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Urticaria is a common reason for emergency department (ED) visits. In guidelines published in 2014, second-generation H1 antihistamines are recommended as first line oral therapy and are advantageous as they are long-acting and usually non-sedating. We hypothesized that oral first-generation H1 antihistamines are still prescribed in the ED and at discharge more often than oral second-generation antihistamines despite the recent guidelines published. METHODS: A retrospective chart review was performed on adults who were discharged from the ED with a diagnosis of urticaria (ICD10 code L50.x). ED treatment and medications at discharge were recorded. The protocol was approved by the IRB. Charts were reviewed from June 2014 to December 2014 and from June 2017 to June 2018. RESULTS: The majority of patients had acute urticaria with an unknown trigger. In 2014, 69% of patients (31 of 45) were treated with H1 antihistamines in the ED: of antihistamines administered, 27% were first-generation parenteral antihistamines and 58% were oral first-generation antihistamines. In 2017-18, 68% (68 of 100) were treated with H1 antihistamines in the ED: of anithistamines administered, 19% were parenteral first-generation antihistamines and 67% were oral first-generation antihistamines. Upon discharge, 80% of patients in both time periods were prescribed oral H1 antihistamines: 83% and 74% were recommended first-generation sedating antihistamines before and after 2014, respectively (no significant difference). CONCLUSIONS: First-generation H1 antihistamines remain the primary treatment of urticaria in the ED and upon discharge. This indicates a potential opportunity to alter practice and provide better outcomes by encouraging implementation of published treatment guidelines.

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RATIONALE: Ovomucoid-specific IgE (OVM-sIgE) levels and OVM-sIgE/total IgE ratio are reportedly predict IgE-mediated egg allergy among children with positive serum OVM-sIgE. Affinity of sIgE was known to critically regulate basophil/mast cell degranulation in vitro, however little is known whether avidity of sIgE is involved in IgE-mediated heated egg allergy in young children in vivo. METHODS: This cross-sectional case-control study enrolled 59 children (2 to 3 yo) with low levels of OVM-sIgE (0.7 to 17.5 UA/mL) as measured by ImmunoCAP who underwent an oral food challenge test (OFC) at the National Center for Child Health and Development in Tokyo between November 2013 and January 2019. The avidity of OVM-sIgE (IC 50-OVM-sIgE (nM)) was measured by competitive binding inhibition assay using densely carboxylated protein (DCP)-chip (Immun Inflamm Dis 2019, 7:74-85). RESULTS: The avidity of OVM-sIgE was significantly higher in children who were allergic to, than in those who were tolerant of heated egg. Receiver operating characteristic analysis showed that a combination of the serum OVM-sIgE level and the avidity of OVM-sIgE ratio (OVM-sIgE/IC 50-OVM-sIgE) had a larger AUC (0.913; 95%CI 0.842-0.983) than OVM-sIgE level or OVM-sIgE/total IgE ratio alone (0.777; 95%CI 0.623-0.931, 0.763; 95%CI 0.63-0.897, respectively) in predicting heated egg allergy. CONCLUSIONS: Our findings suggested that not only the quantity of sIgE but also the quality of sIgE is involved in heated egg allergy, and a combination of these two factors may help more accurate diagnosis of egg allergy.