Blau syndrome is a rare, autosomal dominant, autoinflammatory disease caused by mutations in the NOD2 gene, characterized by arthritis, dermatitis, and uveitis. Symptoms typically appear in early childhood, before age 4, and later presentation is uncommon. We present a patient with late-onset Blau syndrome, with symptom onset at age 10 and diagnosis at age 18. At age 10, our patient developed a severe, refractory generalized rash initially diagnosed as eczema, along with eye redness and irritation initially diagnosed as allergic conjunctivitis. These diagnoses were not challenged due to inconsistent follow-up. The rash was complicated by multiple superimposed skin infections leading to scarring. Our patient was an excellent athlete, but at age 14, he developed thoracic back pain, hip and wrist arthritis, and malformations, including prominent bending of the fifth fingers and toes, which hindered physical activity. The family suspected undiagnosed food allergies, leading to food withholding and resulting in protein deficiency over three years. A skin biopsy, planned several times, was delayed due to family hesitancy but was finally performed at age 16, revealing granulomatous dermatitis. At the same time, he was experiencing chronic diarrhea and bloating, but colonoscopy was never completed due to intolerance of the preparation. Although his symptoms were concerning for inflammatory bowel disease, diagnostic pathology was never obtained for this reason. However, an upper endoscopy revealed H. Pylori gastritis and changes suggestive of celiac disease, including blunted villi. Pathology demonstrated chronic duodenopathy. At age 18, he was referred to allergy and immunology, where genetic testing confirmed a pathogenic NOD2 mutation, diagnosing Blau syndrome. Other laboratory findings included low IgM (33), elevated IgE, but normal IgG and IgA, and fluctuating CRP. QuantiFERON was negative. A unique aspect of this patient’s case is the delayed onset and the significant impact of social determinants of health on the patient’s care. Since diagnosis, consistent in-person follow-up has been difficult to arrange due to frequently missed appointments for unknown reasons. This case highlights the challenges of diagnosing late-onset Blau syndrome in the setting of inconclusive laboratory evaluation and underscores the role of social factors in medical management.

Pharmacoequity refers to equity in access to pharmacotherapy for all patients and is an especially large barrier to biologic agents in patients with allergic diseases. Value-based care models can prompt clinicians to address social determinants of health, promoting pharmacoequity. Pharmacoequity is influenced by numerous factors including socioeconomic status, which may be mediated through insurance status, educational attainment, and access to specialist care. In addition to lower socioeconomic status, race and ethnicity, age, locations isolated from care systems, and off-label indications for biologic agents all constitute barriers to pharmacoequity. Whereas pharmaco-inequity is more apparent for expensive biologics, it also affects many other allergy treatments including epinephrine autoinjectors and SMART for asthma. Current programs aimed at alleviating cost barriers are imperfect. Patient assistance programs, manufacturer-sponsored free drug programs, and rebates often increase the complexity of care, with resultant inequity, particularly for patients with lower health literacy. Ultimately, single silver-bullet solutions are elusive. Long-term improvement instead requires a combination of research, advocacy, and creative problem-solving to design more intelligent and efficient systems that provide timely access to necessary care for every patient, every time.

The story of inequitable access to health care and the resultant health disparities for historically marginalized populations is an old story. The specialty of allergy and immunology (A/I), although not immune to the consequences of health disparities, might possess the capacity to help extinguish them. A/I is a multifaceted subspecialty designed for comprehensive management of asthma, allergic diseases, and immunodeficiencies across a patient’s lifespan, strategically placing it to lead multilevel collaborative solutions.

Asthma and allergies are often diagnosed simultaneously, particularly since the differentiation between allergic vs. nonallergic asthma phenotypes has prognostic and therapeutic implications for patients. Prior research has shown disparities in allergy testing in minority children with asthma living in urban areas. This study aims to evaluate asthma characteristics in a diverse urban population to identify differences in rates of allergy testing in adults with well-controlled vs. poorly controlled asthma.

The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine.

We read with interest the recent report by Keet et al describing an association between food sensitization and cardiovascular risk.1 This analysis has many strengths but also unavoidable weaknesses, including a high likelihood of considerable measured and unmeasured confounding and use of linked databases not designed to study the specific hypothesis tested.1 At present, the study by Keet et al1 provides more questions than answers, with some possibility of unintended harm.

Affecting 10% to 50% of the population, allergic rhinitis (AR) is 1 of the world's most prevalent chronic illnesses, generating a significant burden to society through treatment costs and quality-of-life decrements.1 In the United States, the annual cost of AR is estimated to range from $2 to $5 billion (2003 estimate).1 Allergen immunotherapy is an option for treating AR, but pharmaceutical medications remain the cornerstone of management. Unfortunately, as detailed in the thought-provoking article by Mi et al,2 the cost of many of these rhinologic medications has been increasing, adding more financial burden to patients with AR.

BACKGROUND: Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma. OBJECTIVE: The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity. METHODS: A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed. RESULTS: A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non-office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective. CONCLUSION: With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective. (C) 2022 American Academy of Allergy, Asthma & Immunology

OBJECTIVE:To review influenza epidemics and pandemics for practicing allergists-immunologists.DATA SOURCES:English-language articles published in PubMed from 1990 to present with relevance to allergic disorders and articles cited by or similar to these articles.STUDY SELECTIONS:A total of 472 articles were identified from PubMed. Two independent reviewers appraised the titles for relevance.RESULTS:A total of 212 relevant articles were selected. Additional articles and government websites increased the number to 295 relevant citations.CONCLUSION:Influenza epidemics and pandemics have recurred throughout history. Patients with asthma and immunodeficiency are at an increased risk. Nonpharmaceutical interventions, vaccination, and neuraminidase inhibitors are key strategies for the prevention and treatment of influenza epidemics/pandemics. Allergists play a vital role in protecting high-risk groups and increasing influenza vaccination coverage.

Diversity, Equity, and Inclusion: What Can a Journal Do?The Journal of Allergy and Clinical Immunology: In PracticeVol. 9Issue 11PreviewWith all the turmoil in the last year, it is saddening that to be counted among the tragedies is the fact that we, as a country and as a world, are still battling disparities and inequalities. Despite large steps forward over the decades, these have been accompanied by, most would argue, even larger steps backward. Some may even agree that there was a missed opportunity with the event of the coronavirus disease 2019 pandemic. We were offered a chance for humanity to band together to fight one common evil; the perfect opportunity for equality to reign. Full-Text PDF

Cost-effectiveness analysis is a way to understand the value of a health care intervention in terms of assessing the money spent to produce beneficial outcomes. Cost-effectiveness analyses are used by various stakeholders for such purposes because health care resources and financing may be scarce, depending on the economy, and certain interventions may be costly to produce such outcomes compared with other options. These analyses are built on well-researched and robust inputs for costs and outcomes and may be modeled using a technique called Markov chain models, which allow transitions among various health states (eg, alive, dead, outgrow allergy, allergy relapses) relative to the condition of interest to reflect a base-case scenario. Then, the margins of the inputs are explored for a sensitivity analysis of potential findings. These analyses should be investigated from multiple perspectives (eg, society, health care payer). Limitations of the analysis should be clearly stated. Although such models are an informative way to explore a situation and can be performed without additional direct patient intervention, a weakness of the approach is that this may overlook individual patient nuances. Cost-effectiveness analyses are important policy tools to show, on average, an optimal way to improve value in population health.

Since the first case of severe acute respiratory syndrome coronavirus 2 infection on January 22, 2020, the number of positive cases and deaths has rapidly increased.1 The initial report of 140 hospitalized patients infected with coronavirus disease 2019 (COVID-19) from Wuhan, China, indicated that allergic diseases, asthma, and chronic obstructive pulmonary diseases were not risk factors for severe acute respiratory syndrome coronavirus 2 infection.2 However, the clinical features of this condition with cough and shortness of breath (SOB) might mask, or mimic, an asthma exacerbation.

Upper respiratory infections are associated with up to 80% of asthma exacerbations. Investigating the role of influenza vaccination on asthma exacerbations using electronic health records (EHRs) is challenging due to lack of a computable phenotype for influenza vaccination. The purpose of this project was to develop an influenza vaccination computable phenotype, and evaluate its performance against manual chart review. Individuals with asthma who presented to Rush University Medical Center in Chicago between August 1, 2010 and May 31, 2018 were identified from EHRs using a published asthma computable phenotype. Influenza vaccination records were then extracted by querying EHRs for brand and generic names of influenza vaccine. Haemophilus influenza B and incomplete split vaccine cases were excluded. Influenza vaccination status of a random sample of 100 individuals with asthma was determined by double blind chart review by two independent reviewers. Inter-reviewer reliability was investigated by calculating a kappa score. Final determination of influenza vaccination status was reached with a third reviewer, and agreement with the computable phenotype was analyzed by calculating a kappa score, negative and positive predictive value (NPV, PPV), specificity and sensitivity. The kappa score between the computable phenotype and final manual chart review on influenza vaccination status in 100 patients with asthma was 1.0, with NPV=100%, PPV=94.4%, specificity of 94.3% and sensitivity of 100%. Results demonstrated excellent agreement between EHR algorithm and manual chart review. This computable phenotype could be used in future studies examining the role of influenza vaccination in asthma morbidity and exacerbations.

The coronavirus disease 2019 (COVID-19) pandemic has expanded rapidly in the United States and around the globe, much faster than anticipated. Hundreds of thousands are infected and unfortunately plenty of patients have died. As an academic allergy and immunology division in a large city, our clinical, educational, research, and community responsibilities have been tremendously impacted. Patients needed us more than ever, but mitigation efforts prevented us from seeing them routinely in person. Three weeks ago, as the first severe case of COVID-19 in Chicago was diagnosed and admitted to our intensive care unit, we understood we needed immediate plans. The change happened in multiple categories: clinical operation, training programs, and research (Table I). Although in the past decade we have witnessed a tremendously rapid progress in communication technology, these changes pale in comparison to the speed of change within the last 3 weeks. It was the time to harness this technology to be used for educational activities and patient care. Here, we report on the changes to our clinical and educational activities in response to the COVID-19 pandemic.Table IChallenges and solutions in the urban academic allergy and immunology division in response to the COVID-19 pandemicDomainsChallengesSolutionsClinical•Social distancing (including reducing exposure in outpatient clinic and reducing need to round on inpatient consults with large team of fellows, residents, and students)•Converted all nonurgent in-person clinic visits to virtual (with video) or telephone visit•All inpatient consults triaged for need for physical examination and risk of exposure to coronavirus; physical examination was not done if unnecessary. Discussion rounds were done virtually. Group rounds at patient rooms were avoided•New virtual/telephone visit model•Rapid training of faculty and fellows on virtual/telephone visits•Increased telephone calls from patients concerned about possible COVID-19•Nurses and fellows created phone call pools through a new triaged algorithm•Faculty volunteered at special COVID-19 virtual visits at hospital level•Staffing and nursing shortage due to surge•Stopped all visits at central clinic•Moved any urgent visit to 1 satellite location•Need for coronavirus-specific patient communication (eg, letters, work-from-home excuse, coronavirus symptoms, and risk stratification)•Standardized letters describing symptoms and when patients should call the COVID-19 hotline•Generated COVID-19–specific letters•Biologic medications administration•Except omalizumab and few cases with disabilities, all other biologics were given at home. Moved all biological injections to 1 satellite location•Allergen immunotherapy (IT)•Halted all IT in accordance with AAAAI guidelines for 4 wk•Created IT restart plans for interested individuals, with lowest possible frequency. Plans were discussed with patients over the phoneEducational•Minimizing fellow exposure•Converted all educational meetings to Web-based meetings•Staying current on COVID-19 literature•Expanded journal club and staff meetings•Expanded case conference•Added complexity of fellows schedule in response to increased educational activities and redeployment•Shared calendar•Anticipating future COVID-19 challenges•Frequent discussions with program directors of Allergy/ImmunologyResearch•Patient recruitment•Temporary suspension of all research recruitments•Efforts were focused on completing information and chart reviews•Expedited IRB amendments to switch consenting and follow-up visits to virtual and Web-based questionnaires•Basic science research•Temporary halt of previous experiments•Research lab members who were interested got involved in new studies related to COVID-19 experiments by other labs or volunteered in the clinical laboratoryHospital and community•Need for volunteers on the COVID-19 hotline•Increased need for inpatient coverage for COVID-19 surge•Faculty volunteered to screen concerned patients for COVID-19•Nurses volunteers in various COVID-19 testing areas•All providers were added to hospital surge lists for COVID-19AAAAI, American Academy of Allergy, Asthma & Immunology; IRB, institutional review board; lab, laboratory. Open table in a new tab AAAAI, American Academy of Allergy, Asthma & Immunology; IRB, institutional review board; lab, laboratory. With the exception of urgent visits and biologic medication administration, outpatient clinical operations were transitioned to telemedicine. All faculty and fellows were trained emergently to perform virtual medicine through video and phone visits. Our inpatient consult service changed shape as well; the requested consults ran through an algorithm based on the need for physical examination, and the risk to COVID-19. Faculty volunteered in COVID-19 telemedicine clinics, which provided a unique opportunity to augment our typical curriculum evolving COVID-19 guidelines. The insight gained was tremendously helpful, not only for referring potential COVID-19 cases but also for understanding the impact of this infection on allergic conditions. The changes and strategies implemented by our division are summarized in Table I. The training program was faced with difficult decisions on how to maintain clinical training. Previous reviews have found that supervision using telehealth can be an effective method of clinical training.1White S. ACGME Guidance Statement on Coronavirus (COVID-19) and Resident/Fellow Education and Training Considerations. ACGME Common Program Requirements 2020.https://acgme.org/Newsroom/Newsroom-Details/ArticleID/10068/ACGME-Guidance-Statement-on-Coronavirus-COVID-19-and-Resident-Fellow-Education-and-Training-ConsiderationsGoogle Scholar,2Martin P. Lizarondo L. Kumar S. A systematic review of the factors that influence the quality and effectiveness of telesupervision for health professionals.J Telemed Telecare. 2018; 24: 271-281Crossref PubMed Scopus (47) Google Scholar Both faculty and fellows were trained and provided with adequate information technology support. Faculty, who had previous experience with telemedicine visits, supervised the fellow's telehealth training. Fellows were instructed via university-provided Web-based sessions, through both prerecorded and live interactive sessions, on virtual visits. After these tutorials, fellows were directed to use the virtual hospital desktop. The virtual desktop can be accessed remotely by their office or home computer, in conjunction with a smartphone- or tablet-based video-conferencing application to perform visits. After Web-based tutorial training was completed, the fellow's first virtual visit occurred in a cleaned patient room while the patient was at home. These ad-hoc offices improved social distancing for the fellows. After the review, the supervising attending allergist joined the patient and fellow in a concluding group virtual visit. The first virtual visits allowed the supervising allergist to help the fellow navigate the electronic medical record, trouble shoot, and fix any problem in person. Once the fellow was comfortable, we allowed fellows to work from home. The electronic medical record provided various methods for real-time conversation between the fellow and faculty during the virtual visit. Fellows and faculty created several new letter and documentation templates specific for the COVID-19 crisis. New modules for electronic patient education and coordination of care were created as well. Regulations surrounding telehealth services were modified during this time of national emergency. The federal government instituted waivers for originating site requirements and other previous restrictions to allow for greater provision of telehealth services.3US governmentCoronavirus Preparedness and Response Supplemental Appropriations Act, 2020 in H.R. 6074—116th Congress (2019-2020). 2020Google Scholar The billing and coding procedures for telehealth services changed as well. Staying current on the latest provisions at the local and national levels, communicating with the coding auditors, and educating fellows were essential because of the changing nature of this pandemic. The division held a virtual conference guided by hospital coding experts to go over new regulations, codes, and modifiers. Furthermore, training program directors discussed any new changes with fellows through group emails and separate short conferences. Allergy fellowship educational activities were complicated by a multitude of factors. These factors include overloading of the daily clinic schedule with telemedicine training, the rapid publication of key COVID-19 articles, and social distancing. To address these challenges, the weekly calendar was revised. The training program created a new detailed, shared calendar to follow and document all the fellows' educational and clinical activities. The new calendar reduced scheduling conflicts. Given the rapidly developing crisis and publication of important findings, journal club required an expansion. An online, expanded journal club schedule was embedded in the above schedule. Faculty and fellows were assigned to cover allergy- and immunology-related articles with focus on COVID-19. Example was a 90-minute journal club through which 5 fellows thoroughly discussed the new practice parameters guidelines on COVID-19 pandemic contingency planning published by the American College of Allergy, Asthma & Immunology/American Academy of Allergy, Asthma & Immunology.4Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E.W.Y. et al.Special Article: COVID-19: Pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol Pract. 2020 Mar 26; ([Epub ahead of print]. https://doi.org/10.1016/j.jaip.2020.03.012)Abstract Full Text Full Text PDF Scopus (243) Google Scholar This journal club was followed by a divisional meeting to reinforce some of the changes that needed to be implemented in our clinical practice according to this publication. Similarly, social distancing required the in-person discussing of interesting or challenging cases be transformed to conference calls, with emphasis on cases related to COVID-19 infection. The pandemic and fear of infections aside, going through this significant amount of change in a short period of time has been very stressful. As schools and daycares closed, those with young children faced difficulties to coordinate their personal lives. Unfortunately, grandparents were the high-risk population and not suitable babysitters in the COVID-19 pandemic. Performing telehealth visits, or participating in remote journal club, immunology lectures, and training sessions from home was not always easy. We addressed these issues with provisional planning and changing schedules whenever needed. The fear and uncertainty of the unfolding pandemic was particularly unsettling for fellows in training. An open dialog was essential to allow trainees to voice concerns regarding how this national emergency may impact their individual experience. The availability of program directors and their rapport with fellows to address their concerns and provide reassurance on an almost daily basis were essential and helpful to address some of these challenges. Some other changes were made in response to fellows' concerns. For example, the traditional call schedules were reordered to share the responsibilities, and messages and phone calls were placed in clinical pools as the volume of patient questions increased in the face of the pandemic. We also identified a need for future emergency planning, given the likelihood of the crisis worsening. There would be more difficulties, such as COVID-19 infection among faculty, fellows, and support staff, and increased inpatient responsibilities for all physicians including allergists. Contingency plans and schedules were placed for both inpatient and outpatient responsibilities, with 2 lines of backup for faculty, fellows, and other staff. Furthermore, we shared detailed information on the available resources by university for stress management, employee and family health, and contingency child care. Although we are pressed with immediacy of the COVID-19 pandemic, we also need to keep a long-term view for the future of our specialty. The COVID-19 pandemic has impacted all parts of the world. Given the recent history of other epidemics (eg, severe acute respiratory syndrome, H1N1, ebola, and Middle East respiratory syndrome), it is unlikely that this will be the last epidemic/pandemic crisis. This type of crisis requires allergy divisions and training programs communicate by virtual global assemblies. Communication between program directors and fellows across different programs can provide support and solutions, which can be adapted at each division on the basis of their needs and resources. The entire specialty should unite with the societies such as the World Allergy Organization, the American Academy of Allergy, Asthma & Immunology, and the American College of Allergy, Asthma & Immunology in these difficult times to share experiences and knowledge to overcome present and future difficulties. We would like to thank the Department of Medicine at Rush University and our dedicated clinical and administrative support staff who have tremendously helped us for this transition to be able to continue our clinical and educational activities in the time of COVID-19 pandemic. An academic allergy unit during COVID-19 pandemic in ItalyJournal of Allergy and Clinical ImmunologyVol. 146Issue 1PreviewRecently, Codispoti et al1 delineated the clinical and academic challenges that the coronavirus disease 2019 (COVID-19) pandemic raised at their Division of Allergy and Immunology. They rapidly coordinated a lot of stressful changes in established practices to meet academic and health care needs. Besides congratulating the authors for their promptness, we here share our experience in getting across the COVID-19 pandemic in our Allergy Clinic, at Humanitas Research Hospital in Milan, where the epidemic first started in Italy. Full-Text PDF

Engaging in shared decision-making (SDM) and accounting for patient-reported outcomes within treatment decisions are core tenets of patient-centered care. In the context of a quality improvement (QI) study, we evaluated real-world patient-centered atopic dermatitis (AD) care practices and perceptions. The study comprised physicians, physician assistants, and nurse practitioners in allergy/immunology (AI; n = 23) and dermatology (n = 28) clinics across two health systems. Data collection occurred through: (1) surveys administered to providers, and (2) 200 retrospective chart audits of the systems’ adult patients with moderate-to-severe AD. Data were presented in audit-feedback sessions, where the teams developed action plans to close identified gaps. On 5-point Likert scales, providers reported assessing the impact of AD “most of the time” or “always” on the following patient-reported measures: daily activities (39% AI specialists; 43% dermatologists); sleep quality (35% AI specialists; 39% dermatologists); mental health (17% AI specialists; 46% dermatologists). Low proportions of charts documented that patients were asked about daily activities (19%), sleep quality (10%), and depression (5%). Chart-documented performance of essential SDM practices was high for some (assessing adherence, 92%; providing opportunities for patients to review decisions, 78%), and low for others (asking patients’ treatment goals, 23%; explaining benefits and risks of treatment options, 32%; assessing patient understanding of treatment options, 35%; providing opportunities for patients to ask questions, 39%). Action plans included developing standardized AD assessment templates for documentation and interprofessional workflows for SDM. Audit-feedback of SDM and quality of life measures can inform team-based initiatives to improve patient-centered AD care.

What was the research about?Asthma affects 1 in 10 children in the United States.When asthma isn't managed well, children may need treatment in an emergency room, or ER.Doctors in the ER can use guidelines based on research to decide how to prepare families to manage asthma after they go home.This study compared three ways to prepare children and caregivers to manage asthma after they leave the ER:• Guideline-based, ER only.In this approach, the children and caregivers received instructions in the ER about how to use their medicines and inhalers.Afterward, ER staff set up follow-up office visits.

We would like to thank Kalemci et al1Kalemci S. Sarıhan A. Zeybek A. Does asthma affect outcomes of patients with COVID-19 infections?.J Allergy Clin Immunol Pract. 2021; 9: 591Google Scholar for highlighting our paper published in the August issue of the Journal of Allergy and Clinical Immunology: In Practice.2Mahdavinia M. Foster K.J. Jauregui E. Moore D. Adnan D. Andy-Nweye A.B. et al.Asthma prolongs intubation in COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 2388-2391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar The impact of COVID-19 on patients with asthma and their COVID-19 outcome has been a matter of several investigations in the past few months. As the authors mentioned, asthma is a heterogenic disease with several endotypes, which may respond to infectious processes differently. Our results are in agreement with other papers that were published in the following month showing that asthma does not decrease or increase hospitalization rate and length for COVID-19.3Chhiba K.D. Patel G.B. Vu T.H.T. Chen M.M. Guo A. Kudlaty E. et al.Prevalence and characterization of asthma in hospitalized and nonhospitalized patients with COVID-19.J Allergy Clin Immunol Pract. 2020; 146: 307-314.e4Abstract Full Text Full Text PDF Scopus (218) Google Scholar Additional studies showed that atopy might play an important role in the response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Our follow-up large 2-center study has also shown that atopy is a potential protective factor and a positive prognostic factor for decreased severity of COVID-19.4Keswani A. Dhana K. Rosenthal J.A. Moore D. Mahdavinia M. Atopy is predictive of a decreased need for hospitalization for COVID-19.Ann Allergy Asthma Immunol. 2020; 125: 479-481Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Furthermore, we have found that, among different endotypes of asthma, only nonallergic asthma was associated with prolonged need for intubation,4Keswani A. Dhana K. Rosenthal J.A. Moore D. Mahdavinia M. Atopy is predictive of a decreased need for hospitalization for COVID-19.Ann Allergy Asthma Immunol. 2020; 125: 479-481Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar which agrees with a recent comprehensive large study.5Zhu Z. Hasegawa K. Ma B. Fujiogi M. Camargo Jr., C.A. Liang L. Association of asthma and its genetic predisposition with the risk of severe COVID-19.J Allergy Clin Immunol. 2020; 146: 327-329.e4Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar This study showed that nonallergic asthma was associated with a higher risk of severe COVID-19.5Zhu Z. Hasegawa K. Ma B. Fujiogi M. Camargo Jr., C.A. Liang L. Association of asthma and its genetic predisposition with the risk of severe COVID-19.J Allergy Clin Immunol. 2020; 146: 327-329.e4Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar This is also consistent with translational studies. Although gene expressions of 2 key mediators for SARS-CoV-2 infection, angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2), have been shown to be different in allergic individuals, potentially protecting them from severe illness, in a large study in which all patients with asthma were combined together, the expression of both genes was similar between patients with asthma and healthy subjects.6Peters M.C. Sajuthi S. Deford P. Christenson S. Rios C.L. Montgomery M.T. et al.COVID-19-related genes in sputum cells in asthma. Relationship to demographic features and corticosteroids.Am J Respir Crit Care Med. 2020; 202: 83-90Crossref PubMed Scopus (348) Google Scholar This indicates that asthma in general is not a risk factor for more or less severe COVID-19 illness. However, as a chronic lung disease prone to viral-induced exacerbation, this might place those with severe COVID-19 at risk for a longer duration of pulmonary inflammation.2Mahdavinia M. Foster K.J. Jauregui E. Moore D. Adnan D. Andy-Nweye A.B. et al.Asthma prolongs intubation in COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 2388-2391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar,5Zhu Z. Hasegawa K. Ma B. Fujiogi M. Camargo Jr., C.A. Liang L. Association of asthma and its genetic predisposition with the risk of severe COVID-19.J Allergy Clin Immunol. 2020; 146: 327-329.e4Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar Furthermore, an allergic background and differential expression of ACE2 and TMPRSS2 may dampen the strong inflammatory response to SARS-CoV-2 in patients with allergic asthma, leading to the lack of increased severity reported in patients with nonallergic asthma.2Mahdavinia M. Foster K.J. Jauregui E. Moore D. Adnan D. Andy-Nweye A.B. et al.Asthma prolongs intubation in COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 2388-2391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar,4Keswani A. Dhana K. Rosenthal J.A. Moore D. Mahdavinia M. Atopy is predictive of a decreased need for hospitalization for COVID-19.Ann Allergy Asthma Immunol. 2020; 125: 479-481Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar,5Zhu Z. Hasegawa K. Ma B. Fujiogi M. Camargo Jr., C.A. Liang L. Association of asthma and its genetic predisposition with the risk of severe COVID-19.J Allergy Clin Immunol. 2020; 146: 327-329.e4Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar Another important factor that needs to be considered and further investigated is the impact of racial differences on COVID-19 outcome in patients with asthma. The studies that did not find any difference in terms of COVID-19 severity or intubation time in patients with asthma were performed in predominantly non–African American (AA) populations, such as from China, or study populations with only 21% to 26% AAs.3Chhiba K.D. Patel G.B. Vu T.H.T. Chen M.M. Guo A. Kudlaty E. et al.Prevalence and characterization of asthma in hospitalized and nonhospitalized patients with COVID-19.J Allergy Clin Immunol Pract. 2020; 146: 307-314.e4Abstract Full Text Full Text PDF Scopus (218) Google Scholar In our series from the city of Chicago, 59% of COVID-19 patients with asthma were AA.2Mahdavinia M. Foster K.J. Jauregui E. Moore D. Adnan D. Andy-Nweye A.B. et al.Asthma prolongs intubation in COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 2388-2391Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Interestingly, Peters et al6Peters M.C. Sajuthi S. Deford P. Christenson S. Rios C.L. Montgomery M.T. et al.COVID-19-related genes in sputum cells in asthma. Relationship to demographic features and corticosteroids.Am J Respir Crit Care Med. 2020; 202: 83-90Crossref PubMed Scopus (348) Google Scholar have demonstrated that, among patients with asthma, AA race was associated with higher expression of ACE2 and TMPRSS2. Consistent with that study, our as yet unpublished follow-up study has shown that AAs with asthma and COVID-19 infection had a significantly higher rate of asthma exacerbation and longer duration of asthma symptoms after COVID-19 compared with their white counterparts. Specifically, 68% of AAs versus 35% of whites (P = .032) report symptoms suggestive of asthma exacerbation after COVID, and mean ± standard deviation durations of asthma exacerbation symptoms were 3.6 ± 2.1 weeks versus 1.5 ± 1.3 weeks in AAs and whites, respectively (P = .045). We have also demonstrated that, although asthma is not a risk factor for COVID-19 hospitalization in any age group, AA children are at a significantly higher risk for COVID-19 adverse outcomes.7Bandi S. Nevid M.Z. Mahdavinia M. African American children are at higher risk of COVID-19 infection.Pediatr Allergy Immunol. 2020; 31: 861-864Crossref Scopus (28) Google Scholar Multiple inter-related variables, such as uncontrolled comorbidities, reduced access to health care, and other socioeconomic factors, and possibly a genetic predisposition can impact these important results and need to be further investigated. Kalemci et al1Kalemci S. Sarıhan A. Zeybek A. Does asthma affect outcomes of patients with COVID-19 infections?.J Allergy Clin Immunol Pract. 2021; 9: 591Google Scholar also bring up another important concept about the use of inhaled corticosteroids (ICS) for asthma therapy and risk of COVID-19 severity. Based on the impact of ICS on decreasing the expression of ACE2 expression, it was hypothesized that the use of ICS in asthmatics might decrease COVID-19 severity.6Peters M.C. Sajuthi S. Deford P. Christenson S. Rios C.L. Montgomery M.T. et al.COVID-19-related genes in sputum cells in asthma. Relationship to demographic features and corticosteroids.Am J Respir Crit Care Med. 2020; 202: 83-90Crossref PubMed Scopus (348) Google Scholar However, in a large study, Chhiba et al3Chhiba K.D. Patel G.B. Vu T.H.T. Chen M.M. Guo A. Kudlaty E. et al.Prevalence and characterization of asthma in hospitalized and nonhospitalized patients with COVID-19.J Allergy Clin Immunol Pract. 2020; 146: 307-314.e4Abstract Full Text Full Text PDF Scopus (218) Google Scholar reported that ICS did not increase or decrease the risk of COVID-19 hospitalization in patients with asthma after adjusting for multiple potential confounding factors. Does asthma affect outcomes of patients with COVID-19 infections?The Journal of Allergy and Clinical Immunology: In PracticeVol. 9Issue 1PreviewWe have read with great interest the article entitled "Asthma prolongs intubation in COVID-19," recently published by Mahdavinia et al.1 Full-Text PDF

Overview: Uncontrolled moderate to severe atopic dermatitis (AD) significantly impacts patients’ health, quality of life, and productivity. Through a quality improvement (QI) initiative, we assessed treatment decision-making practices across dermatology and allergy/immunology teams in two health care systems.

Chronic rhinosinusitis (CRS) is a complex disease due to host and environmental factors. Latinos with CRS have greater disease severity and morbidity compared with white non-Latinos. Recent studies have questioned if race or ethnicity plays a role in the make-up of the nasal microbiome. We aimed to determine if Latino ethnicity is associated with differences of the nasal microbiome in CRS patients after adjusting for possible confounding factors. Nasal cotton swabs were collected from 80 patients with CRS. Nasal microbiota composition was analyzed based on 16S ribosomal-RNA gene sequencing from phylum to genus level. Logistic regression analysis was used to compare the relative abundance (RA) and diversity indices of microbiota between Latino and non-Latino white CRS patients, while correcting for a constructed multi-variable socio-economic index, insurance, pollution variables (M2.5 and distance from road), age and asthma status. The nasal microbiota of 80 CRS patients was analyzed;14 Latinos and 66 non-Latinos. The nasal microbiota of Latino patients was significantly less diverse compared to non-Latino whites; Shannon alpha diversity indexExp(B)(95%CI)=0.24(0.07-0.99); adjusted p-value=0.03. The RA of Burkholderia genus was significantly higher in Latino patients with CRS compared to non-Latino whites;Exp(B)(95%CI)=0.98(0.97-0.999); adjusted p-value=0.04. In multivariate model, Latinos with CRS have decreased diversity and higher RA of Burkholderia in their nasal microbiota compared to non-Latino whites with CRS suggesting that variation in the nasal microbiome of Latinos is due to possible genetic or environmental factors linked to ethnicity. Burkholderia could explain worse CRS severity seen in Latinos.