“If you are willing to use it and use it quickly, that's what I want you to have.”
— Dr. Jay Lieberman

Epinephrine is everywhere in allergy practice. Prescribed, refilled, demonstrated, repeated. And still, it carries a strange kind of fear. Patients hesitate. Clinicians sometimes hesitate too. Is it dangerous? Is it a last resort? How bad does the reaction have to be before it counts?

On this episode, Dr. Mariam Hanna is joined by Dr. Jay Lieberman, professor of pediatrics at the University of Tennessee and interim division chief of allergy and immunology at Le Bonheur Children's Hospital. He talks through what epinephrine does in the body, where the evidence is still messier than many assume, and how new needle-free options may change whether patients actually use it when it matters.

Key Points

• Epinephrine remains first-line because it targets the major physiologic problems in anaphylaxis.
• Fear of epinephrine still gets in the way of early use.
• Anaphylaxis definitions are useful, but hard to translate for patients.
• Nasal and sublingual routes may reduce the barrier of the needle.
• The best device is still the one the patient will actually use.

Needle-free epinephrine won't answer every question in anaphylaxis care. But it may change the most practical one: not whether patients know they should treat, but whether they actually will.

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

“You can have a patient that has normal immunoglobulins and abnormal responses to protein antigens as well. Historically, I’ve seen these patients. They do happen. They are out there.” — Dr. Benjamin Prince

Specific antibody deficiency (SAD) has never been a clean diagnosis. Some patients carry normal immunoglobulins and still land in clinic with recurrent infections and poor vaccine responses. The newer pneumococcal vaccines have scrambled the old testing pathways. This episode covers which parts of the workup still hold up, and where a titre should actually change what you do next.

Dr. Mariam Hanna is joined by Dr. Benjamin Prince, Associate Professor of Pediatrics and Associate Division Chief of Research in Allergy and Immunology at Nationwide Children's Hospital in Columbus, Ohio. He walks through the shifting definition of SAD, what pneumococcal titres can and can't tell you, and how to read testing in the Prevnar 20 era.

Key Points

• Clinical history as the gatekeeper for who gets worked up
• What Prevnar 20 did to polysaccharide response testing
• Reading the patient ahead of the titre
• Recommendation 4.7 and impaired protein-antigen responses
• Pneumococcal titre thresholds: useful, imperfect, lab-dependent
• The management range, from watchful waiting through immunoglobulin replacement

A useful listen for any clinician who has stared at a borderline pneumococcal panel and wondered whether to keep pulling the thread. The lab pathway exists, but the history is still what tells you whether the result will mean anything.

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The Allergist is produced for CSACI by PodCraft Productions

“If the asthma is under good control but they are still having these episodes, then I do think that maybe they have a PVFMD component to their breathing issue.” Dr. R. Jun Lin

Patients come into clinic short of breath. It hits during exercise, it looks dramatic, and they may even describe noisy breathing or the feeling that they “can’t get air in.” So we do what clinicians do: we think asthma. We try inhalers. But sometimes, no matter how many puffers are thrown at the problem, nothing changes.

That’s when it may be time to look higher, to the larynx.

On this episode of The Allergist, Dr. Mariam Hanna is joined by Dr. R. Jun Lin, a fellowship-trained laryngologist and chief of the Division of Laryngology at the University of Toronto, for a practical discussion of vocal cord dysfunction, inducible laryngeal obstruction, and paradoxical vocal fold motion disorder. Dr. Lin walks through how these patients present, how to distinguish laryngeal obstruction from asthma, when both may be present, and why respiratory retraining therapy is often the cornerstone of care.

Key Points

• VCD, ILO, EILO, and PVFMD describe the same basic problem through different specialty lenses.
• The key clue: trouble breathing in, not out.
• In teens, it often shows up during warm-up or early competition.
• In adults, common triggers include perfume, bleach, gasoline, cooking fumes, cold air, humidity, speaking, or laughing.
• Asthma and PVFMD can coexist. If asthma is controlled but symptoms persist, think larynx.
• Laryngoscopy is often normal in PVFMD, but helps rule out structural causes.
• Respiratory retraining therapy is the cornerstone of treatment.
• Pursed-lip breathing can reduce the severity and duration of episodes, but patients need to practise it before symptoms peak.
• Food triggers, urticaria, tongue swelling, or rash point away from PVFMD.
• Botox is a last resort, not first-line treatment.

For clinicians, this episode is a reminder that not every dramatic breathing episode starts in the lower airway. When the history points to trouble getting air in, especially with poor response to inhalers, PVFMD deserves a place on the differential.

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The Allergist is produced for CSACI by PodCraft Productions

“AI might feel like magic at times, but mostly it's just powerful technology, and with any technology, it's a tool.” —Merlijn van Breugel

AI is no longer a future-tense possibility for allergists. It is already shaping diagnosis, prediction, documentation, patient communication, and the way clinicians think through complex decisions. But if AI can process more than we can, what still belongs to the clinician?

On this episode of The Allergist, Dr. Mariam Hanna is joined by Merlijn van Breugel, a data scientist and philosopher whose work focuses on AI in allergy and immunology. Together, they get into where AI may be most useful now and in the near future, including phenotyping asthma and eczema, supporting diagnosis in young children, combining genetic, environmental, wearable, and clinical data, and reducing the administrative work that pulls clinicians away from patient care. But the episode does not dodge the hard stuff: hallucinations, bias, validation, liability, overtrust, and the very human problem of changing behaviour in real clinics.

Key Points

• Allergy and immunology are not early adopters of AI, partly because the field relies on complex, heterogeneous data.
• AI is most promising when it helps reveal patterns clinicians struggle to synthesize on their own, such as asthma or eczema subtypes.
• Large language models can hallucinate, so clinicians need to stay critical even when an answer sounds polished and convincing.
• Decision-support tools should augment clinical judgment, not replace it.
• Bias in training data can create real harm if AI tools work better for some patient populations than others.
• The best use cases are significant, underserved problems where AI can do something that older tools could not.
• AI literacy will become a core skill for clinicians who want to use these tools safely and effectively.

For allergists, the message is not to fear the machine or blindly follow it. AI may help identify patterns, reduce administrative work, and open new research possibilities, but the clinician still brings the judgment, context, accountability, and critical eye. The future is not AI instead of allergists. It is allergists who understand how to use AI well.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

“It’s a fun time to be a food allergist”—Dr. David Fleischer

Food allergy treatment is no longer just about avoidance, epinephrine, and hoping for the best. With high-dose OIT, low-dose OIT, SLIT, EPIT, Xolair, and other biologics entering the conversation, allergists now face a more practical question: what are we trying to achieve, and what approach best fits this patient and family?

On this episode, Dr. Mariam Hanna is joined by Dr. David Fleischer, section head of allergy and immunology and director of the Allergy and Immunology Center at Children’s Hospital Colorado, and professor of pediatrics at the University of Colorado School of Medicine. He walks through how dose, route, safety, family goals, practicality, and flexibility all shape the choice of therapy.

Key Points

• Low-dose OIT may offer similar protection to higher-dose protocols in some patients, making the dose question more about goals, risk, and fit.
• Protection is the first goal; clinical remission remains the harder, longer-term hope.
• Lower-dose approaches may offer practical advantages, including fewer up-doses, fewer clinic visits, and potentially fewer side effects.
• SLIT and EPIT may be useful options for families looking for more forgiving, lower-burden approaches.
• Xolair can provide protection for selected patients, but Dr. Fleischer emphasizes that it is not disease-modifying.
• Food allergy treatment is becoming a shared decision about efficacy, safety, practicality, and what the family actually wants from therapy.

With more tools in the food allergy toolbox, the future may not be one perfect protocol for everyone. It may be choosing the right therapy for the right patient, then having the flexibility to change course when life, goals, or tolerance change.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

“We need more than just random care. We need randomized care.” — Dr. Derek Chu

For years, the allergy world has been drowning in a sea of data—risk factors, prevention strategies, and enough diagnostic tools to fill a warehouse. But how do you translate 340 different risk factors into a cohesive plan when an anxious parent is sitting in your clinic demanding a skin test for their four-month-old?. On this episode, Dr. Mariam Hanna is joined by "systematic review genius" Dr. Derek Chu to unpack the evidence-based roadmap for food allergy and atopic dermatitis. It’s time to move past the "noise" and start reading between the lines of what our patients actually need.

Key Points:

• Major vs. Minor Signals: Eczema severity and family history are the big players, while being first-born or male are merely minor notes in the risk profile.
• The Diagnostic Trap: Testing only works if it changes practice; otherwise, you’re just putting a baby through the trauma of an itchy back for a 20% certainty bump.
• De-escalating Momentum: Be skeptical of previous "avoid all nuts" labels; if the patient is already eating the food, do not skin test them to it.
• The TITAN Initiative: We need national, high-quality food challenge capacity to provide the clarity that families are actually looking for.
• Beyond Narrative Synthesis: The new eczema guidelines involve patients as partners and weigh everything from JAK inhibitors to the humble (but low-certainty) bleach bath.
• Clean Hands, Frequent Moisture: Prevention of atopic dermatitis may be gray, but moisturizing with every diaper change—using clean hands—is a low-stakes win

Dr. Chu walks us through the "diagnostic momentum" that often leads clinicians to over-test and over-restrict, and why your Royal College exam cutoffs might not be as definitive as you remember. From the major and minor predictors of food allergy to the "multimorbid" patient with eczema, this conversation is a masterclass in being sensible and judicious at the bedside.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

“We came up with the idea of testing a ketogenic diet… which in mice, it’s basically a lot of Crisco… giving a keto diet to mice with CGD… led to a decreased susceptibility to colitis.” —Dr. Emilia Liana Falcone

The microbiome isn’t something sitting on the sidelines. It’s part of the immune system, interacting with the barrier, shaping responses, and, in IEI, reflecting the underlying defect.

On this episode, Dr. Mariam Hanna is joined by Dr. Emilia Liana Falcone, physician-scientist and director of the Microbiome and Mucosal Defense Research Unit at the Montreal Clinical Research Institute, to walk through how these host–microbe interactions drive disease. From early-life immune programming to microbial signals that activate inflammatory pathways, this is a shift from association to mechanism. And a step toward therapies that target both sides of the equation.

Key Points:

• The microbiome reflects the underlying immune defect in IEI
• Focus on what microbes are doing, not just which ones are present
• Microbiome changes both result from—and contribute to—disease
• Early life is a critical window where these interactions are set
• Loss of protective microbial functions matters more than specific bacteria
• Microbial signals can directly drive inflammation (including inflammasome activation)
• Future treatments will likely combine immune therapy with microbiome-targeted approaches

This is not about adding a probiotic.

It’s about understanding how immune defects reshape the microbial environment, and how that environment feeds back into disease.

Get that interaction right, and you’re not just managing symptoms.

You’re changing the system driving them.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

“This is a safe and very effective therapy, which is probably underutilized within our own community.” —Dr. Susan Wasserman

Subcutaneous immunotherapy (SCIT) sits in that uncomfortable space between routine and risk. It’s one of the few interventions in allergy that can actually modify disease. But it also carries a small, very real risk of severe reactions. On this episode, Dr. Susan Wasserman, professor at McMaster University and a national leader in immunotherapy, walks through what safety really looks like in practice. And where things still go wrong.

Key Points:

• Systemic reactions are uncommon but not rare
• Safety has improved through better patient selection, standardized extracts, and clinic preparedness
• Uncontrolled asthma is the most important risk factor for severe reactions
• Prior systemic reactions require reassessment, especially if the cause is correctable
• Build-up dosing carries higher risk than maintenance
• Rush and cluster protocols increase risk and need clear justification
• The 30-minute observation period captures most but not all reactions
• Beta blockers and ACE inhibitors may worsen reaction severity without increasing incidence

SCIT is one of the few tools we have that can actually change the trajectory of allergic disease. But it demands discipline. Careful screening. Reliable processes. And a team that’s ready to act when things go sideways.

Because most of the time, it’s safe.
And the rare times it isn’t—that’s where preparation matters most.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

"So the future is one IV infusion, likely no chemotherapy, and that'll cure our IEIs." — Dr. Nicola Wright

For children born with inborn errors of immunity, bone marrow transplant has long been the closest thing medicine had to a cure. It works — but it comes with chemotherapy, graft-versus-host disease, and a donor search that doesn't always end well. Gene therapy is changing that calculus. Dr. Mariam Hanna speaks with Dr. Nicola Wright, a pediatric hematologist and clinical immunologist at the Alberta Children's Hospital and holder of the Barb Ibbotson Chair of Pediatric Hematology, whose research focuses on developing gene editing platforms for blood and immune disorders.

On this episode, they discuss:

• Why bone marrow transplant is, in Dr. Wright's words, "almost a poor man's gene therapy" and what gene therapy offers instead
• The spectrum of technologies: lentiviral insertion, CRISPR, base editing, and prime editing. What each does, and where each falls short
• Immune reconstitution outcomes across diseases, including over 90% good immune reconstitution in ADA-deficient SCID treated with lentiviral therapy
• How to counsel a family when gene therapy might be an option and why most patients still can't access it
• The "valley of death": why therapies that work in trials are failing to reach patients, and what it will take to cross it
• CAR T-cell therapy in IEI, including a Canadian trial underway for refractory autoimmune disease
• What long-term follow-up looks like and why 15-year post-trial monitoring is now an FDA requirement

The science is outpacing the infrastructure. Dr. Wright's vision of shipping cells instead of patients, in vivo delivery via lipid nanoparticle, no chemotherapy required isn't speculative. The runway is being built. The plane is already flying.

Have an idea for the show or a comment, send us a text!

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The Allergist is produced for CSACI by PodCraft Productions

"That wholesome conversation that you take a minute or two to go through really creates a physician-patient relationship, expands that communication. Probably will not only improve patient outcomes, but reduce medical-legal risk for physicians in the consent process." — Dr. Lisa Thurgur

A signed form isn't consent. It's paperwork. On this episode, Dr. Mariam Hanna is joined by Dr. Lisa Thurgur — emergency physician, award-winning educator, and a physician advisor with the Canadian Medical Protective Association — to unpack what meaningful consent looks like in daily practice. Inadequate consent is one of the most common allegations in CMPA cases, across every specialty.

On this episode:

• The three elements of valid consent — and what capacity actually means
• Why a signed consent form is not the same as an informed patient
• Implied versus expressed consent: when each applies, and when to re-consent
• Why serious risks like anaphylaxis — and death — must be disclosed, and how to frame that conversation
• Consent in minors: why maturity — not age — determines capacity (with one exception in Quebec)
• What to do when parents disagree — or a minor refuses
• Patients recording their visits: what physicians need to know
• PARQ: a four-point mnemonic for structuring both the conversation and the chart note
• The say-back technique: asking patients what they understood, and why it matters

Done well, consent isn't something you do in addition to practicing good medicine. It improves outcomes, strengthens adherence, and reduces medical-legal risk. In other words, it is good medicine.

Have an idea for the show or a comment, send us a text!

Visit the Canadian Society of Allergy and Clinical Immunology

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions