Background: Drug hypersensitivity reactions (DHR) exhibit substantial clinical heterogeneity. Although established cardiovascular disease is a known risk factor for severe anaphylaxis, the impact of subclinical cardiovascular risk on DHR severity remains poorly understood. Objective: This study investigated the association between Systematic Coronary Risk Evaluation 2 (SCORE2) estimated cardiovascular risk and the severity of immediate-type DHRs. Methods: This retrospective study included 161 patients ages 40-69 years (median age, 49 years; 79.5% women) with immediate-type DHRs. To assess the subclinical risk, those with known cardiovascular disease, diabetes, or chronic kidney disease were excluded. Reaction severity was graded by using the Brown system, and SCORE2 was calculated by using clinical data from the 12 months preceding the reaction. Results: Reaction severity was graded as mild (35.4%), moderate (34.8%), or severe (29.8%). The median SCORE2 values were significantly higher in the severe group versus the mild group (4.10% versus 2.50%; p = 0.022). The proportion of patients in high or very high SCORE2 risk categories increased stepwise with reaction severity (35.1% in the mild group versus 64.6% in the severe group; p = 0.011). In an univariable ordinal logistic regression, each 1-point increase in SCORE2 percentage was associated with higher odds of greater reaction severity (odds ratio 1.144 [95% confidence interval, 1.041-1.257]; p = 0.005). This association remained significant after adjusting for the culprit drug class (p = 0.008). Conclusion: Higher subclinical cardiovascular risk, as estimated by SCORE2, is significantly associated with increased DHR severity. Analysis of these findings suggests that vascular reserve may modulate the clinical presentation of drug-induced allergic reactions, potentially aiding in clinical risk stratification.

Background: This study was conducted to investigate the correlations and independent associations between serum 25-hydroxyvitamin D (25[OH]D) levels and total immunoglobulin E (IgE) values as well as peripheral blood eosinophil (EOS) counts in adults with atopic dermatitis (AD). Methods: This single-center cross-sectional study included 148 adults with AD. Data on age, sex, body mass index, disease duration, season, sensitization status, and allergic comorbidities were collected. Serum 25(OH)D values, total IgE levels, and EOS counts were measured, and the Dermatology Life Quality Index (DLQI), Eczema Area and Severity Index (EASI), and SCORing Atopic Dermatitis (SCORAD) scores were assessed. EOS counts and total IgE levels were designated as coprimary end points, and Bonferroni-adjusted p-values were calculated to control for multiple testing. Results: The median serum 25(OH)D level was 19 ng/mL, and vitamin D deficiency or insufficiency was common. Serum 25(OH)D was inversely correlated with EOS counts (r = -0.502, raw p < 0.001; p < 0.002, Bonferroni adjusted) and total IgE levels (r = -0.492, raw p < 0.001; p < 0.002, Bonferroni-adjusted). Both associations remained statistically significant in the fully adjusted regression models after Bonferroni adjustment. Higher vitamin D categories showed decreasing trends in EOS counts and total IgE levels (both raw p-values for trend < 0.001; both Bonferroni-adjusted p-values for trend < 0.002). However, no statistically significant differences in EASI and SCORAD scores were detected among vitamin D categories (p = 0.160 and p = 0.080, respectively). Conclusion: In adults with AD, serum 25(OH)D was inversely associated with peripheral blood EOS counts and total IgE levels, whereas no statistically significant differences in the clinical severity scores were detected across vitamin D categories. Analysis of these findings suggests an association with systemic inflammatory markers rather than established clinical utility.

Background: Reliable predictors that link first oral food challenge (OFC) responses to the outcomes of follow-up OFCs in children with food allergies are still lacking. Objective: To identify clinical and laboratory factors associated with follow-up OFC outcomes in preschool children with cow's milk allergy after a positive first challenge result. Methods: This retrospective study included 85 preschool children with cow's milk allergy who had a positive first OFC outcome and subsequently underwent follow-up OFCs. Demographic, clinical, and laboratory data were analyzed to identify factors associated with positive follow-up OFC outcomes. Results: Older age at the first OFC, anaphylaxis during the first OFC, pre-first OFC casein immunoglobulin E (IgE) level ≥ 3.71 kUA/L, pre-first OFC cow's milk IgE level ≥ 14 kUA/L, and larger cow's milk skin-prick test (SPT) results were associated with positive follow-up OFC outcomes. A pre-first OFC casein specific IgE (sIgE) level ≥ 3.71 kUA/L remained independently associated with follow-up OFC positivity after multivariable adjustment. In univariable analyses, reactions that occurred after completion of the full-dose protocol during the first OFC were associated with lower follow-up OFC positivity. The combination of a pre-first OFC casein IgE level < 3.71 kUA/L and a reaction after completion of the full-dose protocol during the first OFC was associated with a 92.9% negative predictive value for follow-up OFC outcomes. Conclusion: Clinical and laboratory markers during the first OFC may be related to follow-up OFC outcomes in children with cow's milk allergy. Higher pre-first OFC casein and cow's milk IgE levels and anaphylaxis during the first OFC were associated with follow-up OFC positivity. Lower pre-first OFC casein IgE levels, with reactions after completing the full-dose protocol, were linked to lower follow-up OFC positivity rates.

Background: Graphic medicine can provide a level of clinical connection when words fail. Objective: The objective was to describe the ways in which art and storytelling have contributed to the landscape of allergy and immunology communication. Methods: Narrative review of allergy/immunology literature that focused on art, artistry, and storytelling in allergy/immunology. Results: Art can provide an emotional connection that can facilitate learning and impact clinical outcomes. Across conditions treated in the allergy/immunology clinic, there is low-certainty evidence of potential improvements in clinical communication related to atopic dermatitis, asthma, and even anaphylaxis. Art can help to address challenges with patient literacy, clinician compassion, and feelings of patient and clinician isolation and stigmatization. Several artistic innovations have promoted medical education. Conclusion: Nonverbal communication is a powerful tool in clinical medicine. Leveraging art as a medium for storytelling and connection can serve as a tool to help deliver the right care, at the right time, every time. Graphic medicine and visual storytelling may complement traditional communication and educational approaches in allergy/immunology. Additional rigorous studies are needed to determine their effects on clinical outcomes and identify the patients and settings most likely to benefit.

Chronic spontaneous urticaria is commonly responsive to high-dose antihistamines, anti-IgE therapy, and cyclosporine; however, a subset of patients have persistent symptoms despite guideline-directed treatment. We present a case of long-standing, treatment-refractory urticaria in a 38-year-old man with persistent neutrophilia and elevated inflammatory markers. The clinical presentation prompted consideration of chronic spontaneous urticaria mimics, including urticarial vasculitis, autoimmune disease, hematologic disease, and autoinflammatory syndromes. Further evaluation included skin biopsy, expanded laboratory testing, and additional targeted investigations. This case highlights the importance of broadening the differential diagnosis in patients with chronic urticaria that is refractory to standard therapy, particularly when systemic inflammatory features are present.

Background: Case reports indicate that omalizumab may be therapeutic in patients with irritable bowel syndrome (IBS), but this has not been confirmed with follow-up studies. Objective: The present study sought to determine if biologics used to treat atopy have any effect on recalled IBS severity. Methods: All patients ≥ 12 years of age with IBS and currently taking an atopic biologic were sent a questionnaire that assesses IBS severity currently and before starting their atopic biologic. The IBS Symptom Severity Score (IBS-SSS) and IBS Adequate Relief metric were used to quantify IBS severity pre- and post-atopic biologic. Bonferroni-corrected Wilcoxon signed rank tests with Hodges-Lehman estimated median differences and 95% confidence intervals (CI) compared IBS-SSS pre- and post-atopic biologic start. Subset analyses of patients taking omalizumab or dupliumab were also conducted. Results: Sixteen patients (12% response rate) fully responded to the questionnaire (omalizumab, n = 7; dupilumab, n = 7; mepolizumab, n = 1; tezepelumab, n = 1). The majority were women (75%) with a median (range) age of 41 years (22-71 years). The frequency of respondents who reported adequate relief of their IBS did not differ pre- and post-atopic biologic start (p = 0.688), but patients reported significantly decreased IBS-SSS post-atopic biologic start (estimated median difference 70.0 [95% CI, 20.0-122.5]; z = -2.59, p = 0.0097). One patient (6%) taking omalizumab reported complete resolution of IBS symptoms. The majority of the patients (56%) reported a decrease of at least 50 in the IBS-SSS. Although subset analyses of patients taking omalizumab or dupilumab did not show statistically significant differences pre- and post-atopic biologic start, the estimated median IBS-SSS difference pre- and post-atopic biologic start was 93.8 (95% CI, -15.5 to 201.5) and 22.0 (95% CI, -27.5 to 149.0) for omalizumab and dupilumab, respectively. Conclusion: The patients with IBS reported improved recalled IBS severity after starting an atopic biologic, with patients taking omalizumab reporting a larger difference. Future controlled studies are needed to confirm this finding.

Background: One in seven individuals experience at least four adverse childhood experiences (ACE). These experiences have been associated with poor health outcomes. Objectives: The objective was to map the association between ACEs and asthma, food allergy, allergic rhinitis, atopic dermatitis, urticaria, and mast cell activation syndrome. Methods: Original research that evaluated the association between ACEs and asthma, food allergy, allergic rhinitis, atopic dermatitis, urticaria, or mast cell activation syndrome was selected and abstracted. Review articles and non-peer-reviewed literature were excluded. Sources of evidence included several medical literature databases from inception to April 3, 2026. Each article was reviewed in duplicate at title and abstract, full text, and data extraction, with conflicts resolved by consensus or independent review. Quality assessment was conducted by using a modified assessment tool. Results: After duplicate removal (181 articles), 357 full-text articles were evaluated, with 267 studies excluded. The full text of 90 articles was assessed for eligibility, with 31 studies excluded (1 preprint, 11 wrong outcome, 1 wrong exposure, 17 wrong study design, 1 wrong population). The studies were subject to recall bias and limitations in terms of diagnostic accuracy of the outcome. Of 59 studies selected for inclusion in the review, 57 focused primarily on asthma/lung disease, 6 variably reported on poorly described allergy outcomes, and 2 reported on atopic dermatitis. No studies were identified that explored the association between ACEs and food allergy, urticaria, or mast cell activation syndrome. There is available evidence of an association of ACEs and asthma risk with a potential dose-response effect noted, indicating the possibility of a greater risk with greater ACE exposure. Conclusion: An association between ACEs and asthma is suggested. More research is needed to understand the impact of ACEs on other conditions evaluated by allergist/immunologists.

Background: Although recent studies have examined the impact of metabolic diseases on the immune system, limited data exist on how these conditions and their treatments affect therapeutic approaches for atopic diseases, including subcutaneous immunotherapy (SCIT). Objective: The objective was to evaluate the association of type 2 diabetes mellitus (T2DM), obesity, metabolic syndrome, and patient-reported clinical response to SCIT in a real-world setting. Methods: We conducted an observational cross-sectional study of adults receiving SCIT at Montefiore Medical Center, Bronx, New York, between July and September 2024. The SCIT response was assessed by using visual analog scale scores for overall allergic rhinitis (AR) symptoms, nasal congestion, rhinorrhea, and ocular symptoms, stratified by T2DM, obesity (body mass index ≥ 30 kg/m[2]), and metabolic syndrome. Results: Overall, 95 patients were included, with a mean ± standard deviation age of 51 ± 16 years, the majority being women (71%). Twenty-five patients (26%) had T2DM, 53 (56%) were obese, and 27 (28%) had metabolic syndrome. In the entire cohort, 67% had improvement in overall AR symptoms with SCIT, 72% in nasal congestion, 67% in rhinorrhea, and 63% in ocular symptoms. T2DM was associated with significantly reduced odds of overall symptom improvement (odds ratio [OR] 0.23 [95% confidence interval {CI}, 0.06-0.89]; p = 0.037). The patients with metabolic syndrome had significantly lower odds of improvement in overall AR symptoms (OR 0.21 [95% CI, 0.03-0.61]; p = 0.010), nasal congestion (OR 0.24 [95% CI, 0.06-0.88]; p = 0.036), and rhinorrhea (OR 0.22 [95% CI, 0.06- 0.75]; p = 0.019) while on SCIT. Use of metformin, insulin, sulfonylureas, or glucagon-like peptide-1 receptor agonists did not significantly influence the SCIT response. Conclusion: T2DM and metabolic syndrome may identify a subgroup of patients with lower improvement after SCIT. Prospective studies are needed to determine whether metabolic disorders predict SCIT-associated responsiveness.

Background: Although anti-interleukin (IL) 5/IL-5 receptor therapies effectively reduce the exacerbation burden in severe eosinophilic asthma, some patients continue to experience residual exacerbations despite biologic treatment. The inflammatory characteristics of these exacerbations remain insufficiently defined. Objective: The objective was to evaluate the clinical and inflammatory phenotypes of asthma exacerbations that occur during mepolizumab or benralizumab therapy in patients with severe eosinophilic asthma. Methods: This retrospective real-world study included patients with severe eosinophilic asthma who experienced exacerbations despite anti-IL-5/IL-5 receptor therapy. Exacerbations were classified as eosinophilic, neutrophilic, paucigranulocytic, or mixed granulocytic according to peripheral blood eosinophil and neutrophil counts. Clinical characteristics, inflammatory phenotypes, pulmonary function parameters, eosinophil levels, and annual exacerbation frequencies were evaluated. Results: Forty-two patients who experienced 63 exacerbations during biologic therapy were included. The median age was 48.5 years, and 66.7% of the patients were women. The annual exacerbation frequency significantly decreased after biologic treatment initiation in both treatment groups. Among the patients who completed the first treatment year, 66.7% of the patients treated with benralizumab and 55.1% of the patients treated with mepolizumab remained exacerbation-free. No significant differences were observed between biologic agents with regard to infectious exacerbation frequency or inflammatory exacerbation phenotypes. Paucigranulocytic exacerbations represented the most common phenotype in both treatment groups, whereas mixed granulocytic exacerbations were rare. Pulmonary function parameters and eosinophil levels during exacerbations were comparable between the biologic agents. Conclusion: Residual exacerbations that occurred during anti-IL-5/IL-5 receptor therapy demonstrated heterogeneous inflammatory phenotypes rather than a uniformly eosinophilic pattern. The predominance of paucigranulocytic exacerbations suggests that mechanisms beyond persistent eosinophilic inflammation may contribute to residual exacerbations during biologic therapy in severe eosinophilic asthma.

Background: Ultraviolet (UV) filtration units installed into central heating, ventilation, and air conditioning systems have been shown to modify indoor environmental microbiomes (EM), but it remains unclear whether central UV air filtration systems as a targeted intervention alters the EM sufficiently to modify asthma outcomes. Objective: The objective was to investigate changes in the microbiome from dust samples collected before and after installation of a central UV filtration system in homes of children with mild-moderate persistent asthma. Methods: Enrolled pediatric subjects with asthma were randomized to receive UV filtration or sham devices in their heating, ventilation, and air conditioning units. Dust samples were collected from the furnace filters and each child's bedroom inflow air ducts from the first 20 homes randomized at the two largest recruiting sites at the time of device placement and at study completion (12 months), along with periodic measurements of asthma outcomes markers by using the Composite Asthma Severity Index. Microbial DNA from each paired dust sample underwent shotgun metagenomic sequencing, and taxonomic profiles were generated with MetaPhlAn 4. Associations between changes in bacterial species abundance and changes in asthma severity were assessed with Microbiome Multivariable Associations with Linear Models in R. Results: A total of 14 paired dust samples (7 from the UV homes and 7 from the sham homes) from inflow air ducts with sufficient quantity of dust were included for EM analysis. Within the UV filtration homes, false discovery rate adjusted q-values < 0.05 identified associations between worsening asthma severity and reduced relative abundance of common gastrointestinal commensals, such as Bacteroides and Bifidobacterium, previously linked to a reduced risk of allergic disease and asthma; no associations at this threshold were observed in the sham homes. Conclusion: An exploratory study of UV air filtration units installed in homes of children with asthma identified hypothesis-generating associations between bacterial species changes and asthma severity; because the study was underpowered for between-arm comparisons, these findings do not establish that UV air filtration caused the microbiome changes and should not be interpreted as confirmatory of a UV-specific effect.Clinical trial NCT02715375, <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://www.clinicaltrials.gov">www.clinicaltrials.gov</ext-link>.

Background: Effective communication between physicians and the public has become increasingly important in the modern media environment. Pediatricians and allergist/immunologists play a critical role in shaping public understanding of conditions such as food allergy, asthma, and vaccine safety. Objective: The objective was to provide a practical framework for clinicians to engage effectively with media, improve public health messaging, and enhance patient outcomes through clear, accurate, and impactful communication. Methods: This was a narrative review of literature that integrates health communication, media engagement, pediatric advocacy, allergy and immunology, public health messaging, vaccine communication, and asthma and food allergy education. Results: Successful media engagement requires preparation, audience awareness, message clarity, and strategic delivery. Core principles include simplifying complex medical information; maintaining credibility; and focusing on key public health messages, such as early food introduction, asthma control, and vaccine safety. The RATIO framework (Research, Audience, Targeted Topic, Interview Redirecting, Optimism) provides a structured approach to media advocacy. Conclusion: Physician engagement with media is an essential extension of clinical care. Effective communication can improve public understanding, counter misinformation, promote evidence-based health behaviors, and substantially affect adherence and preventive behaviors, particularly in vaccination and chronic disease management, particularly in pediatric populations.

Background and Objective: This study aimed to evaluate the correlation between fractional exhaled nitric oxide (FeNO) levels and peripheral blood eosinophil (EOS) counts in patients with stable asthma who were undergoing general anesthesia as well as to assess their association with postoperative acute asthma exacerbations (AAE) during the perioperative period. Method: A retrospective analysis was conducted by using perioperative clinical data from 118 patients with stable asthma who received general anesthesia in Chongqing University Fuling Hospital. Logistic regression models and receiver operating characteristic curve analysis were used to identify predictive factors for AAEs during the perioperative period. The early predictive value of FeNO levels and EOS counts for AAEs after general anesthesia was quantitatively evaluated. Results: Perioperative intubation response, elevated intraoperative peak airway pressure, postoperative arterial carbon dioxide tension, extubation time, postoperative FeNO levels, and postoperative EOS counts were significantly associated with the occurrence of AAEs (p < 0.05). Multivariate logistic regression analysis demonstrated that the area under the curve for the combined postoperative FeNO and EOS levels was 0.866, with a sensitivity of 88.5% and specificity of 80.4%. These findings indicate that the combined measurement of these biomarkers offers superior early predictive value for postoperative AAEs in patients with stable asthma. Conclusion: Postoperative measurement of FeNO and peripheral EOS counts seem to enhance the early prediction of AAEs in patients with stable asthma who were undergoing general anesthesia. The combined use of these biomarkers may offer a useful tool for early risk stratification, which supports timely implementation of preventive strategies and improved perioperative management, although further validation in larger and prospective studies is needed.

Objective: Penicillin allergy (PA) is associated with an increased risk for cesarean delivery, prolonged postpartum hospital stay, and less-preferred antibiotic prophylaxis and treatment. However, the majority of pregnant women with PA can safely receive penicillin after an allergy evaluation. We aimed to evaluate the safety and efficacy of PA delabeling across all trimesters and to characterize rates of first-line Group B Streptococcus (GBS) prophylaxis after PA delabeling. Methods: We conducted a retrospective analysis of clinical visits for pregnant women with PA referred to Duke Allergy and Immunology Clinic from October 2023 through May 2025. Outcome measures included removal of the PA label and subsequent peripartum antibiotic use. Results: Of the 117 pregnant patients with PA evaluated in the Allergy and Immunology clinic, 112 (96%) underwent PA testing, with gestational age spanning all trimesters. Two patients (2%) had direct oral challenge, which was tolerated without adverse reaction. The other 110 patients (98%) had skin testing, of which 106 (96%) were negative. Of these, 101 women (95%) subsequently passed oral amoxicillin challenge. All patients with negative testing results were delabeled. Among these, 30 women required GBS prophylaxis. Yet, 10 women (33%) received a penicillin alternative or no antibiotics. In total, 18 women were delabeled and reexposed to intrapartum penicillin. None had adverse reactions. Conclusion: PA evaluation is likely safe and effective through all trimesters of pregnancy. Further research, including randomized controlled trials, are needed to expand this knowledge. Most pregnant women referred for PA evaluation can have PA delabeled. Surprisingly, a large portion of women did not receive first-line GBS prophylaxis despite PA removal, reiterating the need for improved interdisciplinary communication.

Background: Aspirin-exacerbated respiratory disease (AERD), also known as nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, is a chronic condition that is both clinically complex and often difficult for patients to understand. As patients increasingly turn to online tools for medical information, it is important to evaluate the quality of the responses they may receive. Objective: This study assessed the medical accuracy and readability of responses generated by ChatGPT 5.1, Gemini 2.5 Flash, and Claude Sonnet 4.5 to 12 common questions that patients often ask their providers about AERD. Methods: The 12 questions were developed by clinicians and patients; the resulting chatbot responses were de-identified and reviewed by an expert panel of 11 AERD specialists who rated each response for medical accuracy on a 10-point scale. Readability was measured by using readability and grade-level analysis programs. Results: Gemini's responses had the highest overall ratings for medical accuracy, followed by Claude and ChatGPT. The models generated responses written at a postgraduate reading level, which is substantially higher than recommended targets for patient-education materials. Questions with more complex responses showed greater variability in expert ratings, potentially reflecting differences in clinical interpretation. Conclusion: Analysis of these findings suggests that, whereas chatbots may improve access to medical information, their current outputs require clinician review and substantial simplification before they can be reliably used for patient education.