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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 302] [Impact Index Per Article: 100.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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302
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Wang Q, Pittman L, Healey A, Chang J, Song TT. Ideal body position for epinephrine autoinjector administration. Allergy Asthma Proc 2021; 42:147-152. [PMID: 33685560 DOI: 10.2500/aap.2021.42.200108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Epinephrine is the first-line therapy for patients with anaphylaxis, and intramuscular (IM) delivery is shown to be superior to subcutaneous (SC) delivery. There currently is no consensus on the ideal body position for epinephrine autoinjector (EAI) administration. Objective: We designed this study to investigate whether SC tissue depth (SCTD) is affected by body position (e.g., standing, sitting, supine), which can potentially impact delivery of EAI into the IM space. Methods: Volunteer adults (ages ≥ 18 years) from a military medical treatment facility in the United States were recruited to participate in this study. SCTD of the vastus lateralis was measured via ultrasound at standing, sitting, and supine body positions. Subjects' age, sex, and body mass index (BMI) were collected. Statistical analysis was performed to compare average SCTD between body positions, sex, and BMI. Results: An analysis of variance of 51 participants (33 men and 18 women) did not reveal statistically significant difference in SCTD among standing, sitting, and supine body positions. It did show a significantly greater SCTD in women than in men (2.72 ± 1.36 cm versus 1.10 ± 0.38 cm; p < 0.001). There was no significant association observed between BMI and SCTD in this study. Conclusion: Body position did not seem to significantly change the distance between skin and thigh muscle in adults. This would suggest that there might not be an ideal body position for EAI administration. Therefore, in case of anaphylaxis, prompt administration of epinephrine is recommended at any position.
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Affiliation(s)
- Qing Wang
- From the Department of Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Luke Pittman
- Department of Allergy/Immunology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Andrew Healey
- Department of Radiology, Womack Army Medical Center, Fort Bragg, North Carolina; and
| | - James Chang
- From the Department of Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - T. Ted Song
- Department of Allergy/Immunology, University of Washington, Seattle, Washington
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303
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Lobo-Valbuena B, Martin-Gorgojo A, Zafra-Cobo I, Sánchez-Estella J. Safety in Dermatologic Procedures: Anaphylaxis, Vasovagal Reaction, and Hyperventilation. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00115-0. [PMID: 33745892 DOI: 10.1016/j.ad.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 10/21/2022] Open
Abstract
This article, part of a the series on safety in dermatologic procedures, covers the diagnosis, prevention, management, and treatment of 3 situations or conditions. The first condition we address is anaphylaxis, an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence. The second is the vasovagal reaction, which is the most common complication in dermatologic surgery. This event, which occurs in 1 out of every 160 procedures, usually follows a benign course and resolves on its own. However, in patients susceptible to vasovagal reactions, syncope may lead to asystole and cardiac arrest. The third is acute hyperventilation syndrome, which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements. Brief practical recommendations for managing all 3 events are included.
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Affiliation(s)
- Beatriz Lobo-Valbuena
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - Alejandro Martin-Gorgojo
- Servicio ITS/Dermatología, Sección Especialidades Médicas, Organismo Autónomo Madrid Salud - Ayuntamiento de Madrid, Madrid, España.
| | - Isabel Zafra-Cobo
- Servicio de Dermatología, Complejo Asistencial de Zamora, Zamora, España
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304
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Management of Anaphylaxis During the SARS-CoV-2 Pandemic. CURRENT TREATMENT OPTIONS IN ALLERGY 2021; 8:88-96. [PMID: 33723499 PMCID: PMC7946336 DOI: 10.1007/s40521-021-00284-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/21/2022]
Abstract
Purpose of Review Management of anaphylaxis during the SARS-CoV-2 pandemic should consider local infection rates so as to not burden local ED at times of pandemic, while also protecting patients from infection risks and progression of anaphylaxis. In this review, we identify a treatment strategy for anaphylaxis that balances the risks versus benefits of ED versus home management in this unprecedented time. Recent Findings Physicians and patients have had to adapt new approaches to medical care during the SARS-CoV-2 pandemic due to restricted access to health care facilities. Telemedicine has substituted in-person visits, and such a drastic change in the patient care paradigm presents a need to revise the acute management of anaphylaxis. Summary Physicians should utilize telemedicine during this time to engage in shared decision-making with patients and their families to devise an anaphylaxis plan of management that emphasizes home care when symptoms are mild with an exception for ED care if a patient has had severe, near-fatal anaphylaxis episodes in the past. Previous anaphylaxis recommendations should remain in place despite the pandemic, including prompt use of epinephrine when needed, avoidance of known allergens, training of patients and their caregivers, and carrying of epinephrine autoinjector devices at all times to remain prepared in the event of an anaphylaxis episode. Supplementary Information The online version contains supplementary material available at 10.1007/s40521-021-00284-0.
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305
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Odunayo A, Nash KJ, Davidow EB, Blois SL, Goy-Thollot I, Harris L, Humm K, Musulin S, Sharp CR, Spada E, Thomason J, Walton J, Jane Wardrop K. Association of Veterinary Hematology and Transfusion Medicine (AVHTM) transfusion reaction small animal consensus statement (TRACS). Part 3: Diagnosis and treatment. J Vet Emerg Crit Care (San Antonio) 2021; 31:189-203. [PMID: 33751797 DOI: 10.1111/vec.13043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/06/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To systematically review available evidence to develop guidelines for diagnosis and treatment of transfusion-associated reactions in dogs and cats. DESIGN Standardized and systemic evaluation of the literature (identified through Medline via PubMed and Google Scholar searches) was carried out for identified transfusion reaction types in dogs and cats. The available evidence was evaluated using PICO (Population, Intervention, Comparison, Outcome) questions generated for each reaction type. The evidence was categorized by level of evidence (LOE) and quality (Good, Fair, or Poor). Guidelines, diagnostic, and treatment algorithms were generated based on the evaluation of the evidence. Consensus on the final guidelines was achieved through Delphi-style surveys. Draft recommendations were disseminated through veterinary specialty listservs for review and comments, which were evaluated and integrated prior to final publication. RESULTS Medline via PubMed and Google Scholar databases were searched. There were 14 Population Intervention Comparison Outcome questions identified and corresponding worksheets were developed focusing on the diagnosis and treatment of transfusion-associated reactions in dogs and cats. Fourteen guidelines and four algorithms were developed with a high degree of consensus. CONCLUSIONS This systematic evidence evaluation process yielded recommended diagnostic and treatment algorithms for use in practice. However, significant knowledge gaps were identified, demonstrating the need for additional research in veterinary transfusion medicine.
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Affiliation(s)
- Adesola Odunayo
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, Tennessee, USA
| | - Katherine J Nash
- VetMED Emergency and Specialty Veterinary Hospital, Phoenix, Arizona, USA
| | - Elizabeth B Davidow
- Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
| | - Shauna L Blois
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | | | | | - Karen Humm
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Sarah Musulin
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Perth, Australia
| | - Eva Spada
- Department of Veterinary Medicine, University of Milan, Lodi, Italy
| | - John Thomason
- Department of Clinical Sciences, Mississippi State University, Mississippi State, Mississippi, USA
| | | | - K Jane Wardrop
- Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
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306
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Shaker M, Abrams EM, Greenhawt M. A Cost-Effectiveness Evaluation of Hospitalizations, Fatalities, and Economic Outcomes Associated with Universal Versus Anaphylaxis Risk-Stratified COVID-19 Vaccination Strategies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2658-2668.e3. [PMID: 33711496 PMCID: PMC7942189 DOI: 10.1016/j.jaip.2021.02.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Vaccine-associated anaphylaxis is a rare event (1.34 events/million doses; 0.00017% occurrence over 26 years). Several reports of allergic reactions concerning for anaphylaxis have been reported early into the Pfizer-BioNTech and Moderna coronavirus disease 2019 (COVID-19) vaccine campaign in the United States, Canada, and the United Kingdom. OBJECTIVE To perform a cost-effectiveness analysis characterizing the risks of COVID-19 versus vaccine anaphylaxis, comparing universal COVID-19 vaccination versus risk-stratified vaccination approaches. METHODS Cohort analysis models were created to evaluate the cost-effectiveness of universal vaccination versus risk-stratified vaccination (eg, contraindicated in persons with a history of any previous episode of anaphylaxis) with a threshold for cost-effective care at $10,000,000 per death prevented. In the base case, risk of anaphylaxis was estimated at 0.1%, with case-fatality estimated at 0.3%. RESULTS On a population level (n = 300,000,000 simulated persons), universal vaccination was associated with a cost-savings of $503,596,316 and saved 7,607 lives, but the cost-savings was sensitive to increasing rates of vaccine-associated anaphylaxis. The universal strategy dominated at higher rates of COVID-19 infection and low rates of vaccine-associated anaphylaxis in both the health care and societal perspectives. When the risk of vaccine-associated anaphylaxis exceeded 0.8%, the risk-stratified approach to vaccination was the most cost-effective strategy. There was also an interaction between anaphylaxis risk and anaphylaxis fatality, with a risk-stratified approach becoming cost-effective as each risk increased concurrently. Stratified observation time by anaphylaxis history (15 minutes vs 30 minutes) was not cost-effective until a 1% anaphylaxis case-fatality was assumed and risk of vaccine anaphylaxis exceeded 6%. CONCLUSIONS This study demonstrates that unless vaccine anaphylaxis rates exceed 0.8%, a universal vaccination approach dominates a risk-stratified approach where persons with any history of anaphylaxis would be contraindicated from vaccination, with lower cost and superior health outcomes.
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Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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307
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Wasserman RL, Factor J, Windom HH, Abrams EM, Begin P, Chan ES, Greenhawt M, Hare N, Mack DP, Mansfield L, Ben-Shoshan M, Stukus DR, Leek TV, Shaker M. An Approach to the Office-Based Practice of Food Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1826-1838.e8. [PMID: 33684637 DOI: 10.1016/j.jaip.2021.02.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.
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Affiliation(s)
| | - Jeffrey Factor
- New England Food Allergy Treatment Center, West Hartford, Conn
| | - Hugh H Windom
- Windom Allergy, Asthma and Sinus Specialists, Sarasota, Fla
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | | | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Marcus Shaker
- Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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308
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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309
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Dispenza MC, Krier-Burris RA, Chhiba KD, Undem BJ, Robida PA, Bochner BS. Bruton's tyrosine kinase inhibition effectively protects against human IgE-mediated anaphylaxis. J Clin Invest 2021; 130:4759-4770. [PMID: 32484802 DOI: 10.1172/jci138448] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/28/2020] [Indexed: 01/30/2023] Open
Abstract
No known therapies can prevent anaphylaxis. Bruton's tyrosine kinase (BTK) is an enzyme thought to be essential for high-affinity IgE receptor (FcεRI) signaling in human cells. We tested the hypothesis that FDA-approved BTK inhibitors (BTKis) would prevent IgE-mediated responses including anaphylaxis. We showed that irreversible BTKis broadly prevented IgE-mediated degranulation and cytokine production in primary human mast cells and blocked allergen-induced contraction of isolated human bronchi. To address their efficacy in vivo, we created and used what we believe to be a novel humanized mouse model of anaphylaxis that does not require marrow ablation or human tissue implantation. After a single intravenous injection of human CD34+ cells, NSG-SGM3 mice supported the population of mature human tissue-resident mast cells and basophils. These mice showed excellent responses during passive systemic anaphylaxis using human IgE to selectively evoke human mast cell and basophil activation, and response severity was controllable by alteration of the amount of allergen used for challenge. Remarkably, pretreatment with just 2 oral doses of the BTKi acalabrutinib completely prevented moderate IgE-mediated anaphylaxis in these mice and also significantly protected against death during severe anaphylaxis. Our data suggest that BTKis may be able to prevent anaphylaxis in humans by inhibiting FcεRI-mediated signaling.
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Affiliation(s)
- Melanie C Dispenza
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rebecca A Krier-Burris
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Krishan D Chhiba
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bradley J Undem
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Piper A Robida
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bruce S Bochner
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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310
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The allergic myocardial infarction dilemma: is it the anaphylaxis or the epinephrine? J Thromb Thrombolysis 2021; 52:941-948. [PMID: 33544285 DOI: 10.1007/s11239-021-02389-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
We highlight two distinct cases of myocardial infarction occurring concurrently with anaphylaxis at our centre in Singapore. The first case had cardiac symptoms and electrocardiogram changes concomitant with his anaphylaxis presentation, suggestive of Kounis syndrome, while the second case presented with anaphylaxis and only developed cardiac symptoms and electrocardiogram changes after treatment with intramuscular epinephrine, suggestive of epinephrine-induced myocardial infarction. Both these conditions are uncommon and under-recognised, and we review the current literature to compare the similarities and differences in their clinical manifestations, pathophysiology, and management. Kounis syndrome occurs secondary to mast cell degranulation ultimately resulting in coronary vasospasm, platelet activation and inflammatory response, whereas epinephrine causes platelet aggregation. Therefore, treatment priorities of Kounis syndrome are treatment of allergy, treatment of vasospasm, and treatment with anti-platelet therapy and revascularization if coronary plaques are present. For epinephrine-induced myocardial infarction, after epinephrine treatment is discontinued, considerations in management are re-vascularisation or pharmacotherapy. Further research will help with better understanding of both conditions and formulation of clinical management guidelines.
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311
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Abrams EM, Singer AG, Shaker M, Greenhawt M. What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:608-612. [PMID: 33253924 PMCID: PMC7691847 DOI: 10.1016/j.jaip.2020.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022]
Abstract
The coronavirus disease 2019 pandemic has forever changed how we view health care service delivery. Although there are undoubtedly some unintended consequences that will result from current health care service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. To determine what is "routine," what is "essential," and what is "exceptional," it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement definition of the dimensions of quality is based on whether the care is safe, effective, patient-centered, timely, efficient, and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the coronavirus disease 2019 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-coronavirus disease health care system.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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312
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Burroughs-Ray DC, Wells DR, Dennis MM, Jackson CD. Clinical Guideline Highlights for the Hospitalist: Anaphylaxis Management in Adults and Children. J Hosp Med 2021; 16:98-99. [PMID: 33496659 DOI: 10.12788/jhm.3553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022]
Abstract
Anaphylaxis-A 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis RELEASE DATE: April 2020 PRIOR VERSION: Anaphylaxis - a 2019 practice parameter and GRADE analysis DEVELOPER: American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) FUNDING SOURCE: None TARGET POPULATION: Adult and pediatric patients with anaphylaxis.
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Affiliation(s)
- Desirée C Burroughs-Ray
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Daniel R Wells
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Mallie M Dennis
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Christopher D Jackson
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee
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313
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Midun E, Radulovic S, Brough H, Caubet JC. Recent advances in the management of nut allergy. World Allergy Organ J 2021; 14:100491. [PMID: 33510829 PMCID: PMC7811165 DOI: 10.1016/j.waojou.2020.100491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022] Open
Abstract
Peanut/tree nut allergy is common and has been associated with particularly severe reactions. Epidemiological data have shown that the prevalence ranges between 0.05% and 4.9% for tree nut and between 0.5% and 3% for peanut. These large variations can be explained by differences in the age of included patients and the geographical region. In addition, the food consumption modality (ie, raw versus roasted) plays a major role, as heat treatment has the capacity to modify the allergenicity of nuts and legumes. Nut allergies tend to persist into adulthood and consequently have a high impact on quality of life. Recently, it has been demonstrated that a significant proportion of nut allergic patients are able to tolerate other nuts. As opposed to the avoidance of all nuts, this approach is currently proposed in several tertiary allergy centers. However, diagnosis of nut allergy is particularly difficult due to co-sensitization leading to high rate of false positive skin prick tests and/or specific IgE to whole allergen extracts. The use of component resolved diagnosis leads to major improvement of diagnosis, particularly to distinguish between primary and secondary nut allergies. The basophil activation test has been suggested to be useful but is still used mainly as a research tool. Thus, diagnosis remains mainly based on the oral food challenge, which is considered as the gold standard. Regarding treatment, avoidance remains the cornerstone of management of nut allergy. Oral immunotherapy is increasingly proposed as an alternative management strategy.
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Key Words
- Component-resolved diagnostic, CRD
- Cross reactivity
- Double-blind, placebo-controlled, food challenge, DBPCFC
- Food allergy
- Lipid transfer protein, LTP
- Oral allergy syndrome, OAS
- Oral food challenge, OFC
- Oral immunotherapy
- Oral induction tolerance, OIT
- Pathogenesis related protein type 10, PR-10
- Peanut
- Platelet-activating factor, PAF
- Pollen-food syndrome, PFS
- Precautionary Allergen Labels, (PAL)
- Skin prick test, SPT
- Tree nut
- Tree nut, TN
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Affiliation(s)
- Elise Midun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205 Geneva, Switzerland, University Lyon 1 Claude Bernard, 43 Boulevard Du 11-Novembre-1918, 69100, Villeurbanne, France
- Corresponding author.
| | - Suzana Radulovic
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen Brough
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205, Geneva, Switzerland
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314
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Greenhawt M, Abrams EM, Oppenheimer J, Vander Leek TK, Mack DP, Singer AG, Shaker M. The COVID-19 Pandemic in 2021: Avoiding Overdiagnosis of Anaphylaxis Risk While Safely Vaccinating the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1438-1441. [PMID: 33529722 PMCID: PMC7847187 DOI: 10.1016/j.jaip.2021.01.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo.
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | | | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Douglas P Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
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315
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Dribin TE, Schnadower D, Spergel JM, Campbell RL, Shaker M, Neuman MI, Michelson KA, Capucilli PS, Camargo CA, Brousseau DC, Rudders SA, Assa'ad AH, Risma KA, Castells M, Schneider LC, Wang J, Lee J, Mistry RD, Vyles D, Pistiner M, Witry JK, Zhang Y, Sampson HA. Severity grading system for acute allergic reactions: A multidisciplinary Delphi study. J Allergy Clin Immunol 2021; 148:173-181. [PMID: 33476673 DOI: 10.1016/j.jaci.2021.01.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/29/2020] [Accepted: 01/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is no widely adopted severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, thus limiting the ability to optimize and standardize management practices and advance research. OBJECTIVE The aim of this study was to develop a severity grading system for acute allergic reactions for use in clinical care and research. METHODS From May to September 2020, we convened a 21-member multidisciplinary panel of allergy and emergency care experts; 9 members formed a writing group to critically appraise and assess the strengths and limitations of prior severity grading systems and develop the structure and content for an optimal severity grading system. The entire study panel then revised the grading system and sought consensus by utilizing Delphi methodology. RESULTS The writing group recommended that an optimal grading system encompass the severity of acute allergic reactions on a continuum from mild allergic reactions to anaphylactic shock. Additionally, the severity grading system must be able to discriminate between clinically important differences in reaction severity to be relevant in research while also being intuitive and straightforward to apply in clinical care. Consensus was reached for all elements of the proposed severity grading system. CONCLUSION We developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions. Successful international validation, refinement, dissemination, and application of the grading system will improve communication among providers and patients about the severity of allergic reactions and will help advance future research.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | | | - Marcus Shaker
- Dartmouth Geisel School of Medicine, Hanover, NH; Dartmouth-Hitchcock Medical Center, Hanover, NH
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David C Brousseau
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Susan A Rudders
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Amal H Assa'ad
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Risma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mariana Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lynda C Schneider
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Julie Wang
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Juhee Lee
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - David Vyles
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Michael Pistiner
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - John K Witry
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hugh A Sampson
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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316
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Rostaher A, Mueller RS, Meile L, Favrot C, Fischer NM. Venom immunotherapy for Hymenoptera allergy in a dog. Vet Dermatol 2021; 32:206-e52. [PMID: 33439532 DOI: 10.1111/vde.12931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/18/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
A 1.5-year-old male castrated dog was presented in anaphylactic shock after suffering an apparent bee sting. Immunotherapy with bee venom was initiated based upon history, skin testing and serological testing for allergen-specific immunoglobulin (Ig)E. The dog was maintained on venom immunotherapy for five years and showed no signs of adverse effects from therapy or from repeated bee stings.
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Affiliation(s)
- Ana Rostaher
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, Zurich, 8057, Switzerland
| | - Ralf S Mueller
- Small Animal Medicine Clinic, Centre for Clinical Veterinary Medicine, LMU Munich, Veterinaerstr. 13, Munich, 80539, Germany
| | - Lena Meile
- Brünigstrasse 180, Sarnen, 6060, Switzerland
| | - Claude Favrot
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, Zurich, 8057, Switzerland
| | - Nina Maria Fischer
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, Zurich, 8057, Switzerland
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317
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Kelso JM. Anaphylactic reactions to novel mRNA SARS-CoV-2/COVID-19 vaccines. Vaccine 2021; 39:865-867. [PMID: 33441235 PMCID: PMC7837118 DOI: 10.1016/j.vaccine.2020.12.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022]
Affiliation(s)
- John M Kelso
- Division of Allergy, Asthma and Immunology, Scripps Clinic, 3811 Valley Centre Drive, San Diego, CA 92130, United States.
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318
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Li PH, Chua GT, Leung ASY, Chan YC, Chan KKL, Cheung KH, Chong PCY, Ho PPK, Kwan MYW, Lai JCH, Lam KK, Lam TSK, Leung TF, Li TY, Duque JSR, So JLT, Wan KA, Wong HCY, Wu AYY, Lee TH, Ho MHK, Siu AYC. Hong Kong Anaphylaxis Consortium Consensus Statements on prescription of adrenaline autoinjectors in the acute care setting. Asia Pac Allergy 2021; 11:e1. [PMID: 33604271 PMCID: PMC7870372 DOI: 10.5415/apallergy.2021.11.e1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background Adrenaline autoinjectors (AAInj) facilitates early administration of adrenaline and remains the first-line treatment for anaphylaxis. However, only a minority of anaphylaxis survivors in Hong Kong are prescribed AAInj and formal guidance do not exist. International anaphylaxis guidelines have been largely based on Western studies, which may not be as relevant for non-Western populations. Objective To formulate a set of consensus statements on the prescription of AAInj in Hong Kong. Methods Consensus statements were formulated by the Hong Kong Anaphylaxis Consortium by the Delphi method. Agreement was defined as greater than or equal to 80% consensus. Subgroup analysis was performed to investigate differences between allergy and emergency medicine physicians. Results A total of 7 statements met criteria for consensus with good overall agreement between allergy and emergency medicine physicians. AAInj should be used as first-line treatment and prescribed for all patients at risk of anaphylaxis. This should be prescribed prior to discharge from the Accident and Emergency Department together with an immediate referral to an allergy center. The decision for prescribing AAInj should be based on the severity of previous reactions; including objective signs of respiratory involvement, objective signs of cardiovascular involvement and multiorgan involvement (regardless of severity). Patient demographics and comorbidities, specifically history of asthma or chronic obstructive pulmonary disease, should also be considered. Patients deemed eligible for AAInj should be offered avoidance advice and prescribed one AAInj while awaiting review by allergists. AAInj technique should be demonstrated by a healthcare professional or instruction video, and a return demonstration by the patient is required. The patient should also be counseled that the decision on the continued need of AAInj prescription in the long-term should be reviewed by an allergist. Conclusion Consensus statements support the prescription of AAInj by front-line physicians with subsequent allergist review when treating patients at risk of anaphylaxis in Hong Kong.
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Affiliation(s)
- Philip H Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Gilbert T Chua
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Agnes S Y Leung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Yiu-Cheung Chan
- Accident & Emergency Department, United Christian Hospital, Hong Kong
| | - Karen K L Chan
- 24-Hour Outpatient and Emergency Department, Gleneagles Hong Kong Hospital, Hong Kong
| | - Koon-Ho Cheung
- Accident & Emergency Department, Prince of Wales Hospital, Hong Kong
| | | | - Polly P K Ho
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong
| | - Mike Y W Kwan
- Department of Paediatrics & Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Jeffrey C H Lai
- Accident & Emergency Department, Tin Shui Wai Hospital, Hong Kong
| | - Kin-Kwai Lam
- Accident & Emergency Department, United Christian Hospital, Hong Kong
| | - Tommy S K Lam
- Accident & Emergency Department, Pok Oi Hospital, Hong Kong
| | - Ting-Fan Leung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Tin-Yan Li
- Accident & Emergency Department, Queen Elizabeth Hospital, Hong Kong
| | - Jaime S Rosa Duque
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Jerome L T So
- Accident & Emergency Department, Tseung Kwan O Hospital, Hong Kong
| | - Kuang-An Wan
- Accident & Emergency Department, Ruttonjee Hospital, Hong Kong
| | - Henry C Y Wong
- Accident & Emergency Department, Pok Oi Hospital, Hong Kong
| | | | - Tak-Hong Lee
- Allergy Centre, Hong Kong Sanatorium and Hospital, Hong Kong
| | - Marco H K Ho
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Axel Y C Siu
- Accident & Emergency Department, Ruttonjee Hospital, Hong Kong
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319
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Poziomkowska-Gęsicka I, Kostrzewska M, Kurek M. Comorbidities and Cofactors of Anaphylaxis in Patients with Moderate to Severe Anaphylaxis. Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18010333. [PMID: 33466336 PMCID: PMC7794698 DOI: 10.3390/ijerph18010333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes and cofactors of this reaction. This paper presents the analysis of data from the Anaphylaxis Registry gathered over ten years at the Allergy Clinic, Pomeranian Medical University (PMU). A questionnaire-based survey was used for patients visiting the Allergy Clinic to identify potential augmentation factors/comorbidities and/or cofactors of anaphylaxis in patients with a history of moderate to severe anaphylaxis. The registry comprised patients with grade II or higher anaphylaxis. The gathered data concerned chronic comorbidities (cardiovascular diseases, respiratory diseases, and others), recurrence of anaphylaxis, and potential cofactors in anaphylaxis. In the analyzed group, the incidence rate of anaphylaxis was the highest for women aged 19–60 years. Most common comorbidities in patients with moderate to severe anaphylaxis included: cardiovascular diseases, respiratory tract diseases, features of atopy, and thyroid diseases. More than 30% of drug-induced reactions were anaphylactic reactions due to the re-exposure to the same drug, which points to the need for educational initiatives in this area. The incidence rate of anaphylaxis induced by Hymenoptera stings was comparable in patients who had a previous generalized reaction and those who had good tolerance to the previous sting. It is important to take these cofactors into consideration when evaluating patients with anaphylaxis as they may play a role in future anaphylactic reactions.
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Affiliation(s)
- Iwona Poziomkowska-Gęsicka
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, 70-204 Szczecin, Poland;
- Correspondence:
| | - Magdalena Kostrzewska
- Department of Pulmonology, Allergology and Respiratory Oncology, University of Medical Sciences, 60-569 Poznan, Poland;
| | - Michał Kurek
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, 70-204 Szczecin, Poland;
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320
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Dispenza MC, Bochner BS, MacGlashan DW. Targeting the FcεRI Pathway as a Potential Strategy to Prevent Food-Induced Anaphylaxis. Front Immunol 2021; 11:614402. [PMID: 33391286 PMCID: PMC7773654 DOI: 10.3389/fimmu.2020.614402] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/16/2020] [Indexed: 12/25/2022] Open
Abstract
Despite attempts to halt it, the prevalence of food allergy is increasing, and there is an unmet need for strategies to prevent morbidity and mortality from food-induced allergic reactions. There are no known medications that can prevent anaphylaxis, but several novel therapies show promise for the prevention of food-induced anaphylaxis through targeting of the high-affinity IgE receptor (FcϵRI) pathway. This pathway includes multiple candidate targets, including tyrosine kinases and the receptor itself. Small molecule inhibitors of essential kinases have rapid onset of action and transient efficacy, which may be beneficial for short-term use for immunotherapy buildup or desensitizations. Short courses of FDA-approved inhibitors of Bruton’s tyrosine kinase can eliminate IgE-mediated basophil activation and reduce food skin test size in allergic adults, and prevent IgE-mediated anaphylaxis in humanized mice. In contrast, biologics may provide longer-lasting protection, albeit with slower onset. Omalizumab is an anti-IgE antibody that sequesters IgE, thereby reducing FcϵRI expression on mast cells and basophils. As a monotherapy, it can increase the clinical threshold dose of food allergen, and when used as an adjunct for food immunotherapy, it decreases severe reactions during buildup phase. Finally, lirentelimab, an anti-Siglec-8 antibody currently in clinical trials, can prevent IgE-mediated anaphylaxis in mice through mast cell inhibition. This review discusses these and other emerging therapies as potential strategies for preventing food-induced anaphylaxis. In contrast to other food allergy treatments which largely focus on individual allergens, blockade of the FcϵRI pathway has the advantage of preventing clinical reactivity from any food.
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Affiliation(s)
- Melanie C Dispenza
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Bruce S Bochner
- Department of Medicine, Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Donald W MacGlashan
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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321
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Choosing the Optimal Self-Injector Epinephrine. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-020-00276-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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322
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Kim MA, Lee YW, Kim SR, Kim JH, Min TK, Park HS, Shin M, Ye YM, Lee S, Lee J, Choi JH, Jang GC, Chang YS. COVID-19 Vaccine-associated Anaphylaxis and Allergic Reactions: Consensus Statements of the KAAACI Urticaria/Angioedema/Anaphylaxis Working Group. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:526-544. [PMID: 34212542 PMCID: PMC8255352 DOI: 10.4168/aair.2021.13.4.526] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/23/2022]
Abstract
In the era of novel coronavirus epidemics, vaccines against coronavirus disease 2019 (COVID-19) have been recognized as the most effective public health interventions to control the pandemic. An adverse event following immunization (AEFI) is defined as any untoward occurrence following immunization, and the majority of AEFIs are caused by protective immune responses stimulated by vaccines. Most of the reported AEFIs are not serious, and many are not immunologically mediated or even reproducible on re-exposure. However, uncommon severe allergic adverse reactions, such as anaphylaxis or other allergic reactions, can occur after vaccinations. Confirmed allergic reactions to vaccines may be caused by residual non-human protein, preservatives, or stabilizers in the vaccine formulation (also known as excipients). There are 2 main potential allergenic/immunogenic excipients in COVID-19 vaccines, polyethylene glycol (PEG) and polysorbate 80. PEG, also known as macrogol, is an ingredient in various laxatives and injectable formulations, such as depot steroids. Polysorbate 80 is present in various medical products, creams, ointments, lotions, and medication tablets. Contraindications to the administration of COVID-19 vaccines include a previous history of severe allergic reactions to the first dose of COVID-19 vaccine or proven hypersensitivity to a vaccine component, such as PEG or polysorbate 80. Anaphylaxis or other allergic reactions following immunization can cause fear and loss of confidence in the safety of vaccines among the public. A better understanding of these events is thought to help alleviate concerns about the current COVID-19 vaccines and provide reassurance to the general population by analyzing the exact incidence of anaphylaxis and potential risk factors. COVID-19 vaccine-associated anaphylaxis could be prevented and managed by risk stratification based on our local and global experience.
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Affiliation(s)
- Mi Ae Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Yong Won Lee
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - So Ri Kim
- Division of Respiratory Medicine and Allergy, Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School, Jeonju, Korea
| | - Joo Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Taek Ki Min
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Meeyong Shin
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Sooyoung Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jeongmin Lee
- Department of Pediatrics, Yonsei Wonju College of Medicine, Wonju, Korea
| | - Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea.,Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Yoon Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital,Seoul National University College of Medicine, Seongnam, Korea.
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323
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Tsuang A, Chan ES, Wang J. Food-Induced Anaphylaxis in Infants: Can New Evidence Assist with Implementation of Food Allergy Prevention and Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:57-69. [DOI: 10.1016/j.jaip.2020.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 01/06/2023]
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324
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Jones S, Bloom P. Rush immunotherapy in two cats with atopic skin syndrome. JFMS Open Rep 2021; 7:20551169211023327. [PMID: 34221441 PMCID: PMC8221683 DOI: 10.1177/20551169211023327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
CASE SERIES SUMMARY Two cats with feline atopic skin syndrome (FASS) were included in this case series. They were diagnosed with FASS by a combination of history, physical examination and exclusion of other pruritic diseases. They underwent rush immunotherapy (RIT) after determination of offending environmental allergens by either serum IgE or intradermal testing. Cats were premedicated with an antihistamine and hospitalized for the day to undergo the procedure and to ensure adequate observation. Allergen extracts were administered subcutaneously at increasing concentrations every 30 mins until the maintenance dose of 20,000 protein nitrogen units/ml was reached. Both cats successfully completed RIT without any adverse reactions and their clinical signs improved afterwards. RIT appears to be an alternative treatment option for cats with FASS. Larger studies are needed to more accurately assess the safety and long-term efficacy of RIT in the feline patient, as well as the incidence of adverse reactions and optimal premedication protocol. Further evaluation of the route of injections for RIT is also warranted. RELEVANCE AND NOVEL INFORMATION RIT has been reported to be a safe treatment option in canine atopic dermatitis. Its use in FASS is limited to a pilot study of four cats. The purpose of this series was to describe two additional cats that underwent RIT using a different premedication protocol.
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Affiliation(s)
- Selene Jones
- Selene Jones DVM, Allergy, Skin and Ear Clinic for Pets, 31205 Five Mile Road, Livonia, MI 48154, USA
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Mack DP, Soller L, Chan ES, Hanna MA, Terpstra C, Vander Leek TK, Bégin P. A High Proportion of Canadian Allergists Offer Oral Immunotherapy but Barriers Remain. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1902-1908. [PMID: 33359585 DOI: 10.1016/j.jaip.2020.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Limited data on clinical implementation of oral immunotherapy (OIT) have been reported with incomplete evaluation of barriers. OBJECTIVE To survey Canadian allergists on their current practice of OIT and barriers to implementation and expansion of OIT. METHODS A survey investigating current practice and logistical and clinical barriers to offering or expanding OIT was distributed to all Canadian Society of Allergy and Clinical Immunology allergists. RESULTS Of 90 responding allergists, 52.2% reported offering OIT, most commonly to peanut. Food sublingual immunotherapy was offered by 7% of allergists. Having received training for OIT was associated with currently performing OIT (P = .008); 44.7% of allergists offering OIT had received training on OIT, and 81.4% not offering OIT had no training. A total of 87% of allergists performing OIT reported lack of efficacy data and lack of support staff and clinic space, and concerns about increased oral challenges (84%) were "moderately" to "extremely" important barriers to expanding OIT. For clinicians not offering OIT, concerns about safety (95%), after-hours support (95%), efficacy (93%), medicolegal risk (93%), and long-term practice implications (93%) were prioritized as significant barriers. Qualitative assessment suggested concerns about the practical challenges associated with OIT, the need for increased safety and efficacy data, and a desire for OIT guidelines and training. CONCLUSION The implementation of OIT faces many barriers, both clinical and logistical. Increasing high-quality safety and efficacy data may support those hesitant to offer OIT, and improving funding may address the practical infrastructure challenges. In addition, training will help expand access for allergists interested in performing OIT.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
| | - Lianne Soller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Mariam A Hanna
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Collin Terpstra
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Philippe Bégin
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada
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326
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Healthcare provision for insect venom allergy patients during the COVID-19 pandemic. ACTA ACUST UNITED AC 2020; 29:257-261. [PMID: 33312843 PMCID: PMC7722411 DOI: 10.1007/s40629-020-00157-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022]
Abstract
The population prevalence of insect venom allergy ranges between 3–5%, and it can lead to potentially life-threatening allergic reactions. Patients who have experienced a systemic allergic reaction following an insect sting should be referred to an allergy specialist for diagnosis and treatment. Due to the widespread reduction in outpatient and inpatient care capacities in recent months as a result of the COVID-19 pandemic, the various allergy specialized centers in Germany, Austria, and Switzerland have taken different measures to ensure that patients with insect venom allergy will continue to receive optimal allergy care. A recent data analysis from the various centers revealed that there has been a major reduction in newly initiated insect venom immunotherapy (a 48.5% decline from March–June 2019 compared to March–June 2020: data from various centers in Germany, Austria, and Switzerland). The present article proposes defined organizational measures (e.g., telephone and video appointments, rearranging waiting areas and implementing hygiene measures and social distancing rules at stable patient numbers) and medical measures (collaboration with practice-based physicians with regard to primary diagnostics, rapid COVID-19 testing, continuing already-initiated insect venom immunotherapy in the outpatient setting by making use of the maximal permitted injection intervals, prompt initiation of insect venom immunotherapy during the summer season, and, where necessary, using outpatient regimens particularly out of season) for the care of insect venom allergy patients during the COVID-19 pandemic.
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327
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Russell AF, Kagan OS, Huber MM. Parent perspectives on food allergy management and safety during the COVID-19 pandemic. JOURNAL OF FOOD ALLERGY 2020; 2:142-151. [PMID: 39022319 PMCID: PMC11250524 DOI: 10.2500/jfa.2020.2.200033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Background U.S. national emergency was declared in mid-March 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. Subsequently, a period of stay-at-home orders, regulatory changes, evolving medical recommendations, and food supply chain disruptions occurred. There is little published research on how such changes affected food allergy management for children with this diagnosis. Objective The study goal was to identify parent perspectives with regard to if and/or how pandemic-related regulatory changes and evolving medical recommendations have affected food allergy management. Methods A survey was distributed to parents of children with food allergy. An electronic Internet forms survey link was available for completion during July 2020. Data were presented as descriptive statistics, cleaned, and coded into a spreadsheet before analysis. Frequencies and percentage were calculated to describe participants' characteristics and responses. Results Of 377 responses, 359 met inclusion criteria. Concerns about COVID-19 exposure were expressed in 65.7% about accessing an emergency department and 73.6% had school reentry concerns; 66% had not discussed recommended anaphylaxis management algorithm changes with a provider; 85.8% had not discussed the temporary U.S. Food and Drug Administration food labeling policy with a provider. Most (62%) reported shortages of preferred safe food brands. 62% spent more time cooking safe foods from scratch. With regard to the recommendation by the U.S. Centers for Disease Control and Prevention (CDC) for classroom dining, 57.7% planned to request modifications. With regard to the CDC's recommendation to use inhalers versus nebulizers, 37.7% had not discussed the topic with a provider. Ninety-two written comments were analyzed and grouped into seven themes. Conclusion New pandemic-related regulations, food supply chain disruptions, and evolving medical recommendations resulted in intensified burdens for respondents, including the increased time needed to complete food allergy management and school reentry concerns. Study results can inform clinical team members (e.g., physicians, nurses, dieticians) of effects that pandemic-related changes may have on this patient population, with subsequent consideration of patient-specific screening, education, and shared decision-making with regard to risk mitigation needs.
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Affiliation(s)
- Anne F. Russell
- From the School of Nursing, Spring Arbor University, Spring Arbor, Michigan
- Food Allergy and Anaphylaxis Michigan Association, Ann Arbor, Michigan
| | - Olga S. Kagan
- Division of Nursing, Molloy College, Rockville Center, New York, and
| | - Mary M. Huber
- Food Allergy and Anaphylaxis Michigan Association, Ann Arbor, Michigan
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328
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Roberts G, Almqvist C, Boyle R, Crane J, Hogan SP, Marsland B, Saglani S, Woodfolk JA. Developments allergy in 2019 through the eyes of Clinical and Experimental Allergy, Part II clinical allergy. Clin Exp Allergy 2020; 50:1302-1312. [PMID: 33283366 DOI: 10.1111/cea.13778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In the second of two linked articles, we describe the development in clinical as described by Clinical & Experimental Allergy and other journals in 2019. Epidemiology, clinical allergy, asthma and rhinitis are all covered. In this article, we described the development in the field of allergy as described by Clinical and Experimental Allergy in 2019. Epidemiology, clinical allergy, asthma and rhinitis are all covered.
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Affiliation(s)
- Graham Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
| | - C Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - R Boyle
- Department of Paediatrics, Imperial College London, London, UK
| | - J Crane
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - S P Hogan
- Department of Pathology, Michigan Medicine, Mary H Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, USA
| | - B Marsland
- Department of Immunology and Pathology, Monash University, Melbourne, Vic, Australia
| | - S Saglani
- National Heart & Lung Institute, Imperial College London, London, UK
| | - J A Woodfolk
- Division of Asthma, Allergy and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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329
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An update on international practice variation in peanut introduction: conundrums, controversies, and a new direction. Curr Opin Pediatr 2020; 32:825-831. [PMID: 33060444 DOI: 10.1097/mop.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Introduction of peanut during the first year of life is associated with an 81% relative risk reduction of developing peanut allergy in infants with severe eczema, egg allergy, or both. However, significant international variation exists in risk stratification prior to peanut introduction. RECENT FINDINGS A policy-level screening approach, such as the one in the United States, is not practical and is associated with higher costs and more cases of peanut allergy over time, in contrast to international models that recommend universal early introduction without prescreening. In Australia, population-level efforts to introduce peanut early without screening have demonstrated high rates of peanut introduction before 12 months of age and low rates of severe allergic reactions. In contrast, screening prior to peanut introduction in the United States is associated with 'screening creep' - the tendency of clinicians to test populations where screening is not recommended. SUMMARY Early peanut introduction can reduce the risk of developing food allergy and is more effective without a risk-based screening approach. In some circumstances, shared clinical decision-making can facilitate food allergy prevention in a manner consistent with family values and preferences.
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330
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Lieberman JA, Camargo CA, Pistiner M, Wang J. Pediatrician perspectives on symptom presentation and treatment of acute allergic reactions. Ann Allergy Asthma Immunol 2020; 126:273-277. [PMID: 33232828 DOI: 10.1016/j.anai.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anaphylaxis remains difficult to diagnose and epinephrine underused. OBJECTIVE To better understand the thoughts of pediatricians regarding when acute allergic reactions constitute anaphylaxis and when epinephrine should be given by conducting an anonymous online survey. METHODS The survey consisted of 8 case-based scenarios of allergic reactions with the following 2 questions on each case: (1) does this case represent anaphylaxis? and (2) if this patient immediately presented to you, would you treat the patient with epinephrine during the reaction? RESULTS A total of 1001 responses were analyzed. When assessing all cases combined, there was discordance in whether a case represented anaphylaxis and administration of epinephrine was warranted in 8% of the cases. An average of 5% of all the respondents suggested that the case represented anaphylaxis but would not warrant epinephrine, whereas an average of 3% suggested that the case did not represent anaphylaxis but that epinephrine was warranted. CONCLUSION The results of this survey reveal that there is discordance among pediatricians on when an allergic reaction is considered anaphylaxis and when epinephrine is warranted. These data highlight the need for continued improvement of the definition of anaphylaxis and continued need for education regarding the diagnosis and management of anaphylaxis.
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Affiliation(s)
- Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee; Division of Pulmonology, Allergy, and Immunology, Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Pistiner
- Division of Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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331
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Pistiner M, Mendez-Reyes JE, Eftekhari S, Carver M, Lieberman J, Wang J, Camargo CA. Caregiver-Reported Presentation of Severe Food-Induced Allergic Reactions in Infants and Toddlers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:311-320.e2. [PMID: 33217612 DOI: 10.1016/j.jaip.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recognizing anaphylaxis in infants and toddlers can be challenging for health care providers and caregivers, and current diagnostic criteria and anaphylaxis action plans do not specifically address this younger population. OBJECTIVE To describe symptoms and signs observed by primary caregivers of infants and toddlers during severe food-induced allergic reactions. METHODS We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when less than 36 months of age. Respondents who were present during the child's most severe reaction were asked to report symptoms and signs observed. The survey asked about infant- and toddler-specific symptoms and signs in lay language for caregivers. Data were compared with patient-reported data from past studies to identify distinct patterns among the younger population. RESULTS The survey was completed for 374 children (193 infants, 181 toddlers). The most common symptoms and signs reported were skin reactions (90%), facial and extremity swelling (59%), gastrointestinal issues (51%), and coughing/wheezing (45%). Infants (aged <12 months) more frequently experienced skin reactions, skin mottling, and ear pulling/scratching or putting fingers in ears, as compared with toddlers (aged 12-35 months). Toddlers experienced throat itching and coughing/wheezing more frequently than infants. CONCLUSIONS Anaphylaxis presentation demonstrates similarities and differences in infants and toddlers. Modifying the terminology used in the current criteria allowed for reporting of symptoms and signs of anaphylaxis that are more common in infants and toddlers. Diagnostic criteria, clinical guidelines, and anaphylaxis action plans may be enhanced to address this young, often nonverbal, population.
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Affiliation(s)
- Michael Pistiner
- Mass General Hospital for Children, Harvard Medical School, Boston, Mass.
| | | | | | | | - Jay Lieberman
- The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tenn
| | - Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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332
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Pimentel-Hayashi JA, Navarrete-Rodriguez EM, Moreno-Laflor OI, Del Rio-Navarro BE. Physicians' knowledge regarding epinephrine underuse in anaphylaxis. Asia Pac Allergy 2020; 10:e40. [PMID: 33178565 PMCID: PMC7610080 DOI: 10.5415/apallergy.2020.10.e40] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Anaphylaxis is a life-threating hypersensitivity reaction. Epinephrine underuse in patients with anaphylaxis could lead to poor outcomes. There is evidence that the epinephrine use in such patients could be as low as 8%. OBJECTIVE To assess the percentage of physicians who know that epinephrine is the first-line treatment in anaphylaxis. The secondary objective was to assess knowledge gaps regarding anaphylaxis diagnosis and treatment that could lead to epinephrine underuse. METHODS We performed an online survey for physicians in Mexico City, using a 10-item questionnaire assessing anaphylaxis knowledge. We obtained measures of central tendency for statistical analysis, such as frequency, 95% confidence interval, as well as the chi-square test for comparing the groups. RESULTS A total of 196 surveys were considered for analysis. Of all the participants, 96.44% were able to correctly diagnose an anaphylaxis case with cutaneous, respiratory, and cardiovascular symptoms. Fifty-two percent correctly diagnosed anaphylaxis without cutaneous symptoms. The 72.4% of the respondents chose epinephrine as the first-line treatment, 42.3% correctly answered that there is no absolute contraindication to giving epinephrine, and 20.9% ignored whether there was any contraindication for its use. Only 38.3% of participants answered that during discharge they would prescribe an autoinjector. Regarding the administration route, 63.4% answered that the first dose of epinephrine is applied intramuscularly and 50% of the participants chose the correct dose of epinephrine. Only 2.6% of the participants answered all 10 questions correctly. CONCLUSION There is still some difficulty recognizing anaphylaxis without cutaneous symptoms. Even though two-thirds of physicians identified that epinephrine is the treatment of choice, only 49.5% would have used intramuscular epinephrine as first-line treatment. We found a low percentage of epinephrine ampule prescription and knowledge of the correct dose. These findings can account for epinephrine underuse when dealing with anaphylaxis in the real clinical practice.
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Affiliation(s)
- Joaquin A Pimentel-Hayashi
- Department of Allergy and Immunology, WAO Center of Excellence, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Elsy M Navarrete-Rodriguez
- Department of Allergy and Immunology, WAO Center of Excellence, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Oscar I Moreno-Laflor
- Department of Allergy and Immunology, WAO Center of Excellence, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Blanca E Del Rio-Navarro
- Department of Allergy and Immunology, WAO Center of Excellence, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
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333
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Jeimy S, Ben-Shoshan M, Abrams EM, Ellis AK, Connors L, Wong T. Practical guide for evaluation and management of beta-lactam allergy: position statement from the Canadian Society of Allergy and Clinical Immunology. Allergy Asthma Clin Immunol 2020; 16:95. [PMID: 33292466 PMCID: PMC7653726 DOI: 10.1186/s13223-020-00494-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/26/2020] [Indexed: 01/09/2023] Open
Abstract
The vast majority of individuals labelled as allergic are not deemed truly allergic upon appropriate assessment by an allergist. A label of beta-lactam allergy carries important risks for individual and public health. This article provides an overview of beta-lactam allergy, implications of erroneous beta-lactam allergy labels and the impact that can be provided by structured allergy assessment. We provide recommendations on how to stratify risk of beta-lactam allergy, beta lactam challenge protocols as well as management of patients at high risk of beta-lactam allergy.
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Affiliation(s)
- Samira Jeimy
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON, N6A4V2, Canada.
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Lori Connors
- Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Tiffany Wong
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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334
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Wachnian CJ, Baadjes B, Cheng S, Ramanzin A, Hildebrand KJ. Anaphylaxis to parenteral nutrition in a pediatric oncology patient treated with induction of drug tolerance protocol. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:553-554. [PMID: 33096267 DOI: 10.1016/j.jaip.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/28/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Cielle J Wachnian
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Bjorn Baadjes
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada; Division of Pediatric Hematology/Oncology/BMT, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sylvia Cheng
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada; Division of Pediatric Hematology/Oncology/BMT, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alyssa Ramanzin
- Nutrition Services, BC Children's Hospital, Vancouver, BC, Canada
| | - Kyla J Hildebrand
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada; BC Children's Hospital Research Institute, Vancouver, BC, Canada
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335
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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336
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A rapid review of advanced life support guidelines for cardiac arrest associated with anaphylaxis. Resuscitation 2020; 159:137-149. [PMID: 33068641 DOI: 10.1016/j.resuscitation.2020.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND We conducted a rapid review of current international and Australian advanced life support (ALS) guidelines for cardiac arrest associated with anaphylaxis to (1) assess the variation and (2) determine if a systematic review update of ALS guideline recommendations is warranted. METHOD A search and comparison of key recommendations was conducted for major international and Australian clinical guidelines, including member societies and councils of the World Allergy Organisation and the International Liaison Committee on Resuscitation (ILCOR). Systematic database searches (Medline, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of anaphylaxis and cardiac arrest. RESULTS Eight international guidelines were identified from Australia/New Zealand, Europe, United States and Canada, and 5 national guidelines were identified for Australia. There was general consensus across all guidelines for the use of adrenaline, oxygen, patient positioning and glucagon. There was variation across international and Australian guidelines for adrenaline dosing and frequency, antihistamines and corticosteroid recommendations. Most recommendations were based on low-level evidence, and the review of published systematic reviews and clinical trials identified new evidence in the last decade. CONCLUSIONS We found significant variation between current ALS guideline recommendations for treating anaphylaxis. While there is no new evidence to suggest a systematic review of guideline recommendations is needed, there may be an opportunity to produce more consistent international guideline recommendations and educational materials.
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337
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A Proposal from the Montpellier World Health Organization Collaborating Centre for Better Management and Prevention of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:676-683.e1. [PMID: 33059097 DOI: 10.1016/j.jaip.2020.09.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/23/2022]
Abstract
Since the first description of anaphylaxis in 1902, its clinical importance as an emergency condition has been recognized worldwide. Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction characterized by rapid onset and the potential to endanger life through respiratory or circulatory compromise. It is usually, although not always, associated with skin and mucosal changes. Although the academic/scientific communities have advocated to promote greater awareness and protocols for the management of anaphylaxis based on best evidence, there are few efforts documenting feedback as to the success of these efforts. In this article, we review the key unmet needs related to the diagnosis and management of anaphylaxis, and propose a public health initiative for prevention measures and a timetable action plan that intends to strengthen the collaboration among health professionals and especially primary care physicians dealing with anaphylaxis, which can encourage enhanced quality of care of patients with anaphylaxis. More than calling for a harmonized action for the best management of anaphylaxis to prevent undue morbidity and mortality, the Montpellier World Health Organization Collaborating Centre here proposes an action plan as a baseline for a global initiative against anaphylaxis. We strongly believe that these collaborative efforts are a strong public health and societal priority that is consistent with the overarching goals of providing optimal care of allergic patients and best practices of allergology.
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338
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Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, Senna G, Sheikh A, Tanno LK, Thong BY, Turner PJ, Worm M. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J 2020; 13:100472. [PMID: 33204386 PMCID: PMC7607509 DOI: 10.1016/j.waojou.2020.100472] [Citation(s) in RCA: 399] [Impact Index Per Article: 99.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022] Open
Abstract
Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.
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Affiliation(s)
- Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d’Hebron, and ARADyAL research network, Barcelona, Spain
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Yehia El-Gamal
- Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt
| | | | - Stanley Fineman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Mario Geller
- Division of Medicine, Academy of Medicine of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Paul A. Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mario Sanchez Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad and Clinica El Ávila, Caracas, Venezuela
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Aziz Sheikh
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Luciana Kase Tanno
- Hospital Sírio Libanês, Brazil andUniversity Hospital of Montpellier, São Paulo, Montpellier, and Sorbonne Université, INSERM Paris, France, and WHO Collaborating Centre on Scientific Classification Support Montpellier, and WHO ICD-11 Medical and Scientific Advisory Committee Geneva, Switzerland
| | - Bernard Y. Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Paul J. Turner
- National Heart Lung Institute, Imperial College London and Discipline of Paediatrics and Child Health, School of Medicine, University of Sydney, Sydney, Australia
| | - Margitta Worm
- Department of Dermatology and Allergology, Charite-Universitätsmedizin, Berlin, Germany
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339
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Trivedi A, Katelaris C. Presentation, diagnosis, and the role of subcutaneous and sublingual immunotherapy in the management of ocular allergy. Clin Exp Optom 2020; 104:334-349. [PMID: 32944983 DOI: 10.1111/cxo.13129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Allergic eye disease or ocular allergy is a debilitating condition with a significant impact on quality of life and productivity. As atopy continues to be on the rise, primary care providers are likely to encounter increasing numbers of patients with allergic eye disease. This review outlines the classification and pathophysiology of allergic eye disease and its clinical presentation. This paper does not detail traditional first-line therapies of allergic eye disease but describes the interdisciplinary management between the eye-care provider and allergist. It is recommended that patients with ongoing signs and symptoms of ocular allergy despite first-line therapies be referred for allergen immunotherapy, as it is highly effective for treatment of allergic eye disease. Through induction of immune tolerance, allergen immunotherapy is a disease-modifying therapy that can result in long-term improvement of ocular allergy. A thorough literature review was conducted on the efficacy and safety of allergen immunotherapy, including subcutaneous immunotherapy and sublingual immunotherapy, and its role in allergic eye disease.
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Affiliation(s)
- Amruta Trivedi
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
| | - Constance Katelaris
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
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340
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Protudjer JLP, Golding M, Salisbury MR, Abrams EM, Roos LE. High anxiety and health-related quality of life in families with children with food allergy during coronavirus disease 2019. Ann Allergy Asthma Immunol 2020; 126:83-88.e1. [PMID: 32950685 PMCID: PMC7498414 DOI: 10.1016/j.anai.2020.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/18/2020] [Accepted: 09/11/2020] [Indexed: 11/18/2022]
Abstract
Background Food allergy has a known effect on quality of life (QoL), but this has not been extensively studied during the coronavirus disease 2019 pandemic. Objective To characterize the levels of anxiety of mothers of children aged 0 to 8 years with food allergy compared with families of children without a food allergy and the health-related QoL among children with food allergy during the coronavirus disease 2019 pandemic. Methods In a mixed-methods study, Canadian mothers of children aged 0 to 8 years with (cases) and without (controls) food allergy provided demographic data and completed age-appropriate anxiety questionnaires between April 14, 2020, and April 28, 2020. The cases also provided food allergy-related data and completed the Food Allergy Quality of Life Questionnaire. In-depth interviews were subsequently conducted with purposefully selected cases. Results In a total of 580 participants, 5.5% were cases and 94.5% were controls. For mothers of children aged 0 to 1.5 years, anxiety levels did not differ between cases and controls. For mothers of children aged 1.5 to 8 years, anxiety levels were higher in cases vs controls (P < .05). Among the cases, neither overall nor domain-specific Food Allergy Quality of Life Questionnaire scores differed between age groups (0-3 vs 4-7 years), even after adjustment for confounding variables, including childcare during the pandemic. Qualitatively, the following 3 themes were identified: unexpected challenges of food shopping; less food-related food anxiety during the pandemic; and differences and delays in food allergy testing and therapy. Conclusion Mothers of children with food allergy reported high anxiety and poor health-related QoL. Yet, qualitatively, day-to-day food allergy management was better during the pandemic.
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Affiliation(s)
- Jennifer L P Protudjer
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; The Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; The Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.
| | - Michael Golding
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; The Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Marlee R Salisbury
- Division of Allergy & Immunology, Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; The Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Division of Allergy & Immunology, Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Leslie E Roos
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; The Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
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341
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Glassberg B, Nowak-Wegrzyn A, Wang J. Factors contributing to underuse of epinephrine autoinjectors in pediatric patients with food allergy. Ann Allergy Asthma Immunol 2020; 126:175-179.e3. [PMID: 32950683 PMCID: PMC7498408 DOI: 10.1016/j.anai.2020.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/21/2020] [Accepted: 09/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Epinephrine autoinjectors (EAs) are the standard of care for severe food allergic reactions, although they are frequently underused or misused. OBJECTIVE To understand the factors associated with underuse of EA by caregivers of pediatric patients with food allergy. METHODS A survey was administered to 200 caregivers of pediatric patients with food allergies to assess most severe lifetime allergic reaction, EA education, and use and factors associated with incorrect use or underutilization. RESULTS A total of 164 surveys were completed; of which 118 (72%) of lifetime most severe reactions warranted EA use, but the EA was used in only 45 (38.1%). Reasons caregivers indicated for not administering the EA included the following: reactions did not seem severe enough; it was the patient's first allergic reaction; use of other medication; and fear of using EA. CONCLUSION Multiple factors contribute to underuse of EA in the treatment of severe allergic reactions. Results from this study highlight the need for continuous EA education in caregivers of and pediatric patients with food allergies, using a multipronged approach targeting clear symptom recognition and alleviation of fear of EA use.
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Affiliation(s)
- Brittany Glassberg
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, New York University Langone Health, New York, New York; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Julie Wang
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, New York
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342
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Characteristics of Anaphylactic Reactions: A Prospective Observational Study in Japan. J Emerg Med 2020; 59:812-819. [PMID: 32917450 DOI: 10.1016/j.jemermed.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/25/2020] [Accepted: 07/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anaphylaxis is a systemic, life-threating, allergic reaction in which the clinical features may vary in different populations or due to the allergic triggers. Moreover, the timing and characteristics of biphasic anaphylactic reactions remain unclear. OBJECTIVES The purpose of this study was to investigate the clinical characteristics of anaphylaxis cases assessed and treated in Japanese hospitals. METHODS This was a prospective observational study of anaphylactic reactions treated in the Emergency Department (ED) of two medical centers from June 2016 to May 2019. All patients diagnosed with anaphylaxis were enrolled in this study. Data collected included patient demographics, symptoms and signs, treatment, clinical course, and suspected triggers. Descriptive statistics and univariate methods were used in the analyses. RESULTS We enrolled 302 patients. The median age was 32 years (interquartile range 13-37) and the sample included 182 (60.3%) women. Of the 302 patients, 179 (59.3%) had a history of allergic reactions. The dermatologic, respiratory, gastrointestinal, and cardiac systems were involved in 297 (98.3%), 248 (82.1%), 150 (49.7%), and 55 (18.2%), respectively. Nineteen patients (6.3%) experienced biphasic anaphylactic reactions. Epinephrine use was associated with a lower incidence of biphasic anaphylactic reaction (odds ratio 0.3, 95% confidence interval 0.1-0.9). Time to recurrence of symptoms ranged from 2 to 48 h (median: 10 h). CONCLUSIONS In this prospective ED study, foods were the most common triggers of anaphylaxis, and epinephrine administration was associated with a decreased occurrence of biphasic anaphylactic reactions. Over half of patients experiencing biphasic anaphylactic reactions developed symptoms more than 10 h after presentation.
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343
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Abstract
Anaphylaxis is a serious allergic reaction that is rapid in onset and may be life threatening. An informal review of the literature was performed in a nonsystematic way for this article. Key published work was identified and included. The incidence and prevalence of anaphylaxis have increased over time. Anaphylaxis is unpredictable and can be the result of various allergic triggers, including food, insect venom, and medication. In children, the most frequent trigger is food. The diagnosis is based on clinical criteria. After confirmation of the relevant allergen trigger, prevention occurs through strict avoidance of the allergen and optimal management of existing comorbidities. Patients with anaphylaxis require immediate assessment and treatment. The management of a patient with anaphylaxis should start with the removal of exposure to the known or suspected trigger, followed by the assessment of the patient's circulation, airway patency, breathing, and mental status. The administration of epinephrine at a dose of 0.01 mg/kg (1:1000) intramuscularly is the first-line treatment for anaphylaxis, and there are no absolute contraindications to this treatment. The maximum single dose of epinephrine is 0.5 mg and may be repeated after 5-10 minutes if needed. After administration of epinephrine, patients with anaphylaxis should be placed supine with their lower limbs elevated. They should not be placed in the upright position. Studies of fatal and near-fatal allergic reactions identified potential risk factors for fatalities such as asthma, peanuts and/or tree nuts, and delayed epinephrine use, and provided important information that may help minimize the future risk. Patients and their families need to be well educated on how to manage potential anaphylactic reactions with training in the use of epinephrine autoinjectors and personalized emergency management plans. Health care professionals must be familiar with this clinical emergency and able to respond to anaphylaxis in a timely and appropriate manner.
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Affiliation(s)
- Melissa Hearrell
- From the Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Houston, Texas, and
- Section of Pediatric Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Texas
| | - Aikaterini Anagnostou
- From the Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Houston, Texas, and
- Section of Pediatric Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Texas
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344
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Flores S. Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department. Am J Emerg Med 2020; 38:1987.e1-1987.e3. [PMID: 32456834 DOI: 10.1016/j.ajem.2020.05.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022] Open
Abstract
The emergency department (ED) is responsible for managing a variety of acute illnesses including undifferentiated shock. A newer less recognized syndrome termed BRASH - bradycardia, renal failure, AV-node blockers, shock and hyperkalemia - is a cycle of synergy between hyperkalemia and AV-blockade that can result in shock. This entity is more common amongst the elderly, considering polypharmacy and co-morbid diseases. Some cases have an inciting trigger of hypovolemia. Anaphylaxis is a potentially lethal form of shock that most emergency physicians (EP) treat in the ED. The two entities have never occurred simultaneously. Herein, we report a case of anaphylaxis induced BRASH syndrome occurring in an elderly diabetic man. The EP should be aware of this unique presentation of BRASH. It was concluded that the patient's anaphylaxis, caused hypovolemia, coupled with polypharmacy, and physiological stress, precipitated this severe form of shock and multi-organ system failure.
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Affiliation(s)
- Stefan Flores
- Department of Emergency Medicine, Columbia University, 622 West, 168th Street VC-260, New York, NY 10032, United States of America.
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345
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Anaphylaxis induced by inhaling guinea pig allergen. Chin Med J (Engl) 2020; 134:239-240. [PMID: 32842010 PMCID: PMC7817293 DOI: 10.1097/cm9.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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346
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Dribin TE, Sampson HA, Camargo CA, Brousseau DC, Spergel JM, Neuman MI, Shaker M, Campbell RL, Michelson KA, Rudders SA, Assa'ad AH, Risma KA, Castells M, Schneider LC, Wang J, Lee J, Mistry RD, Vyles D, Vaughn LM, Schumacher DJ, Witry JK, Viswanathan S, Page EM, Schnadower D. Persistent, refractory, and biphasic anaphylaxis: A multidisciplinary Delphi study. J Allergy Clin Immunol 2020; 146:1089-1096. [PMID: 32853640 DOI: 10.1016/j.jaci.2020.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/17/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of inconsistent definitions for anaphylaxis outcomes limits our understanding of the natural history and epidemiology of anaphylaxis, hindering clinical practice and research efforts. OBJECTIVE Our aim was to develop consensus definitions for clinically relevant anaphylaxis outcomes by utilizing a multidisciplinary group of clinical and research experts in anaphylaxis. METHODS Using Delphi methodology, we developed agenda topics and drafted questions to review during monthly conference calls. Through online surveys, a 19-member panel consisting of experts in allergy and/or immunology and emergency medicine rated their level of agreement with the appropriateness of statements on a scale of 1 to 9. A median value of 1.0 to 3.4 was considered inappropriate, a median value of 3.5 to 6.9 was considered uncertain, and a median value of 7.0 to 9.0 was considered appropriate. A disagreement index was then calculated, with values less than 1.0 categorized as "consensus reached." If consensus was not reached after the initial survey, subsequent surveys incorporating the aggregate de-identified responses from prior surveys were sent to panel members. This process was repeated until consensus was reached or 4 survey rounds had been completed, after which the question was categorized as "no consensus reached." RESULTS The panel developed outcome definitions for persistent, refractory, and biphasic anaphylaxis, as well as for persistent and biphasic nonanaphylactic reactions. There was also consensus among panel members regarding the need to develop an anaphylaxis severity grading system. CONCLUSION Dissemination and application of these definitions in clinical care and research will help standardize the terminology used to describe anaphylaxis outcomes and serve as the foundation for future research, including research aimed at development of an anaphylaxis severity grading system.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Hugh A Sampson
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David C Brousseau
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Marcus Shaker
- Dartmouth Geisel School of Medicine, Hanover, NH; Dartmouth-Hitchcock Medical Center, Hanover, NH
| | | | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Susan A Rudders
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Amal H Assa'ad
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Risma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mariana Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lynda C Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Julie Wang
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York
| | - Juhee Lee
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colo
| | - David Vyles
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Lisa M Vaughn
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daniel J Schumacher
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John K Witry
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shiv Viswanathan
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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347
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Anaphylactic shock following the diagnosis of coronavirus disease 2019. Ann Allergy Asthma Immunol 2020; 125:477-478. [PMID: 32745608 PMCID: PMC7395240 DOI: 10.1016/j.anai.2020.07.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 12/26/2022]
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348
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Kaito D, Homma K, Sasaki J. Rapid collapse of the inferior vena cava in a patient with cardiac arrest induced by anaphylactic shock after iodinated contrast medium injection. J Am Coll Emerg Physicians Open 2020; 1:379-382. [PMID: 33000060 PMCID: PMC7493500 DOI: 10.1002/emp2.12166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/11/2020] [Accepted: 06/02/2020] [Indexed: 11/09/2022] Open
Abstract
Anaphylactic shock to contrast media can progress to cardiac arrest despite appropriate treatment. During anaphylactic shock to contrast media, rapid vasodilation and a massive fluid shift can occur. Here we report a patient who developed cardiac arrest induced by anaphylactic shock to iodinated contrast medium and exhibited rapid collapse of the inferior vena cava (IVC) on enhanced abdominal computed tomography (CT) images. The patient underwent postsurgical unenhanced and contrast-enhanced abdominal CT follow-up of cecum cancer. She had neither allergy nor medical history except for the cancer. She did not complain of any symptoms immediately after completion of the CT. However, she developed anaphylactic shock and pulseless electrical activity cardiac arrest only 2 minutes after finishing the CT despite appropriate treatment. Emergency physicians successfully treated the patient using advanced life support and targeted temperature management. She recovered with good overall and cerebral performance (Overall Performance Category (OPC) 1 and Cerebral Performance Category (CPC) 1). On the contrast-enhanced CT images, she exhibited rapid collapse of the IVC, although it was normal on the unenhanced CT images. The collapsed IVC is a good indicator of hypovolemia in patients with trauma. In this case, we considered that rapid vasodilation and a massive volume shift might have caused the collapsed IVC. This finding suggests the importance of aggressive volume resuscitation as well as epinephrine injection in patients with anaphylactic shock to contrast media. Furthermore, this finding occurred before the onset of clinical symptoms, and there is a possibility that it could be used as an indicator of anaphylactic shock to contrast media.
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Affiliation(s)
- Daiki Kaito
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Koichiro Homma
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Junichi Sasaki
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
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349
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Constantino K, Pawlukiewicz AJ, Spear L. A Case Report on Rhabdomyolysis After Multiple Bee Stings. Cureus 2020; 12:e9501. [PMID: 32879823 PMCID: PMC7458714 DOI: 10.7759/cureus.9501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Envenoming syndrome is an uncommon condition associated with significant morbidity and mortality following multiple Hymenoptera stings. We review the case of a 90-year-old male who presented after receiving greater than 100 bee stings and was found to have rhabdomyolysis with concomitant acute kidney injury. Physicians should consider envenoming syndrome in all patients presenting with greater than 50 bee stings, despite hemodynamically stability upon initial presentation.
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350
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Self-injectable epinephrine: doctors' attitude and patients' adherence in real-life. Curr Opin Allergy Clin Immunol 2020; 20:474-481. [PMID: 32657793 DOI: 10.1097/aci.0000000000000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues. RECENT FINDINGS This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices. SUMMARY Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.
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