Anna Arroyo, MD

View details for DOI 10.1513/AnnalsATS.202212-994RL

View details for PubMedID 37233740

Abstract

Data on the association of maternal gestational weight gain (GWG) and gestational diabetes mellitus (GDM) with childhood asthma are limited and inconsistent. We aimed to investigate these associations in a U.S. pre-birth cohort. Analyses included 16,351 mother-child pairs enrolled in the Massachusetts General Hospital Maternal-Child Cohort (1998-2010). Data were obtained by linking electronic health records for prenatal visits/delivery to determine BMI, GWG, and GDM (National Diabetes Data Group criteria) and to determine asthma incidence and allergies (atopic dermatitis or allergic rhinitis) for children. The associations of prenatal exposures with asthma were evaluated using logistic regression adjusted for maternal characteristics. A total of 2306 children (14%) developed asthma by age 5 years. Overall, no association was found between GWG and asthma. GDM was positively associated with offspring asthma (OR 1.46, 95% CI 1.14-1.88). Associations between GDM and asthma were observed only among mothers with early pregnancy BMI between 20 and 24.9 kg/m2 (OR 2.31, CI 1.46-3.65, p-interaction 0.02). We report novel findings on the impact of prenatal exposures on asthma, including increased risk among mothers with GDM, particularly those with a normal BMI. These findings support the strengthening of interventions targeted toward a healthier pregnancy, which may also be helpful for childhood asthma prevention.

View details for DOI 10.3390/nu14235188

View details for PubMedID 36501218

View details for PubMedCentralID PMC9741125

View details for Web of Science ID 000929478000007

Abstract

BACKGROUND: Acid suppressant medications (ASMs) are commonly prescribed in infancy. Little is known about the relationship between ASM exposure and risk of childhood asthma and atopic conditions.OBJECTIVE: We sought to examine the association between infant ASM exposure and risk for developing recurrent wheeze, allergen sensitization, and asthma in early childhood.METHODS: We used data from a diverse, multi-center, prospective cohort study of 921 infants with a history of bronchiolitis. ASM exposure (histamine-2 receptor antagonists and/or proton pump inhibitors) during infancy (age <12 months) was ascertained by parent report and medical record review. The outcomes were recurrent wheeze by age 3 years, early childhood allergen sensitization (serum specific IgE), and asthma by age 6 years. We constructed multivariable Cox proportional hazards models and multivariable logistic regression models adjusting for multiple confounders.RESULTS: Of the 921 children in the cohort, 202 (22%) were exposed to ASMs during infancy. Compared to unexposed children, those exposed to ASM were more likely to develop recurrent wheeze by age 3 years (adjusted hazard ratio 1.58, 95%CI 1.20-2.08, P=0.001) and asthma by age 6 years (adjusted odds ratio 1.66, 95%CI 1.22-2.27, P=0.001). ASM exposure during infancy was not significantly associated with the development of early childhood allergen sensitization (adjusted odds ratio 1.00, 95%CI 0.70-1.44, P=0.99).CONCLUSIONS: While exposure to ASMs during infancy does not increase the risk of allergen sensitization in early childhood, ASM exposure during infancy increases the risk of recurrent wheeze and asthma during early childhood.

View details for DOI 10.1016/j.jaip.2022.07.013

View details for PubMedID 35872214

View details for DOI 10.1016/j.anai.2022.04.024

View details for PubMedID 35717136

View details for DOI 10.1016/j.jaip.2022.01.031

View details for PubMedID 35397816

View details for DOI 10.1111/pai.13760

View details for PubMedID 35338744

View details for Web of Science ID 000778999300264

Abstract

While fluoroquinolones, vancomycin, macrolides, and tetracyclines are generally safe antibiotics, they can induce both immediate and delayed hypersensitivity reactions (HSRs). Historically, less has been published on allergies to these antibiotics compared to beta lactams, but the prevalence of non-beta lactam HSRs is increasing. To fluoroquinolones, immediate HSRs are more common than delayed reactions. Both IgE and non-IgE mechanisms, such as the mast cell receptor Mas-related G protein-coupled receptor X2 (MRGPRX2), have been implicated in fluoroquinolone-induced anaphylaxis. Skin testing for fluoroquinolones is controversial, and the gold standard for diagnosis is a graded dose challenge. To vancomycin, the most common reaction is vancomycin infusion reaction (previously called "red man syndrome"), which is caused by infusion rate-dependent direct mast cell degranulation. Severity can range from flushing and pruritis to angioedema, bronchospasm, and hypotension that mimic type I HSRs. MRGPRX2 has been implicated in vancomycin infusion reactions. IgE-mediated HSRs to vancomycin are rare. Vancomycin skin testing yields high false positive rates. Thus, direct provocation challenge with slower infusion rate and/or antihistamine pre-treatment is preferred if symptoms are mild to moderate, and desensitization can be considered if symptoms are severe. To tetracyclines, non-IgE-mediated and delayed HSRs predominate with cutaneous reactions being the most common. There is no standardized skin testing for tetracyclines, and avoidance is generally recommended after a severe reaction because of the paucity of data for testing. Graded dose challenges and desensitizations can be considered for alternative or index tetracyclines if there are no alternatives. With macrolides, urticaria/angioedema is the most common immediate HSR, and rash is the most common delayed HSR. The predictive value for skin testing to macrolides is similarly poorly defined. In general, HSRs to fluroquinolones, vancomycin, macrolides, and tetracyclines are challenging to diagnose given the lack of validated skin testing and in vitro testing. Direct provocation challenge remains the gold standard for diagnosis, but the benefits of confirming an allergy may not outweigh the risk of a severe reaction. Skin testing, direct provocation challenge, and/or desensitization to the index non-beta lactam antibiotic or alternatives in its class may be reasonable approaches depending on the clinical context and patient preferences.

View details for DOI 10.1007/s12016-021-08919-5

View details for PubMedID 35092578

View details for DOI 10.1016/j.anai.2021.12.002

View details for PubMedID 34879264

View details for DOI 10.1016/j.anai.2021.11.017

View details for PubMedID 34863951

View details for DOI 10.3390/nu13072318

View details for Web of Science ID 000676656300001

Abstract

Background and Objective: Allergic reactions, including anaphylaxis, are rising among children. Little is known about health care utilization among infants and toddlers. Our objective was to characterize health care utilization and charges for acute allergic reactions (AAR). Methods: We conducted a retrospective cohort study of trends in emergency department (ED) visits and revisits, hospitalizations and rehospitalizations, and charges among infants and toddlers (ages < 3 years), with an index ED visit or hospitalization for AAR (including anaphylaxis). We used data from population-based multipayer data: State Emergency Department Databases and State Inpatient Databases from New York and Nebraska. Multivariable logistic regression was used to identify factors associated with ED revisits and rehospitalizations. Results: Between 2006 and 2015, infant and toddler ED visits for AAR increased from 27.8 per 10,000 population to 35.2 (Ptrend < 0.001), whereas hospitalizations for AAR remained stable (Ptrend = 0.11). In the one year after an index AAR visit, 5.1% of these patients had at least one AAR ED revisit and 5.9% had at least one AAR rehospitalization. Factors most strongly associated with AAR ED revisits included an index visit hospitalization and receipt of epinephrine. Total charges for AAR ED visits (2009-2015) and hospitalizations (2011-2015) were more than $29 million and $11 million, respectively. Total charges increased more than fourfold for both AAR ED revisits for AAR rehospitalizations during the study period. Conclusion: Infants and toddlers who presented with an AAR were at risk for ED revisits and rehospitalizations for AAR within the following year. The charges associated with these revisits were substantial and seemed to be increasing.

View details for DOI 10.2500/aap.2021.42.210031

View details for PubMedID 33980339

Abstract

BACKGROUND: The US older adult population (65 years) is increasing and may be at increased risk for severe anaphylaxis. Little is known about the healthcare utilization for acute allergic reactions (AAR), including anaphylaxis, among older adults.OBJECTIVES: To characterize trends in emergency department (ED) visits and hospitalizations for AAR and anaphylaxis among US older adults from 2006-2014, and to examine factors associated with severe anaphylaxis.METHODS: We performed cross-sectional analyses of trends in ED visits and hospitalizations among older adults using data from the Nationwide Emergency Department Sample and the National (Nationwide) Inpatient Sample in 2006-2014. We used International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes to identify visits for AAR, including anaphylaxis. Multivariable logistic regression modeling was used to identify factors associated with severe anaphylaxis (cardiac arrest, intubation and death).RESULTS: In 2006-2014, older adults experienced approximately 1,019,967 AAR-related ED visits; 173,844 AAR-related hospitalizations; 93,795 anaphylaxis-related ED visits; and 72,677 anaphylaxis-related hospitalizations. While AAR-related ED visit and hospitalization rates remained stable (P-trends=0.28 and 0.16, respectively), anaphylaxis-related ED visit and hospitalization rates significantly increased over time (37 visits per 100,000 population in 2006 to 51 in 2014, P-trend<0.001; 13 hospitalizations per 100,000 population in 2006 to 23 in 2014, P-trend<0.001), especially hospitalization rates for drug-related anaphylaxis (47 hospitalizations per 100,000 population in 2006 to 85 in 2014, P-trend<0.001). Risk factors for anaphylaxis-related death included older age and drug-related trigger.CONCLUSIONS: In a nationally representative sample of US older adults, the rate of anaphylaxis-related ED visits and hospitalizations increased over time. Drug-related triggers represented a substantial portion of the increased healthcare utilization and are a growing risk in this vulnerable population.

View details for DOI 10.1016/j.jaip.2021.03.032

View details for PubMedID 33798790

Abstract

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction. The overall prevalence of anaphylaxis appears to be rising in children, but temporal trends among infants and toddlers are not well studied.OBJECTIVE: To characterize the trends in U.S. emergency department (ED) visits and hospitalizations among infants and toddlers with anaphylaxis from 2006-2015.METHODS: We conducted a study of temporal trends in anaphylaxis among children (age <18 years) and, more specifically, infants and toddlers (age <3 years) presenting to the ED between 2006-2015 using a large, nationally representative database. For internal consistency, we defined anaphylaxis using ICD-9-CM diagnosis codes and excluded visits with ICD-10-CM (late 2015). We calculated trends in the number and proportion of ED visits and hospitalizations and used multivariable logistic regression to identify predictors of hospitalization.RESULTS: Among infants and toddlers, the proportion of ED visits for anaphylaxis per year increased from 20 per 100,000 visits to 50 per 100,000 visits (Ptrend <0.001). The rate of ED visits for anaphylaxis increased from 15 to 32 ED visits per 100,000 population of infants and toddlers (Ptrend <0.001). Food was the most commonly identified trigger. The proportion of hospitalization among anaphylaxis-related ED visits decreased from 19% to 6% (Ptrend <0.001). Among ED patients, those more likely to be hospitalized were male, privately insured, from higher income families, and presenting to urban, metropolitan teaching hospital EDs.CONCLUSION: In a large, nationally representative US database, from 2006 to 2015, ED visits by infants and toddlers with anaphylaxis increased, while hospitalization of these patients decreased.

View details for DOI 10.1016/j.jaip.2021.01.010

View details for PubMedID 33486144

View details for DOI 10.1016/j.jaip.2021.10.035

View details for PubMedID 34782303

Abstract

BACKGROUND: Anaphylaxis is a potentially fatal acute allergic reaction. Its overall prevalence appears to be rising, but little is known about U.S. hospitalization trends among infants and toddlers.OBJECTIVE: To identify the trends and predictors of hospitalization for anaphylaxis among infants and toddlers.METHODS: We used the nationally representative National Inpatient Sample (NIS), from 2006-2015, to perform an analysis of trends in U.S. hospitalizations for anaphylaxis among infants and toddlers (age <3 years) and other children (age 3-18 years). For internal consistency, we identified patients with anaphylaxis by ICD-9-CM diagnosis code and excluded those with ICD-10-CM (late 2015). We calculated trends in anaphylaxis hospitalizations over time by age group, then used multivariable logistic regression to describe anaphylaxis hospitalizations among infants and toddlers.RESULTS: Among infants and toddlers, there was no significant change in anaphylaxis hospitalizations during the 10-year study period (P trend =0.14). Anaphylaxis hospitalization among infants and toddlers was more likely in males, with private insurance, in the highest income quartile, with chronic pulmonary disease, who presented on a weekend day, to an urban teaching hospital, located in the Northeast. In contrast, anaphylaxis hospitalizations among older children (age 3 to <18 years) rose significantly during the study (P trend <0.001).CONCLUSION: Anaphylaxis hospitalizations among infants and toddlers in the US were stable from 2006-2015, while hospitalizations among older children were rising. Future research should focus on the trends in disease prevalence and healthcare utilization in the understudied population of infants and toddlers.

View details for DOI 10.1016/j.anai.2020.09.003

View details for PubMedID 32911059

View details for DOI 10.1016/j.jaip.2020.12.028

View details for PubMedID 33359588

View details for DOI 10.1016/j.jaip.2019.02.039

View details for PubMedID 30878709

View details for PubMedID 28970087

View details for PubMedCentralID PMC5876061

View details for PubMedID 29626636

Abstract

We conducted a retrospective, observational, population-based study to investigate the effect of staphylococcal infections on the hospitalization of children in California during 1985-2009. Hospitalized children with staphylococcal infections were identified through the California Office of Statewide Health Planning and Development discharge database. Infections were categorized as community onset, community onset health care-associated, or hospital onset. Infection incidence was calculated relative to all children and to those hospitalized in acute-care facilities. A total of 140,265 records were analyzed. Overall incidence increased from 49/100,000 population in 1985 to a peak of 83/100,000 in 2006 and dropped to 73/100,000 in 2009. Staphylococcal infections were associated with longer hospital stays and higher risk for death relative to all-cause hospitalizations of children. The number of methicillin-resistant Staphylococcus aureus infections increased, and the number of methicillin-susceptible S. aureus infections remained unchanged. Children <3 years of age, Blacks, and those without private insurance were at higher risk for hospitalization.

View details for DOI 10.3201/eid1901.111740

View details for PubMedID 23260060

Abstract

This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age.Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06).Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.

View details for DOI 10.1111/j.1553-2712.2012.01356.x

View details for PubMedID 22594358

View details for PubMedCentralID PMC3443629