Alcohol-induced respiratory symptoms are common in patients with aspirin exacerbated respiratory disease

BACKGROUND

A large percentage of patients with aspirin exacerbated respiratory disease (AERD) report the development of alcohol-induced respiratory reactions, but the true prevalence of respiratory reactions caused by alcoholic beverages in these patients was not known.

OBJECTIVE

We sought to evaluate the incidence and characteristics of alcohol-induced respiratory reactions in patients with AERD.

METHODS

A questionnaire designed to assess alcohol-induced respiratory symptoms was administered to patients at Brigham and Women's Hospital and Scripps Clinic. At least 50 patients were recruited into each of 4 clinical groups: (1) patients with aspirin challenge-confirmed AERD, (2) patients with aspirin-tolerant asthma (ATA), (3) patients with aspirin tolerance and with chronic rhinosinusitis, and (4) healthy controls. Two-tailed Fisher exact tests with Bonferroni corrections were used to compare the prevalence of respiratory symptoms among AERD and other groups, with P ≤ .017 considered significant.

RESULTS

The prevalence of alcohol-induced upper (rhinorrhea and/or nasal congestion) respiratory reactions in patients with AERD was 75% compared with 33% with aspirin-tolerant asthma, 30% with chronic rhinosinusitis, and 14% with healthy controls (P < .001 for all comparisons). The prevalence of alcohol-induced lower (wheezing and/or dyspnea) respiratory reactions in AERD was 51% compared with 20% in aspirin-tolerant asthma and with 0% in both chronic rhinosinusitis and healthy controls (P < .001 for all comparisons). These reactions were generally not specific to one type of alcohol and often occurred after ingestion of only a few sips of alcohol.

CONCLUSION

Alcohol ingestion causes respiratory reactions in the majority of patients with AERD, and clinicians should be aware that these alcohol-induced reactions are significantly more common in AERD than in controls who are aspirin tolerant.

Use of simulated physician handoffs to study cross-cover chart biopsy in the electronic medical record

Clinical handoffs involve the rapid transfer of patient information from one provider or team to another, through activities which may introduce errors and affect care delivery. "Cross-coverage" requires quickly familiarizing oneself with unfamiliar patients whose management plans were established by another provider or team. Through this work, we describe physicians' information seeking approaches within an electronic medical record (EMR) during physician handoff and chart biopsy at a major academic medical center. We conducted simulated handoff sessions and interviews with 21 physicians using standardized patient cases and we analyzed screen capture data, and video and audio recordings of interactions with the EMR and handoff printouts. We found highly variable navigation of the EMR but greater similarity in physicians' EMR navigation behavior when the chart review was prompted by simulated interruptions. Understanding how physicians seek and assimilate patient data can inform handoff tool design and suggest strategies for explicitly supporting EMR chart biopsies.

Insulinoma presenting with cardiac arrest and cardiomyopathy

A 33-year-old woman presented with ventricular fibrillation cardiac arrest and was found to have a blood glucose of 1.83 mmol/L. Cardiac catheterisation revealed a dilated left ventricle with an ejection fraction (EF) of 26% and angiographically normal coronary arteries. Continuous dextrose infusion was required to treat hypoglycaemia, which prompted consideration of insulinoma as a possible cause for her cardiomyopathy. Whipple's triad was demonstrated; a 72 h fast provided biochemical evidence of insulinoma, and imaging localised a tumour in her pancreas. The tumour was resected and pathology confirmed insulinoma; pancreaticoduodenectomy cured her hypoglycaemia. No alternate cause of cardiomyopathy was found and 4 months after surgery her EF improved to 41%. High insulin levels can close cardiac K(ATP) channels associated with dilated cardiomyopathy; the catecholamine surge from hypoglycaemia may also contribute to ventricular remodelling. Hypoglycaemia can cause QT segment prolongation, and may have precipitated fibrillation in this patient's arrhythmia-prone myocardium.

The clinical dilemma of "silent desensitization" in aspirin-exacerbated respiratory disease

Aspirin desensitization is a treatment option for patients with aspirin-exacerbated respiratory disease (AERD). Some patients with an excellent history of aspirin or nonsteroidal anti-inflammatory drug (NSAID) reactions have negative aspirin challenges/desensitization. This study discusses the clinical entity of silent desensitization in AERD and the dilemma that this presents to the practicing allergist/immunologist. We discuss a series of patients with a strong history of NSAID reactions who initially underwent a negative challenge/silent desensitization. These patients were subsequently proven to have AERD after a second positive aspirin challenge. Silent desensitization is an uncommon but important outcome to recognize in AERD. Clinicians performing aspirin desensitization should understand that this can occur and consider a second confirmatory aspirin challenge in some patients.

Characterization of aspirin allergies in patients with coronary artery disease

BACKGROUND

Aspirin prevents coronary thrombosis and is used extensively in cardiovascular prophylaxis. However, patients with a prior history of an aspirin "reaction" are routinely denied this medication.

OBJECTIVE

To characterize the clinical presentation of a cohort of patients with coronary artery disease (CAD) and aspirin reactions.

METHODS

Between 2009 and 2012, using a retrospective computer analysis, information was collected on all patients within a county-wide health care system presenting with CAD and a prior history of aspirin reactions.

RESULTS

Of 9,565 patients with CAD, a prior history of aspirin reactions was recorded in 142 patients. Of these 142 patients, 30 (21%) had histories compatible with cutaneous and/or respiratory reactions. The other patients described adverse effects to aspirin, mostly gastrointestinal intolerance and bleeding. Aspirin-induced anaphylaxis was recorded in patients but may have been misdiagnosed, describing instead respiratory hypersensitivity reactions. Of the 142 patients, only 34 (24%) were receiving daily cardiovascular prophylaxis with aspirin. Of 108 patients not receiving aspirin, 25 (17.6%) were prescribed clopidogrel.

CONCLUSION

Histories of aspirin reactions in patients with CAD are uncommon, occurring in only 1.5% of our study population. The 21% of patients with histories compatible with aspirin hypersensitivities can be challenged and, if the results are positive, successfully desensitized. Moreover, almost all patients with gastric intolerance to aspirin can be treated with aspirin and a proton pump inhibitor. However, both approaches, which result in restoration of cardiovascular prophylaxis, were seriously underused in our study population.

Approach to patients with aspirin hypersensitivity and acute cardiovascular emergencies

The occurrence of an emergent need for aspirin therapy in an aspirin or nonsteroidal anti-inflammatory drug (NSAID)-"allergic" individual presents one of the more challenging situations the allergist may face. A common request is for the allergist to evaluate an acutely ill patient in a monitored hospitalized setting with a vague and remote history of a "reaction to aspirin." Because of significant diagnostic limitations, introducing aspirin can be very difficult. The concern about the potential for causing anaphylaxis in an acutely ill patient can lead to fear about performing any challenge or desensitization in these patients. The objective of this article was to review the literature regarding aspirin challenges and desensitization in the emergency setting and present a rational approach to administering aspirin to patients that require this drug.

Aspirin-exacerbated respiratory disease: update on pathogenesis and desensitization

Aspirin-exacerbated respiratory disease (AERD) is a unique syndrome of airway inflammation that frequently occurs in patients with nasal polyposis, chronic sinusitis, and asthma. These patients tend to have progressive and recalcitrant sinus disease requiring frequent surgical intervention and in many cases systemic corticosteroids. Much about the pathogenesis of AERD remains unclear, but environmental factors likely play a prominent role in its development. Avoidance of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) is imperative in the initial counseling of these patients. Because most of the exposure to these medications is available over the counter, most patients will experience a significant respiratory reaction to full therapeutic doses of seemingly innocent NSAIDs. Although the history of a reaction to aspirin or another NSAID is a very important part of making the diagnosis, the gold standard remains an observed aspirin challenge. Given the prevalence and usefulness of aspirin and NSAID therapy in primary care clinics, an accurate diagnosis should be made in all patients. Desensitization is an effective treatment option for many patients. Recent advances have made this procedure considerably safer and outpatient aspirin desensitization is now the standard of care.

Current trends in interprofessional education of health sciences students: a literature review

There is a pressing need to redesign health professions education and integrate an interprofessional and systems approach into training. At the core of interprofessional education (IPE) are creating training synergies across healthcare professions and equipping learners with the collaborative skills required for today's complex healthcare environment. Educators are increasingly experimenting with new IPE models, but best practices for translating IPE into interprofessional practice and team-based care are not well defined. Our study explores current IPE models to identify emerging trends in strategies reported in published studies. We report key characteristics of 83 studies that report IPE activities between 2005 and 2010, including those utilizing qualitative, quantitative and mixed method research approaches. We found a wide array of IPE models and educational components. Although most studies reported outcomes in student learning about professional roles, team communication and general satisfaction with IPE activities, our review identified inconsistencies and shortcomings in how IPE activities are conceptualized, implemented, assessed and reported. Clearer specifications of minimal reporting requirements are useful for developing and testing IPE models that can inform and facilitate successful translation of IPE best practices into academic and clinical practice arenas.

Fever, urticaria, lymphadenopathy, and protracted arthralgia and myalgia resistant to corticosteroid therapy

Allergen immunotherapy is commonly incorporated in the management of allergic rhinoconjunctivitis, allergic asthma, and insect sting hypersensitivity. It is generally safe, but systemic reactions occasionally occur, mainly of the immediate type and rarely of the delayed type. We report a case of a 50-year-old man with allergic rhinoconjunctivitis on immunotherapy for 3 years and then received an injection from another patient's extract. The latter contained a higher concentration of house-dust mite and pollens of grasses, trees, and weeds. It also contained molds that the patient's correct extract did not have. Within half an hour, he developed a systemic reaction that resolved with symptomatic treatment. Two weeks later, he received one-half of his usual immunotherapy dose. Within a week, he developed urticaria, arthralgia, myalgia, fever, and lymphadenopathy. Laboratory abnormalities included leukocytosis, elevated erythrocyte sedimentation rate, hematuria, and elevated liver enzymes. Oral corticosteroid therapy for 3 weeks was ineffective. He developed significant myalgia and apparent mood changes, attributable to corticosteroid intake. After a single plasmapheresis, he felt remarkable improvement within <24 hours. Corticosteroid therapy was gradually withdrawn over 10 weeks without relapse of symptoms. This is a rare case of probable serum sickness after the administration of a wrong allergy immunotherapy extract. However, a causal relationship could not be proven. The response was poor to prolonged corticosteroid therapy but was remarkable to one plasmapheresis.

How trainees would disclose medical errors: educational implications for training programmes

OBJECTIVES

The disclosure of harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how their practices evolve during training could help educators design programmes to address this gap. This study was conducted to determine how trainees would disclose medical errors.

METHODS

We surveyed 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centres. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses.

RESULTS

Trainees reported their intent to disclose the error as 'definitely' (43%), 'probably' (47%), 'only if asked by patient' (9%), and 'definitely not' (1%). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognise (55% versus 30%; p < 0.01). Respondents varied widely in the type of information they would disclose. Overall, 50% of trainees chose to use statements that explicitly stated that an error rather than only an adverse event had occurred. Regarding apologies, trainees were split between conveying a general expression of regret (52%) and making an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (trend p < 0.01). Prior disclosure training was associated with increased willingness to disclose errors (odds ratio 1.40, p = 0.03).

CONCLUSIONS

Trainees may not be prepared to disclose medical errors to patients and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees' skills in meeting patients' expectations for the open disclosure of harmful medical errors.

Anaphylactoid reactions to radiocontrast agents: prevention and treatment in the cardiac catheterization laboratory

The use of iodinated contrast agents for angiography dates back to the 1920s. The initial prototype has undergone modifications to reduce the toxicity and discomfort associated with the early contrast molecules. More importantly, these changes have dramatically decreased the rate and risk for severe adverse reactions such as hypersensitivity and anaphylaxis. With over 15 million contrast-requiring procedures performed annually in the United States, it is important to understand the risk factors, pathogenesis, diagnosis, prevention and treatment of contrast-induced anaphylactoid reactions. Reviews of adverse reactions are sparse in the cardiology literature, except for a landmark review in 1995 by Goss et al, which has served as the only practice guideline to date for cardiologists. In this report, we review the most recent literature to provide a guide for the general and interventional cardiologist in regards to the pretreatment and management of contrast-related reactions specifically in the cardiac catheterization laboratory.

The attitudes and experiences of trainees regarding disclosing medical errors to patients

PURPOSE

To measure trainees' attitudes and experiences regarding medical error and error disclosure.

METHOD

In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers.

RESULTS

The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure.

CONCLUSIONS

Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

Melkersson-Rosenthal syndrome: a form of pseudoangioedema

BACKGROUND

Melkersson-Rosenthal syndrome is an unusual cause of facial swelling that can be confused with angioedema.

OBJECTIVE

To describe a young woman with facial swelling initially considered to be angioedema.

METHODS

A biopsy specimen of the eyelid demonstrated findings consistent with Melkersson-Rosenthal syndrome.

RESULTS

After reviewing the differential diagnosis of pseudoangioedema, a presumptive diagnosis of Melkersson-Rosenthal syndrome was made. The patient was successfully treated with infliximab for Melkersson-Rosenthal syndrome. Owing to medication adverse effects, infliximab treatment was discontinued. Treatment was then continued with adalimumab, with good effect and without adverse events.

CONCLUSIONS

We report the case of a patient with Melkersson-Rosenthal syndrome presenting as angioedema. Furthermore, we report the first successful treatment of Melkersson-Rosenthal syndrome with adalimumab.

Failure to maintain an aspirin-desensitized state in a patient with aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin desensitization is a useful therapy in patients with aspirin-exacerbated respiratory disease.

OBJECTIVE

To describe the clinical course of a man with aspirin-exacerbated respiratory disease who was unable to be desensitized to oral aspirin.

METHODS

A standard aspirin desensitization protocol was used to achieve a maximum dose of 650 mg of oral aspirin. The patient initially tolerated this dose of aspirin.

RESULTS

Within days of desensitization, the patient began to react to 650 mg of aspirin. Monitored challenge with this dose of aspirin led to marked decrease in forced expiratory volume in 1 second and pronounced nasal and ocular symptoms.

CONCLUSIONS

We present a patient with classic aspirin-exacerbated respiratory disease, who despite undergoing a standard aspirin desensitization protocol was unable to maintain his desensitized state.

A 55-year-old woman with muscle pain and eosinophilia

We present the case of a 55-year-old female with three months of severe, diffuse muscle aching and pain. She had recently undergone orthopedic surgery, but had otherwise not noticed any changes to her baseline health. Her physical examination demonstrated only diffuse muscle tenderness and post-surgical changes to her right knee. Her laboratory evaluation was notable for plasma eosinophilia. An extensive rheumatological workup revealed no evidence of an underlying connective tissue disease. After undergoing a diagnostic procedure, the patient enjoyed a dramatic response to therapy for this disease. This disorder often has subtle clinical manifestations and is associated with vague systoms that can confound an accurate diagnosis.

The blocking effect of essential controller medications during aspirin challenges in patients with aspirin-exacerbated respiratory disease

BACKGROUND

The blocking effect of controller medications for asthma could have an effect on the outcome of aspirin challenges in patients suspected of having aspirin-exacerbated respiratory disease (AERD).

OBJECTIVE

To evaluate whether there was any blocking effect of long-acting beta2-agonists, systemic corticosteroids, and/or inhaled corticosteroids alone or as co-therapy with leukotriene modifier drugs (LTMDs).

METHODS

Between 1981 and 2004, 678 patients with suspected AERD were admitted for aspirin challenge and desensitization. All patients had asthma, chronic sinusitis, nasal polyposis, and at least 1 historical reaction to a nonsteroidal anti-inflammatory drug. Asthma controller medications taken during aspirin challenge were recorded and analyzed with respect to their potential effects on 4 possible outcomes of aspirin challenge, namely, naso-ocular reaction, lower airway reaction, classic upper and lower airway reaction, or a negative challenge result.

RESULTS

When compared with AERD patients who received no controller medications, the combined use of LTMDs, inhaled corticosteroids, and long-acting beta2-agonists led to a statistically significant change in aspirin challenge outcomes (P = .009), mainly shifting the reaction from a classic upper and lower respiratory tract reaction to naso-ocular reactions only. LTMDs appeared to have the strongest effect (P < .001) in blocking lower respiratory tract reactions. Systemic corticosteroids did not have the same effects. Blocking of both upper and lower respiratory tract reactions to aspirin as a result of taking controller medications did not occur.

CONCLUSION

Controller medications are frequently needed to stabilize airways of patients with AERD. LTMDs alone or in combination with other controllers blocked lower respiratory tract reactions during aspirin challenge in some patients with AERD but did not change the overall rate of positive aspirin challenge results and did not lead to false-negative challenges.