and to derive a more complete dataset that enables precision medicine. However, the utility and efficacy of using wearable devices to monitor adolescent patients' asthma outcomes have not been established., Objective: The objective of this study was to explore the association between self‑reported sleep data, Fitbit sleep and physical activity data, and pediatric asthma impact (PAI)., Methods: We conducted an 8‑week pilot study with 22 adolescent asthma patients to collect: (1) weekly or biweekly patient‑reported data using the Patient-Reported Outcomes Measurement Information System (PROMIS) measures of PAI, sleep disturbance (SD), and sleep‑related impairment (SRI) and (2) real-time Fitbit (ie, Fitbit Charge HR) data on physical activity (F-AM) and sleep quality (F‑SQ). To explore the relationship among the self-reported and Fitbit measures, we computed weekly Pearson correlations among these variables of interest., Results: We have shown that the Fitbit-derived sleep quality F-SQ measure has a moderate correlation with the PROMIS SD score (average r=-.31, P=.01) and a weak but significant correlation with the PROMIS PAI score (average r=-.18, P=.02). The Fitbit physical activity measure has a negligible correlation with PAI (average r=.04, P=.62)., Conclusions: Our findings support the potential of using wrist-worn devices to continuously monitor two important factors-physical activity and sleep-associated with patients' asthma outcomes and to develop a personalized asthma management platform., (©Jiang Bian, Yi Guo, Mengjun Xie, Alice E Parish, Isaac Wardlaw, Rita Brown, François Modave, Dong Zheng, Tamara T Perry. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 25.07.2017.)

Background: Adolescents with asthma are at risk of poor outcomes and are traditionally difficult to reach., Objective: To examine adolescents' use of and asthma outcomes associated with smartphone- vs paper-based asthma action plans (AAPs)., Methods: We conducted a 6-month randomized clinical trial with adolescents (12-17 years old) with persistent asthma. Participants used their respective smartphone or paper AAPs for medication instructions and peak flow or asthma symptoms logging. AAP use was measured electronically for smartphone users and via mail-in diaries for the paper group. Changes in Asthma Control Test (ACT) and self-efficacy scores were examined., Results: Thirty-four adolescents participated in this study (median age, 15.4 years). Participants were mostly African American (62%) with state-issued insurance (71%). Adolescents in the smartphone group accessed the AAP a median of 12.17 times per week or 4.36 days per week but only recorded medications or symptoms and peak flow data in the electronic diary a median of 10 days per month during the 6-month period. Participants in the paper group recorded data a median of 23.5 days per month on their paper diaries. Overall, there were no changes in ACT and self-efficacy scores between groups. Adolescents with uncontrolled asthma (baseline ACT score ≤19) had an improvement in ACT for the smartphone group (before, 11; after, 20) ([P = .04) compared with no change in the paper group (before, 17; after, 17) (P = .64). Adolescent satisfaction with the application was high, with 100% stating they would recommend the smartphone AAP to a friend., Conclusion: Adolescents were frequent and highly satisfied users of the smartphone AAP with a subset of participants with uncontrolled asthma demonstrating possible clinical benefit. Findings suggest a need for larger-scale studies to determine the effectiveness of smartphone-based AAPs among high-risk patients with asthma., Trial Registration: clinicaltrials.gov Identifier: NCT02091869., (Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Though peanut oral immunotherapy (OIT) is a promising investigational therapy, its potential is limited by substantial adverse events (AEs), which are relatively understudied., Objective: A retrospective analysis was conducted, pooling data from 3 pediatric peanut OIT trials, comprising the largest analysis of peanut OIT safety to date., Methods: We pooled data from 104 children with peanut allergy from 3 peanut OIT studies. We catalogued AEs from parental reports, daily symptom diaries, and dose escalations. We included events that were considered likely related to OIT and identified potential baseline predictors of higher AE rates using generalized linear regression models., Results: Eighty percent of subjects experienced likely related AEs during OIT (72% during buildup and 47% during maintenance). Of these AEs, over 90% occurred while at home. Approximately 42% of subjects experienced systemic reactions, and 49% experienced gastrointestinal symptoms. Twenty percent of subjects dropped out, with half (10% of the overall group) due to persistent gastrointestinal symptoms. Baseline allergic rhinitis (AR) and peanut SPT wheal size were significant predictors of higher overall AE rates. SPT wheal size predicted increased gastrointestinal AEs, and AR predicted increased systemic reactions. Over the course of OIT, 61% of subjects received treatment for likely related AEs, 59% with antihistamines and 12% with epinephrine., Conclusions: Peanut OIT is associated with frequent AEs, with rates declining over time, and most graded mild. However, systemic reactions and intolerable gastrointestinal AEs do occur and are significantly associated with AR and peanut SPT wheal size, respectively. Further study is needed of predictive biomarkers and the overall risks and benefits of OIT., (Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Although there is concern that food allergy reactions may negatively affect the natural history of food allergy, the impact of reactions on food-specific IgE (sIgE) levels or skin prick test (SPT) wheal size is unknown., Objective: To measure the effects of allergic reactions on SPT wheal size and sIgE concentrations to milk, egg, and peanut., Methods: Participants included 512 infants with likely milk or egg allergy enrolled in a multicenter observational study. Changes in sIgE level and SPT wheal size to milk, egg, and peanut were measured before and after oral food challenge (OFC) or accidental exposure for 377 participants., Results: The median age of the cohort at the time of analysis was 8.5 years (67% males). There were no statistically significant changes in sIgE level or SPT wheal size after positive OFC to milk, egg, or peanut (n = 20-27 for each food). Change in sIgE level and SPT wheal size was measured after 446 and 453 accidental exposure reactions, respectively. The median change in sIgE level was a decrease of 0.33 kU(A)/L (P < .01) after milk and 0.34 kU(A)/L (P < .01) after egg reactions, but no other statistically significant changes in sIgE level or SPT wheal size were observed for milk, egg, or peanut. When we limited the analysis to only those participants who had diagnostic testing done within 6 months of an accidental exposure reaction, we found that peanut SPT wheal size increased by 1.75 mm (P < .01), but a significant increase was not noted when all participants with testing done within 12 months were considered., Conclusions: The results suggest that reactions from OFCs and accidental exposure are not associated with increases in sensitization among children allergic to milk, egg, or peanut., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Double-blinded, placebo-controlled food challenges (DBPCFCs) remain the gold standard for diagnosing food allergies. Skin prick tests (SPTs) and allergen-specific IgE (sIgE) are routinely used in medical practice but are not sufficient to predict severity of clinical reactivity., Objective: To compare the utility of SPT wheal diameter, sIgE, allergen-specific IgG4 (sIgG4), total IgE (tIgE), sIgE/sIgG4 and sIgE/tIgE ratios, peanut component-specific IgE, and basophil activation in predicting outcome and severity of reactions at DBPCFCs., Methods: Sixty-seven subjects (12-45 years old) underwent DBPCFCs for peanut, tree nut, fish, shrimp, and/or sesame as part of screening for enrollment in a clinical trial. The SPT, sIgE, tIgE, sIgG4, and peanut component-specific IgE (if applicable) levels were measured. CD63 upregulation on basophils in response to in vitro allergen challenge was analyzed by flow cytometry. Correlations between these measurements and DBPCFC severity scores were analyzed., Results: The SPT and sIgE showed a weak correlation with DBPCFC severity scores, but tIgE and sIgG4 did not. The sIgE/sIgG4 ratio differentiated between positive and negative reactions but did not correlate with DBPCFC severity scores. A low positive correlation was seen between DBPCFC severity score and Ara h 2 IgE, whereas a low negative correlation with Ara h 8 IgE was observed. Basophil activation was positively correlated with DBPCFC severity scores. Receiver operating characteristic curves showed basophil reactivity had the largest area under the curve at 0.904 and sIgE at 0.870., Conclusion: These results indicate that basophil activation testing can enhance discrimination between allergic and nonallergic individuals and could serve as an additional tool to predict clinical severity., (Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Normal-hearing listeners show masking release, or better speech understanding in a fluctuating-amplitude masker than in a steady-amplitude masker, but most cochlear implant (CI) users consistently show little or no masking release even in artificial conditions where masking release is highly anticipated. The current study examined the hypothesis that the reduced or absent masking release in CI users is due to disruption of linguistic segmentation cues. Eleven CI subjects completed a sentence keyword identification task in a steady masker and a fluctuating masker with dips timed to increase speech availability. Lexical boundary errors in their responses were categorized as consistent or inconsistent with the use of the metrical segmentation strategy (MSS). Subjects who demonstrated masking release showed greater adherence to the MSS in the fluctuating masker compared to subjects who showed little or no masking release, while both groups used metrical segmentation cues similarly in the steady masker. Based on the characteristics of the segmentation cues, the results are interpreted as evidence that CI listeners showing little or no masking release are not reliably segregating speech from competing sounds, further suggesting that one challenge faced by CI users listening in noisy environments is a reduction of reliable segmentation cues.

Purpose: To examine feasibility and utilization of a mobile asthma action plan (AAP) among adolescents., Methods: Adolescents (aged 12-17 years) with persistent asthma had their personalized AAP downloaded to a smartphone application. Teens were prompted by the mobile application to record either daily symptoms or peak flow measurements and to record medications. Once data were entered, the application provided immediate feedback based on the teen's AAP instructions. Asthma Control Test (ACT(®)) and child asthma self-efficacy scores were examined pre- and post-intervention., Results: Adolescents utilized the mobile AAP a median 4.3 days/week. Participant satisfaction was high with 93% stating that they were better able to control asthma by utilizing the mobile AAP. For participants with uncontrolled asthma at baseline, median (interquartile range) ACT scores improved significantly from 16 (5) to 18 (8) [p = 0.03]. Median asthma attack prevention self-efficacy scores improved from 34 (3.5) to 36 (5.3) [p = 0.04]., Conclusions: Results suggest that personalized mobile-based AAPs are a feasible method to communicate AAP instructions to teens., Competing Interests: Declaration of interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.