BackgroundSkin prick/puncture testing (SPT) is widely accepted as a safe, dependable, convenient, and cost-effective procedure to detect allergen-specific IgE sensitivity. It is, however, prone to influence by a variety of factors that may significantly alter test outcomes, affect the accuracy of diagnosis, and the effectiveness of subsequent immunotherapy regimens. Proficiency in SPT administration is a key variable that can be routinely measured and documented to improve the predictive value of allergy skin testing.MethodsLiterature surveys were conducted to determine the adherence to repeated calls for development and implementation of proficiency testing standards in the 1990’s, the mid-2000’s and the 2008 allergy diagnostics practice parameters.ResultsAuthors publishing clinical research in peer-reviewed journals and conducting workshops at annual scientific meetings have recommended proficiency testing based primarily on its potential to reduce variability, minimize confounding test results, and promote more effective immunotherapeutic treatments. Very few publications of clinical studies, however, appear to report proficiency testing data for SPT performance. Allergen immunotherapy recommendations are updated periodically by the Joint Task Force on Practice Parameters representing the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), and the Joint Council of Allergy, Asthma and Immunology (JCAAI).ConclusionsDespite consensus that all staff who perform SPT should meet basic quality assurance standards that demonstrate their SPT proficiency, the gap between recommendations and daily practice persists. By embracing standards, the accuracy of SPT and allergy diagnosis can be optimized, ultimately benefiting patients with allergic disease.

Critical aspects of formulating allergy immunotherapy vaccines include the selection, total number, and proportions of each allergen component in therapeutic mixtures. The immunotherapy prescription, determined by a medical provider, details the dosing and schedule for treatment as well as the specific composition of the treatment vials. Allergen extracts are composed of many components such as proteins, glycoproteins, and proteases. Some components in allergen extracts are cross-reactive, meaning that treatment with an extract from one species may confer partial protection against a triggering allergen from another species. Conversely, some allergen extracts are incompatible with other extracts when combined in a mixture for treatment, resulting in lowered therapeutic potential for the patient. Therefore, knowledge of allergen extract cross-reactivities and incompatibilities guides the preparation of subcutaneous immunotherapy prescriptions. In a clinical setting, an understanding of what can and can not be mixed is one critical element in improving treatment outcomes.

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Poster Presentations P257 POSTERSincluded medial maxillectomy, image guidance, and intraoperative antibiotic irrigation. Postoperative management included nasal saline irrigation, dornase alfa inhalation, and serial antibiotic lavage. Most studies were limited to case reviews with relatively small numbers of patients. Very few randomized controlled studies were identified. Conclusion:Despite the prevalence of recurrent sinonasal disease after FESS in CF patients, sparse Level I data exists to support perioperative techniques that improve outcomes in this population. Most recommendations are based on small case series. Multicenter studies to evaluate perioperative strategies that improve FESS outcomes in CF patients are warranted. Results: A limited tolerance to elevated glycerin levels can prompt reductions in injection volume (and allergen dose) for patient safety and compliance. The IDT and MQT algorithms introduce a variety of allergen and glycerin levels to patient vials that can be difficult to monitor or calculate easily. Rhinology/Allergy Conclusion:The effectiveness and safety of subcutaneous immunotherapy is linked directly to patient tolerance of both allergen loads and glycerin levels. Convenient tools have been created to simplify calculation of final glycerin concentrations present in buildup and maintenance immunotherapy mixtures, and the final allergen doses.Rhinology/Allergy the "Mickey Mouse" Sign Jaiganesh Manickavasagam, MBBS, MRCS (presenter); Showkat Mirza; Saurabh SinhaObjective: In transnasal endoscopic pituitary surgery and transsellar approaches to anterior skull base lesions, a bony sella window is created with the lateral limits being the carotid arteries.Method: Coronal CT scan of the sphenoid sinuses were reviewed in a tertiary referral hospital and compared with intra operative findings.Results: Sphenoid anatomy is variable in terms of the degree of pneumatization and bony anatomy around the pituitary gland and internal carotid arteries. We describe a radiological sign ascertained from computerized tomography (CT) that when present indicates whether the carotid arteries can be readily identified endoscopically on entering the sphenoid sinus. On the axial CT the carotid arteries may produce protuberances either side of the sella which together with the bony sella and dorsum sella appear to form the outline of the head of Mickey Mouse or a teddy bear. Conclusion:When this sign is not present then the junction between the sella and carotids may not be clear and surgeons must be cautious or use neuronavigation. Rhinology/Allergy the Role of SEB on the Differentiation of t Cells in CRS Yong Min Kim, MD (presenter); Young-Hoon YoonObjective: Recent studies indicate that there is a subset of CD4+CD25+FoxP3+ T cells (Treg cells) that express interleukin (IL)-17 and the cells might be new proinflammatory cells because of the expression of IL-17. The aim of this study was to investigate the role of SEB on the differentiation of regulatory T cells to cells that express retinoic acid related or...

Current practice parameters state that extracts rich in proteases, such as fungal and insect extracts, can be combined during preparation of allergy immunotherapy vaccines. However, until recently, this guideline has not been the subject of investigation. Scientists now have data that shed light on high-protease allergenic extract mixtures used in allergy immunotherapy. A study published in Annals of Allergy, Asthma & Immunology in 2012 reports on the compatibility of combining fungal and insect extracts and emphasizes the importance of understanding how protease activities and total glycerin levels in allergy extracts can affect the stability of allergy immunotherapy vaccine mixtures. This research provides a critical assessment of the mixing compatibilitiesof several well-characterized high-protease extracts and may influence future immunotherapy practice parameters and immunotherapy extract preparation guidelines.