Anil Nanda’s research while affiliated with University of Texas Southwestern Medical Center and other places

The COVID 19 pandemic increased stress and reduced wellness for patients and physicians alike. The uncertainty, frequent changes, fear of illness/death and supply chain issues taxed an already broken healthcare system. The pandemic undermined the factors that allow for a healthy workplace - control, predictability and certainty. During this time, rates of depression, suicidality, and anxiety all increased among physicians and the community at large. These challenges were aggravated by disagreements regarding masking and vaccinations. These factors, as well as, the degree to which someone felt valued or not also contributed to burnout. Some changes like the transition to telemedicine, while initially stressful, led to patient satisfaction and allowed clinical care to continue. Other changes, like trying to home school or watching young children while simultaneously trying to work were less desirable. Patients and physicians did their best to combat isolation, fear, anxiety and the numerous societal changes. Burnout fluctuated throughout the pandemic related to local and systemic factors like rates of infection, vaccination, supply chain issues and individual support. The pandemic highlighted problems with our healthcare system, including structural racism, healthcare disparities and how easily the system can be overwhelmed. Physicians may have been thrown into roles they did not feel comfortable filling and may have had insufficient staff to practice in a way they wanted to. These factors led to frustration among patients and physicians alike. The National Plan for Healthforce well-being outlines the need for healthcare reform to allow for effective and safe healthcare while protecting clinicians from burnout.

This guidance updates 2021 GRADE recomendations regarding immediate allergic reactions following COVID-19 vaccines and addresses re-vaccinating individuals with 1st dose allergic reactions and allergy testing to determine re-vaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 re-vaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommenations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the UK, and the US formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy, and re-vaccination after a prior immediate allergic reaction. We suggest against >15-minute post-vaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest re-vaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise, in a properly equipped setting. We suggest against pre-medication, split-dosing, or special precautions because of a comorbid allergic history.

Nasal allergen challenge (NAC) is applied in a variety of settings (research centers, specialty clinics, and hospitals) as a useful diagnostic and research tool. NAC is indicated for diagnosis of seasonal and perennial allergic rhinitis, local allergic rhinitis, and occupational rhinitis; to design the composition of allergen immunotherapy in patients who are polysensitized; and to investigate the physio-pathological mechanisms of nasal diseases. NAC is currently a safe and reproducible technique, although it is time- and resource-consuming. NAC can be performed by a variety of methods, but the lack of a uniform technique for performing and recording the outcomes represents a challenge for those considering NAC as a clinical tool in the office. The availability of standardized allergens for NAC is also different in each country. The objective of this workgroup report is to review the current information about NAC, focusing on the practical aspects and application for diagnosis of difficult rhinitis phenotypes (eg, local allergic rhinitis, occupational rhinitis), taking into account the particular context of practice in the United States and the European Union.

The most recent recommendations from the 2020 National Asthma Education and Prevention Program (NAEPP) Update and Global Initiative for Asthma (GINA) 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This workgroup report reviews the current state of the new asthma guideline implementation, presents updated evidence-based therapeutic options with attention to specific patient populations, and addresses barriers to the implementation of these guidelines in minoritized, marginalized, and under resourced communities. Allergists and immunologists can utilize practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the lifespan, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.