Publications by authors named "Elana Lavine"

12 Publications

  • Page 1 of 1

Establishing Amoxicillin Allergy in Children Through Direct Graded Oral Challenge (GOC): Evaluating Risk Factors for Positive Challenges, Safety, and Risk of Cross-Reactivity to Cephalosporines.

J Allergy Clin Immunol Pract 2021 Jul 19. Epub 2021 Jul 19.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada; Infectious Diseases and Immunity in Global Health Program, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada.

Background: Data on the diagnostic properties of direct oral challenges without the use of skin tests in children with suspected amoxicillin allergy are sparse.

Objective: Assess the use of direct oral challenges.

Methods: A cohort study was conducted between March 2013 and March 2020, in Montreal and Winnipeg. All children referred with reported history of benign reactions (ie, limited to the skin with no mucosal lesions and no vesicles) to amoxicillin were recruited and a 2-step graded oral challenge (GOC) was conducted. Data were collected on demographic characteristics, clinical characteristics, and comorbidities. Eligible children were followed to assess reactions to subsequent use of amoxicillin and to assess the safety of cephalexin use in children with a positive GOC.

Results: Among 1914 children recruited, 1811 (94.6%) tolerated the GOC, 42 (2.2%) developed mild immediate reactions, and 61 (3.2%) developed mild nonimmediate reactions. Among 265 participants who had a negative GOC and reused amoxicillin, 226 (85.3%) reported tolerance and 39 (14.7%) had mild cutaneous reactions. Chronic urticaria (adjusted odds ratio [aOR], 1.16; 95% CI, 1.09-1.23) and an index reaction occurring within 5 minutes of exposure (aOR, 1.09; 95% CI, 1.04-1.14) were associated with immediate reactions during the GOC. Symptoms lasting longer than 7 days (aOR, 1.05; 95% CI, 1.02-1.09) and parental drug hypersensitivity (aOR, 1.04; 95% CI, 1.03-1.06) were associated with nonimmediate reactions. Among those reacting to the GOC, 12.5% reacted with mild cutaneous reactions to cephalexin challenge.

Conclusions: Direct GOCs are an accurate and safe confirmatory to establish true hypersensitivity among children reporting benign reactions to amoxicillin.
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http://dx.doi.org/10.1016/j.jaip.2021.06.057DOI Listing
July 2021

Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge.

J Allergy Clin Immunol Pract 2021 02 6;9(2):916-921. Epub 2020 Sep 6.

Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Serum sickness-like reactions (SSLRs) are defined by the presence of rash (primarily urticaria) and joint complaints (arthralgia/arthritis) that are believed to occur due to a non-IgE-mediated response to medications. However, similar reactions can occur due to viral infections, and it can be difficult to distinguish between the two. This may lead to unnecessary avoidance of the culprit antibiotic.

Objective: We aimed to evaluate children presenting with suspected SSLRs through a graded oral challenge (GOC).

Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy (β-lactam or other antibiotics) and a clinical presentation compatible with SSLR were recruited for the study between March 2013 and February 2020. A standardized survey with questions on treatment, symptoms, and associated factors was completed, and a GOC (10% and subsequently 90% of the oral antibiotic dose) was conducted. Patients with a negative GOC were contacted annually to query on subsequent antibiotic use.

Results: Among 75 patients presenting with suspected SSLRs, the median age was 2.0 years and 46.7% were males. Most reactions were attributed to amoxicillin. Among the 75 patients, 2.7% reacted immediately (within 1 hour) to a GOC and 4.0% had a nonimmediate reaction. Of the 43 patients successfully contacted, 20 reported subsequent culprit antibiotic use of whom 25.0% had a subsequent mild reaction (macular/papular rash).

Conclusions: This is the first and largest pediatric study to assess SSLR using a GOC. Our findings suggest that using a GOC is safe and appropriate for differentiating between β-lactam-induced SSLR and viral exanthem in this population.
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http://dx.doi.org/10.1016/j.jaip.2020.08.047DOI Listing
February 2021

Diagnosis of Ibuprofen allergy through oral challenge.

Clin Exp Allergy 2020 05 3;50(5):636-639. Epub 2020 Apr 3.

Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1111/cea.13596DOI Listing
May 2020

Anaphylaxis to hidden pea protein: A Canadian pediatric case series.

J Allergy Clin Immunol Pract 2019 Jul - Aug;7(6):2070-2071. Epub 2019 Feb 19.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaip.2019.02.010DOI Listing
September 2020

Prospective evaluation of testing with baked milk to predict safe ingestion of baked milk in unheated milk-allergic children.

Allergy Asthma Clin Immunol 2016 24;12:54. Epub 2016 Oct 24.

University of Toronto, Toronto, ON Canada ; Department of Pediatrics, Division of Immunology and Allergy, The Hospital for Sick Children, Toronto, ON Canada.

Background: Cow's milk allergy is one of the most common food allergies affecting young children. A subset of milk-allergic individuals can eat baked milk without allergic symptoms which is beneficial in terms of prognostication and liberalization of the diet. A retrospective study suggested that skin prick testing (SPT) with a baked milk (muffin) slurry may provide a sensitive means of predicting the outcome of a medically supervised baked milk oral food challenge. We evaluated the predictive value of SPT with baked milk to identify unheated milk-allergic children who are able to safely eat baked milk.

Methods: Children aged 2-16 years with a prior history of reaction to milk and a milk extract SPT of 8-14 mm were recruited. Investigator-blinded SPT to muffin slurry and powdered milk in triplicate and specific IgE (sIgE) to casein and milk were performed. Graded oral challenge to egg-free baked milk muffins (total 2.6 gm milk protein) was performed in the hospital. Reliability of tests was analyzed for intraclass correlation. Statistical significance for clinical characteristics of population and muffin testing versus baked milk reactivity was calculated with Fisher exact test for dichotomous and t-test for continuous variables. Wilcoxon rank sum test was used to compare immunological characteristics between individuals who tolerated or reacted to baked milk. Fitted predicted probability curves and ROC curves were generated.

Results: Thirty-eight children were consented and 30 met study criteria. The muffin SPT and casein sIgE were significantly different in those who passed versus failed baked milk challenge. Negative (<3 mm) baked milk tests were found in 8/30 children (27 %) and were associated with non-reactivity to baked milk (p = 0.01) with a sensitivity of 1 (0.70-1.00). All children with negative SPT for baked milk passed the oral challenge. Specificity was 0.41 (0.19-0.67). The optimal decision point for the muffin SPT was 4 mm and the casein sIgE was 6 kU/L. The powdered milk test was not helpful.

Conclusions: Skin prick testing with a baked milk (muffin) slurry may have a role in clinical practice to identify baked milk tolerance in milk-allergic patients.
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http://dx.doi.org/10.1186/s13223-016-0162-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5078900PMC
October 2016

Allergy to sunflower seed and sunflower butter as proposed vehicle for sensitization.

Allergy Asthma Clin Immunol 2015 8;11(1). Epub 2015 Jan 8.

Department of Pediatrics, Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, QC Canada.

Background: It is hypothesized that household exposure to allergenic proteins via an impaired skin barrier, such as atopic dermatitis, may contribute to the development of IgE sensitization. Household presence of peanut is a risk factor for the development of peanut allergy in children. Sunflower seed butter is a peanut-free alternative to peanut butter, and sunflower seed allergy is an uncommon but reported entity.

Case Presentation: A 3 year old boy presented with oral discomfort that developed almost immediately after he ate sunflower seeds for the first time. He was given a dose of diphenhydramine. Subsequently he vomited, and his symptoms gradually resolved. A similar episode occurred to a commercial snack made with sunflower seed butter. Skin prick testing demonstrated a large positive (10 mm wheal) wheal-and-flare response to a slurry of fresh sunflower seed within 3-4 minutes associated with severe pruritus. This child has an older sibling with confirmed peanut allergy (PNA). After the PNA diagnosis was made, the family home became peanut-free. In lieu of peanut butter, sunflower butter was purchased and eaten frequently by family members, but not by the child reported herein. Subsequent to the episodes above, the child ate a bread roll with visible poppy seeds and developed itchy throat, dyspnea, and urticaria. Epicutaneous skin testing elicited a >10 mm wheal size within 3-4 minutes in response to a slurry of whole poppy seeds and 8 mm to fresh pumpkin seed, which had never been consumed.

Conclusions: A case of sunflower allergy in the context of household consumption of sunflower butter has not yet been reported. We suggest that homes which are intentionally peanut-safe may provide an environment whereby infants with impaired skin barrier are at increased risk of allergy to alternative "butter" products being used, via cutaneous exposure to these products preceding oral introduction to the child.
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http://dx.doi.org/10.1186/s13223-014-0065-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311509PMC
February 2015

CSACI Position statement on the testing of food-specific IgG.

Allergy Asthma Clin Immunol 2012 Jul 26;8(1):12. Epub 2012 Jul 26.

University of Alberta, Department of Pediatrics, Division of Allergy and Immunology, 903 College Plaza 8215-112 Street, Edmonton, AB, T6G 2C8, Canada.

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http://dx.doi.org/10.1186/1710-1492-8-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3443017PMC
July 2012

Blood testing for sensitivity, allergy or intolerance to food.

Authors:
Elana Lavine

CMAJ 2012 Apr 19;184(6):666-8. Epub 2012 Mar 19.

Department of Pediatrics, Humber River Regional Hospital, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.110026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314037PMC
April 2012

Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial.

JAMA 2006 Mar;295(11):1274-80

Division of Pediatric Emergency Medicine, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario.

Context: Children with croup are often treated with humidity even though this is not scientifically based, consumes time, and can be harmful. Although humidity using the traditional blow-by technique is similar to room air and no water droplets reach the nasopharynx, particles sized for laryngeal deposition (5-10 microm) could be beneficial.

Objective: To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer or blow-by humidity.

Design And Setting: A randomized, single-blind, controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department.

Participants: A convenience sample of 140 previously healthy children 3 months to 10 years of age with Westley croup score of more than 1 or 2 or higher (scoring system range, 0-17); 21 families refused participation.

Intervention: Thirty-minute administration of humidity using traditional blow-by technique (commonly used placebo, n = 48), controlled delivery of 40% humidity (optimally delivered placebo, n = 46), or 100% humidity (n = 46) with water particles of mass median diameter 6.21 microm.

Main Outcome Measure: A priori defined change in the Westley croup score from baseline to 30 and 60 minutes in the 3 groups.

Results: Groups were comparable before treatment. At 30 minutes the difference in the improvement in the croup score between the blow-by and low-humidity groups was 0.03 (95% confidence interval [CI], -0.72 to 0.66), between low- and high-humidity groups, 0.16 (95% CI, -0.86 to 0.53), and between blow-by and high-humidity groups, 0.19 (95% CI, -0.87 to 0.49). Results were similar at 60 minutes. Differences between groups in pulse and respiratory rates and oxygen saturation changes were insignificant, as were proportions of excellent responders; proportions with croup score of 0 at study conclusion; and proportions receiving dexamethasone, epinephrine, or requiring additional medical care or hospitalization.

Conclusions: One hundred percent humidity with particles specifically sized to deposit in the larynx failed to result in greater improvement than 40% humidity or humidity by blow-by technique. This study does not support the use of humidity for moderate croup for patients treated in the emergency department.

Trial Registration: ClinicalTrials.gov Identifier: NCT00230841.
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http://dx.doi.org/10.1001/jama.295.11.1274DOI Listing
March 2006

The role of attribution to clerk factors and contextual factors in supervisors' perceptions of clerks' behaviors.

Teach Learn Med 2004 ;16(4):317-22

Department of Pediatrics, University of Toronto, Ontario, Canada.

Background: Novice clinical clerks are expected to integrate smoothly into a medical team, often with little guidance.

Purpose: To explore medical residents' and attendings' perceptions of clerk behaviors that may aid or hinder this integration.

Methods: Three resident focus groups and 5 attending staff interviews were conducted. Transcripts were analyzed using grounded theory.

Results: One hundred thirty-seven instances of clerk behaviors were identified. Many similar behaviors were alternately perceived as positive or negative, depending critically on 2 dimensions the clerk (speculated motives or personality traits) or the context (timing of behavior or clerk's stage of training). Motives and traits were mentioned nearly 3 times as often as contextual factors, possibly reflecting the fundamental attribution error, as described in social psychology. Supervisors' perceptions of why or when a behavior was enacted were an important factor in their perceptions.

Conclusions: With explicit discussion of this phenomenon, supervisors' judgments might suffer from fewer biases, and students' integration into the team and profession might occur with less ambiguity and stress.
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http://dx.doi.org/10.1207/s15328015tlm1604_3DOI Listing
January 2005

Cranial pachymeningitis: an unusual manifestation of Wegener's granulomatosis.

J Rheumatol 2003 Sep;30(9):2070-4

Department of Medicine, Division of Rheumatology, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, M1-101, Toronto, Ontario M4N 3M5, Canada.

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September 2003
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