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Food Allergic Patients in the Hospital: a Pharmacy Model Applied to Kitchen Practice
AB212 Abstracts
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Food Allergic Patients in the Hospital: a Pharmacy Model Applied to Kitchen Practice S. Kaur, D. Goldsmith, A. Greenberg; Capital Health, Trenton, NJ. A 60 year old female was admitted to the telemetry unit for chest pain. Shortly after eating dinner, she developed dyspnea with rash and swelling of her face and chest. Her allergy profile included shellfish, and the soup on her tray was identified as clam chowder. The patient later reported feeling suspicious of eating the soup, however, she stated that since she was in the hospital, she expected all items on her tray were safe. She was transferred to the critical care unit where she recovered after medical treatment and close observation. At discharge, she received counseling on shellfish avoidance and a prescription for injectable epinephrine. RATIONALE: Evaluate the kitchen process when completing a meal order for a patient with a reported food allergy. METHODS: A root-cause analysis was performed at a multidisciplinary adverse event meeting to indentify modifiable practices in the kitchen process. RESULTS: Significant changes in the kitchen process were implemented, such as a new standardized daily menu, with allergy information managed by a registered dietician. Food orders are entered in a computer touch screen system. For those with a food allergy, all options that contain the allergen are removed from the patient’s ability to order those items. A flow chart of the old versus new kitchen processes revealed substantial similarities to the pharmacy process for profiling medication orders against medication allergies. CONCLUSIONS: Modifications in the hospital kitchen which resemble medication profiling processes in the pharmacy may decrease the risk of accidental ingestions in the inpatient setting.
830
TUESDAY
Sesame Allergy In The Canadian Pediatric Population: A Descriptive Study L. M. Segal1, A. Clarke2, M. Primeau1, L. Joseph2, C. Neville2, K. Kilorn2, A. Gancia-Godoy2, D. Lejtenyi1, Y. St. Pierre2, R. Alizadehfar1; 1 Montreal Childrens Hospital, McGill University, Montreal, QC, CANADA, 2Montreal General Hospital, McGill University, Montreal, QC, CANADA. RATIONALE: To characterize sesame allergy in a Canadian pediatric population. METHODS: Sesame-allergic children were identified through chart review. Those with a clinically convincing allergic reaction within 120 minutes of ingestion of a sesame-containing food and either a skin prick test (SPT) to sesame 3 mm, a sesame-specific IgE 0.35 kUA/L, or a positive oral food challenge were included. Multivariate logistic regression was used to identify potential factors associated with experiencing an initial anaphylactic reaction. RESULTS: Forty-two children were included. Average age of first allergic reaction was 4.3 years (range 0.5-12 years) with a bimodal distribution of age of first presentation (peaks 18 months, 9-10 years). Thirty-three percent were female. Forty-two percent reacted to whole sesame seeds and 58% to sesame paste. Average size of initial SPT was 8.1 mm (range 1-22 mm). Average initial IgE (n528) was 20.9 kUA/l (range <0.35->100 kUA/L). Two patients had a negative SPT or IgE. Seventy-three percent had other allergist-diagnosed food allergies; most commonly peanut, tree-nut, egg and legume. Twenty-two (52%) presented with anaphylaxis; of the 17 for whom treatment data were available, 5 received epinephrine. One child outgrew her allergy. There was no association between anaphylaxis and either age, form of sesame ingested, SPT size, IgE level, other food allergies or asthma, but wide confidence intervals preclude definitive conclusions. CONCLUSIONS: In other series, most patients are monosensitized infants, but our population had a bimodal incidence of presentation and most had multiple food allergies. Over 50% presented with anaphylaxis and only 29% of these received epinephrine.
831
Parental Attitudes Towards Epinephrine Auto-Injectors L. Chad1, M. Ben-Shoshan2, R. Alizadehfar2, J. Fragapane1, L. Soller1, L. Joseph1,3, L. Harada4, C. Fortin5, M. Allen6, A. E. Clarke1,7; 1 Division of Clinical Epidemiology, Department of Medicine, McGill
J ALLERGY CLIN IMMUNOL FEBRUARY 2010
University Health Center, Montreal, QC, CANADA, 2Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, CANADA, 3Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, CANADA, 4Anaphylaxis Canada (AC), Toronto, ON, CANADA, 5 Association Que´be´coise des Allergies Alimentaires (AQAA), Montreal, QC, CANADA, 6Allergy/Asthma Information Association (AAIA), Montreal, QC, CANADA, 7Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Center, Montreal, QC, CANADA. RATIONALE: To characterize parental attitudes towards epinephrine auto-injector (EAI) use. METHODS: Parents of children prescribed an EAI with an allergist-confirmed diagnosis of peanut allergy were queried on EAI use. RESULTS: Of 1166 parents surveyed, 844 (72.4%) responded. 53.2% [95%CI, 49.8-56.6%] of parents reported being afraid or somewhat afraid of using the EAI. Fears included hurting the child, using the EAI incorrectly, or fear of the needle itself. With inadvertent exposure, 13.0% [10.8-15.4%] of parents would use the EAI immediately even if the child was asymptomatic, 47.8% [44.4-51.2%] would use with at least mild symptoms, 30.1% [27.0-33.3%] with at least moderate symptoms, 7.7% [6.1-9.8%] with only severe symptoms, and 1.4% [0.8-2.5%] would never use it. Parents received initial EAI prescriptions more often from allergists (51.2% [47.8-54.6%]) than from family physicians (21.0% [18.3-23.9%]), emergency physicians (16.4% [14.0-19.0%]) or pediatricians (9.6% [7.811.8%]). 60.6% [56.0-65.2%] of allergists provided instruction at the time of the initial prescription, whereas 36.1% [26.6-47.0%] of pediatricians, 27.7% [21.6-34.8%] of family physicians, and 12.3% [7.8-18.9%] of emergency physicians did so. Overall, 18.4% [15.9-21.2%] were not instructed on EAI use and 39.0% [35.7-42.4%] received instruction from someone other than the first prescriber. Clearer guidelines and practice with trainer devices were among parentsÕ suggestions to improve instruction. CONCLUSIONS: Although 53% of parents are afraid to use the EAI, over 60% would use it either immediately or if their child developed at least mild symptoms. Parental fear and uncertainty regarding indications for EAI administration likely reflect inadequate instruction. Anaphylaxis teaching programs should thus be standardized and disseminated.
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Hazelnut Sensitization In Infants With Atopic Dermatitis M. M. Verweij, M. M. Hagendorens, C. H. Bridts, L. S. de Clerck, W. J. Stevens, D. G. Ebo; University of Antwerp, Wilrijk, BELGIUM. RATIONALE: To investigate the profile of hazelnut sensitization in infants with atopic dermatitis (AD). METHODS: Sera of infants with AD with (n520; median age 9 months (4-11)) or without (n514; median age 7 months (5-12)) hazelnut sensitization (ImmunoCAP for hazelnut) were assessed for IgE reactivity against hazelnut (Corylus avellana) allergens Cor a 1, Cor a 8 and Cor a 9 with the allergen microarray immunoassay (ISACTM, VBC Genomics Bioscience Research, Vienna, Autstria). Data were expressed as ISAC standardized units (ISU/L) and values 0>ISU/L were considered as positive. Sera of 3 infants without AD and negative sIgE for inhalant and food allergens (including hazelnut) served as healthy controls. RESULTS: Twelve (60%) of the children sensitized for hazelnut demonstrated isolated IgE reactivity for the 11S legumin-like seed-storage protein from hazelnut Cor a 9. No sensitization for the Bet v 1 homologue (Cor a 1) or the lipid transfer protein (Cor a 8) from hazelnut was demonstrable. None of the infants with AD without sensitization for hazelnut and the healthy controls demonstrated IgE reactivity for Cor a 1, 8 or 9 on the microarray. Half of the children sensitized for Cor a 9 demonstrated IgE reactivity for its homologue in peanut (Arachis hypogaea; Ara h 3) from which 5 were also sensitized for Gly m glycinin from soy (Glycine max). CONCLUSIONS: Cor a 9 seems a major allergen in very young infants with AD sensitized for hazelnut. The way(s) how these children become sensitized for this allergen remain(s) elusive.
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Food Allergic Patients in the Hospital: a Pharmacy Model Applied to Kitchen Practice S. Kaur, D. Goldsmith, A. Greenberg; Capital Health, Trenton, NJ. A 60 year old female was admitted to the telemetry unit for chest pain. Shortly after eating dinner, she developed dyspnea with rash and swelling of her face and chest. Her allergy profile included shellfish, and the soup on her tray was identified as clam chowder. The patient later reported feeling suspicious of eating the soup, however, she stated that since she was in the hospital, she expected all items on her tray were safe. She was transferred to the critical care unit where she recovered after medical treatment and close observation. At discharge, she received counseling on shellfish avoidance and a prescription for injectable epinephrine. RATIONALE: Evaluate the kitchen process when completing a meal order for a patient with a reported food allergy. METHODS: A root-cause analysis was performed at a multidisciplinary adverse event meeting to indentify modifiable practices in the kitchen process. RESULTS: Significant changes in the kitchen process were implemented, such as a new standardized daily menu, with allergy information managed by a registered dietician. Food orders are entered in a computer touch screen system. For those with a food allergy, all options that contain the allergen are removed from the patient’s ability to order those items. A flow chart of the old versus new kitchen processes revealed substantial similarities to the pharmacy process for profiling medication orders against medication allergies. CONCLUSIONS: Modifications in the hospital kitchen which resemble medication profiling processes in the pharmacy may decrease the risk of accidental ingestions in the inpatient setting.
830
TUESDAY
Sesame Allergy In The Canadian Pediatric Population: A Descriptive Study L. M. Segal1, A. Clarke2, M. Primeau1, L. Joseph2, C. Neville2, K. Kilorn2, A. Gancia-Godoy2, D. Lejtenyi1, Y. St. Pierre2, R. Alizadehfar1; 1 Montreal Childrens Hospital, McGill University, Montreal, QC, CANADA, 2Montreal General Hospital, McGill University, Montreal, QC, CANADA. RATIONALE: To characterize sesame allergy in a Canadian pediatric population. METHODS: Sesame-allergic children were identified through chart review. Those with a clinically convincing allergic reaction within 120 minutes of ingestion of a sesame-containing food and either a skin prick test (SPT) to sesame 3 mm, a sesame-specific IgE 0.35 kUA/L, or a positive oral food challenge were included. Multivariate logistic regression was used to identify potential factors associated with experiencing an initial anaphylactic reaction. RESULTS: Forty-two children were included. Average age of first allergic reaction was 4.3 years (range 0.5-12 years) with a bimodal distribution of age of first presentation (peaks 18 months, 9-10 years). Thirty-three percent were female. Forty-two percent reacted to whole sesame seeds and 58% to sesame paste. Average size of initial SPT was 8.1 mm (range 1-22 mm). Average initial IgE (n528) was 20.9 kUA/l (range <0.35->100 kUA/L). Two patients had a negative SPT or IgE. Seventy-three percent had other allergist-diagnosed food allergies; most commonly peanut, tree-nut, egg and legume. Twenty-two (52%) presented with anaphylaxis; of the 17 for whom treatment data were available, 5 received epinephrine. One child outgrew her allergy. There was no association between anaphylaxis and either age, form of sesame ingested, SPT size, IgE level, other food allergies or asthma, but wide confidence intervals preclude definitive conclusions. CONCLUSIONS: In other series, most patients are monosensitized infants, but our population had a bimodal incidence of presentation and most had multiple food allergies. Over 50% presented with anaphylaxis and only 29% of these received epinephrine.
831
Parental Attitudes Towards Epinephrine Auto-Injectors L. Chad1, M. Ben-Shoshan2, R. Alizadehfar2, J. Fragapane1, L. Soller1, L. Joseph1,3, L. Harada4, C. Fortin5, M. Allen6, A. E. Clarke1,7; 1 Division of Clinical Epidemiology, Department of Medicine, McGill
J ALLERGY CLIN IMMUNOL FEBRUARY 2010
University Health Center, Montreal, QC, CANADA, 2Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, CANADA, 3Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, CANADA, 4Anaphylaxis Canada (AC), Toronto, ON, CANADA, 5 Association Que´be´coise des Allergies Alimentaires (AQAA), Montreal, QC, CANADA, 6Allergy/Asthma Information Association (AAIA), Montreal, QC, CANADA, 7Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Center, Montreal, QC, CANADA. RATIONALE: To characterize parental attitudes towards epinephrine auto-injector (EAI) use. METHODS: Parents of children prescribed an EAI with an allergist-confirmed diagnosis of peanut allergy were queried on EAI use. RESULTS: Of 1166 parents surveyed, 844 (72.4%) responded. 53.2% [95%CI, 49.8-56.6%] of parents reported being afraid or somewhat afraid of using the EAI. Fears included hurting the child, using the EAI incorrectly, or fear of the needle itself. With inadvertent exposure, 13.0% [10.8-15.4%] of parents would use the EAI immediately even if the child was asymptomatic, 47.8% [44.4-51.2%] would use with at least mild symptoms, 30.1% [27.0-33.3%] with at least moderate symptoms, 7.7% [6.1-9.8%] with only severe symptoms, and 1.4% [0.8-2.5%] would never use it. Parents received initial EAI prescriptions more often from allergists (51.2% [47.8-54.6%]) than from family physicians (21.0% [18.3-23.9%]), emergency physicians (16.4% [14.0-19.0%]) or pediatricians (9.6% [7.811.8%]). 60.6% [56.0-65.2%] of allergists provided instruction at the time of the initial prescription, whereas 36.1% [26.6-47.0%] of pediatricians, 27.7% [21.6-34.8%] of family physicians, and 12.3% [7.8-18.9%] of emergency physicians did so. Overall, 18.4% [15.9-21.2%] were not instructed on EAI use and 39.0% [35.7-42.4%] received instruction from someone other than the first prescriber. Clearer guidelines and practice with trainer devices were among parentsÕ suggestions to improve instruction. CONCLUSIONS: Although 53% of parents are afraid to use the EAI, over 60% would use it either immediately or if their child developed at least mild symptoms. Parental fear and uncertainty regarding indications for EAI administration likely reflect inadequate instruction. Anaphylaxis teaching programs should thus be standardized and disseminated.
832
Hazelnut Sensitization In Infants With Atopic Dermatitis M. M. Verweij, M. M. Hagendorens, C. H. Bridts, L. S. de Clerck, W. J. Stevens, D. G. Ebo; University of Antwerp, Wilrijk, BELGIUM. RATIONALE: To investigate the profile of hazelnut sensitization in infants with atopic dermatitis (AD). METHODS: Sera of infants with AD with (n520; median age 9 months (4-11)) or without (n514; median age 7 months (5-12)) hazelnut sensitization (ImmunoCAP for hazelnut) were assessed for IgE reactivity against hazelnut (Corylus avellana) allergens Cor a 1, Cor a 8 and Cor a 9 with the allergen microarray immunoassay (ISACTM, VBC Genomics Bioscience Research, Vienna, Autstria). Data were expressed as ISAC standardized units (ISU/L) and values 0>ISU/L were considered as positive. Sera of 3 infants without AD and negative sIgE for inhalant and food allergens (including hazelnut) served as healthy controls. RESULTS: Twelve (60%) of the children sensitized for hazelnut demonstrated isolated IgE reactivity for the 11S legumin-like seed-storage protein from hazelnut Cor a 9. No sensitization for the Bet v 1 homologue (Cor a 1) or the lipid transfer protein (Cor a 8) from hazelnut was demonstrable. None of the infants with AD without sensitization for hazelnut and the healthy controls demonstrated IgE reactivity for Cor a 1, 8 or 9 on the microarray. Half of the children sensitized for Cor a 9 demonstrated IgE reactivity for its homologue in peanut (Arachis hypogaea; Ara h 3) from which 5 were also sensitized for Gly m glycinin from soy (Glycine max). CONCLUSIONS: Cor a 9 seems a major allergen in very young infants with AD sensitized for hazelnut. The way(s) how these children become sensitized for this allergen remain(s) elusive.