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Hlady AL, Weinman AF, Zhang Y, Mullan AF, Campbell RL. Outcomes associated with prehospital epinephrine in adult and pediatric patients with anaphylaxis. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00498-8. [PMID: 39154908 DOI: 10.1016/j.anai.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/13/2024] [Accepted: 08/06/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Prompt epinephrine administration is important to improve outcomes in anaphylaxis. OBJECTIVE To assess the impact of prehospital epinephrine on clinical outcomes of hospital admission, biphasic reactions, and emergency department (ED) length of stay (LOS) in a cohort of ED patients who had anaphylaxis including both children and adults. METHODS We conducted a single-center prospective and retrospective cohort study of patients who had anaphylaxis from April 2008 to December 2022. Associations between prehospital epinephrine administration with biphasic reactions and ED LOS were assessed with univariable models and the association with ED disposition was assessed with both univariable and multivariable logistic regression. RESULTS A total of 1107 patient visits were included for analysis. The median patient age was 29 (IQR: 14-50), 593 (53.6%) patients were of female sex, and 366 (33.1%) were younger than 18 years of age. Patients in the prehospital epinephrine group were also less likely to experience a biphasic reaction (5.4% vs 9.3%; odds ratio [OR] 0.56, 95% CI: 0.34-0.92) and had a decreased ED LOS (median 4.0 hours vs 4.7 hours). There was no difference in hospital admission between patients with and without prehospital epinephrine in both the univariable (19.5% vs 15.7%; OR 1.30, 95% CI: 0.94-1.79) and multivariable (adjusted OR 1.08, 95% CI: 0.71-1.64) models. CONCLUSION Prehospital epinephrine administration reduced the odds of a biphasic reaction and decreased ED LOS but did not reduce hospitalization in this cohort of ED patients who had anaphylaxis. Our findings suggest that timely administration of prehospital epinephrine is associated with improved patient outcomes.
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Affiliation(s)
- Andrea L Hlady
- Department of Emergency Medicine, Mayo Clinic Health System, Austin and Albert Lea, Minnesota
| | - Aliza F Weinman
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yuedan Zhang
- Department of Emergency, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.
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Disparities in the Diagnosis and Management of Anaphylaxis. Curr Allergy Asthma Rep 2023; 23:13-19. [PMID: 36454450 DOI: 10.1007/s11882-022-01053-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to characterize health disparities impacting the recognition and treatment of anaphylaxis. RECENT FINDINGS Previous research has identified major health disparities related to atopic conditions including asthma, atopic dermatitis, and food allergies (FA); however, disparities related to anaphylaxis have yet to be examined in depth. We found widespread health disparities in the incidence and severity of anaphylaxis, as well as in the management of allergies (particularly food allergies) that place individuals at risk of anaphylaxis. Sociodemographic factors are associated with numerous negative health outcomes related to anaphylaxis. We highlight several key steps that must be taken to address these disparities.
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Jan L, Naig A. Food allergen labeling of commonly used ingredients in Chinese restaurants in the United States. Food Control 2021. [DOI: 10.1016/j.foodcont.2021.108381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Miles LM, Ratnarajah K, Gabrielli S, Abrams EM, Protudjer JLP, Bégin P, Chan ES, Upton J, Waserman S, Watson W, Gerdts J, Ben-Shoshan M. Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2321-2333. [PMID: 33549844 DOI: 10.1016/j.jaip.2021.01.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines. OBJECTIVES A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis. METHODS Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis. RESULTS Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine. CONCLUSION The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.
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Affiliation(s)
- Laura May Miles
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.
| | - Kayadri Ratnarajah
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
| | - Sofianne Gabrielli
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Jennifer L P Protudjer
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Philippe Bégin
- Division of Clinical Immunology and Allergy, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, ON, Canada
| | - Wade Watson
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, NS, Canada
| | - Jennifer Gerdts
- Executive Director, Food Allergy Canada, Toronto, ON, Canada
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
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Dribin TE, Michelson KA, Zhang Y, Schnadower D, Neuman MI. Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study. J Pediatr 2020; 220:159-164.e2. [PMID: 31987654 DOI: 10.1016/j.jpeds.2019.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/04/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess whether a history of asthma was associated with anaphylaxis severity in children hospitalized for anaphylaxis. STUDY DESIGN Retrospective cohort study of children ≤21 years old hospitalized for anaphylaxis from 2009 to 2016. The primary outcome was severe anaphylactic reactions defined by examination findings (stridor, respiratory distress, or hypotension) or administered therapies (≥2 dose of intramuscular epinephrine, continuous albuterol, vasopressors, or positive pressure ventilation). Multivariable analyses were used to assess whether a history of asthma was associated with severe anaphylactic reactions, adjusting for patient age, allergen, and history of atopic dermatitis or anaphylaxis. RESULTS Among 603 children hospitalized for anaphylaxis, 231 (38.3%) had a history of asthma. Children with a history of asthma were older (median age, 6.6 years [IQR, 3.6-12.1] vs 4.0 years [IQR, 1.6-9.3]), more likely to have a history of anaphylaxis (38.1% vs 18.0%), and have food as the inciting allergen (68.0% vs 52.2%). Children with a history of asthma were not more likely to have severe anaphylactic reactions (OR, 0.97; 95% CI, 0.67-1.39). CONCLUSIONS Children hospitalized for anaphylaxis with a history of asthma were not more likely to have severe anaphylactic reactions compared with children without asthma. This study supports managing children with anaphylaxis based on the severity of symptomatology, and, if validated, clinicians should not consider asthma comorbidity as a stand-alone criterion for hospitalization.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Li M, Lu ZK, Amrol DJ, Mann JR, Hardin JW, Yuan J, Cox CL, Love BL. Antibiotic Exposure and the Risk of Food Allergy: Evidence in the US Medicaid Pediatric Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:492-499. [PMID: 30468878 DOI: 10.1016/j.jaip.2018.09.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 09/12/2018] [Accepted: 09/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Food allergy is a significant public health concern in the United States, especially in the pediatric population. It places substantial clinical and economic burdens on the health care system. Exposure to antibiotics in early childhood is thought to increase the risk of subsequent food allergy. OBJECTIVE To examine the impact of exposure to antibiotics early in life on time to development of food allergy. METHODS We conducted a population-based matched cohort study using Medicaid data from 28 states. Antibiotic nonusers were matched 1:1 to antibiotic users on date of birth, sex, race, and state. A Cox proportional hazards regression model was used to evaluate the effect of antibiotic exposure on time to development of food allergy. Sensitivity analyses were performed to assess the robustness of study findings. RESULTS We matched 500,647 antibiotic nonusers to 500,647 antibiotic users in the Medicaid pediatric population. In the adjusted Cox proportional hazards regression analysis, antibiotic exposure was significantly associated with faster development of food allergy (hazard ratio, 1.40; 95% CI, 1.34-1.45). The magnitude and significance of the association between antibiotic exposure and food allergy did not change in the sensitivity analyses. A significant association between antibiotic exposure and faster development of food allergy was found in 17 of 28 states. CONCLUSION Compared with antibiotic nonusers, children with antibiotic prescription had an increased risk of food allergy.
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Affiliation(s)
- Minghui Li
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Z Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC
| | - David J Amrol
- Division of Allergy, Asthma and Immunology, Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Joshua R Mann
- Department of Preventive Medicine, School of Medicine and John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Miss
| | - James W Hardin
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Jing Yuan
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC
| | - Christina L Cox
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC
| | - Bryan L Love
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC.
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Sundquist BK, Jose J, Pauze D, Pauze D, Wang H, Järvinen KM. Anaphylaxis risk factors for hospitalization and intensive care: A comparison between adults and children in an upstate New York emergency department. Allergy Asthma Proc 2019; 40:41-47. [PMID: 30582495 DOI: 10.2500/aap.2019.40.4189] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Anaphylaxis is an acute, systemic allergic reaction that can be life threatening, and with an increasing incidence and costs associated with hospitalization and intensive care. Objective: To assess the risk factors for hospitalization by comparing pediatric and adult patients. Methods: We performed a retrospective chart review for patients with anaphylactic reactions who presented to the Albany Medical Center emergency department between 2005 and 2012. Results: We identified 267 anaphylactic reactions in 258 patients (143 adults). Of those, 128 (48%) were not coded as anaphylaxis despite fulfilling diagnostic criteria. Foods were the most common trigger both in adults and children. Factors associated with increased odds of hospitalization (intensive care unit [ICU] and hospital floor combined) included a severity score of 3 in both children (odds ratio [OR] 41.86 [95% confidence interval {CI}, 2.9-602.48], p = 0.006) and adults (OR 32.52 [95% CI, 6.28-168.35], p < 0.001), and those who received multiple doses of epinephrine in children (OR 15.36 [95% CI, 1.9-121.4], p = 0.009) and adults (OR 11.49 [95% CI, 3.08-44.13], p < 0.001). Patient characteristics associated with ICU admission in children and adults combined included Medicare and/or Medicaid insurance (OR 4.96 [95% CI, 1.14-21.67], p = 0.023), cutaneous symptoms (OR 0.19 [95% CI, 0.04-0.79], p = 0.23), and cardiovascular symptoms (OR 5.8 [95% CI, 1.16-28.87], p = 0.032). Conclusion: Anaphylaxis remains underrecognized and improperly treated in the emergency department. Severity of symptoms and receiving multiple doses of epinephrine were associated with hospitalization in both children and adults. Medicare and/or Medicaid insurance, and cardiovascular or cutaneous symptoms were characteristics associated with ICU admission in our cohort.
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Affiliation(s)
- Britta K. Sundquist
- From the Division of Allergy and Immunology, Department of Medicine, Albany Medical College School of Medicine, Albany, New York
| | - Jaison Jose
- From the Division of Allergy and Immunology, Department of Medicine, Albany Medical College School of Medicine, Albany, New York
| | - Daniel Pauze
- Department of Emergency Medicine, Albany Medical College School of Medicine, Albany, New York
| | - Denis Pauze
- Department of Emergency Medicine, Albany Medical College School of Medicine, Albany, New York
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Kirsi M. Järvinen
- From the Division of Allergy and Immunology, Department of Medicine, Albany Medical College School of Medicine, Albany, New York
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Kraaijvanger N, Rijpsma D, Roovers L, van Leeuwen H, Kaasjager K, van den Brand L, Horstink L, Edwards M. Development and validation of an admission prediction tool for emergency departments in the Netherlands. Emerg Med J 2018; 35:464-470. [DOI: 10.1136/emermed-2017-206673] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/22/2018] [Accepted: 03/18/2018] [Indexed: 11/03/2022]
Abstract
ObjectiveEarly prediction of admission has the potential to reduce length of stay in the ED. The aim of this study is to create a computerised tool to predict admission probability.MethodsThe prediction rule was derived from data on all patients who visited the ED of the Rijnstate Hospital over two random weeks. Performing a multivariate logistic regression analysis factors associated with hospitalisation were explored. Using these data, a model was developed to predict admission probability. Prospective validation was performed at Rijnstate Hospital and in two regional hospitals with different baseline admission rates. The model was converted into a computerised tool that reported the admission probability for any patient at the time of triage.ResultsData from 1261 visits were included in the derivation of the rule. Four contributing factors for admission that could be determined at triage were identified: age, triage category, arrival mode and main symptom. Prospective validation showed that this model reliably predicts hospital admission in two community hospitals (area under the curve (AUC) 0.87, 95% CI 0.85 to 0.89) and in an academic hospital (AUC 0.76, 95% CI 0.72 to 0.80). In the community hospitals, using a cut-off of 80% for admission probability resulted in the highest number of true positives (actual admissions) with the greatest specificity (positive predictive value (PPV): 89.6, 95% CI 84.5 to 93.6; negative predictive value (NPV): 70.3, 95% CI 67.6 to 72.9). For the academic hospital, with a higher admission rate, a 90% probability was a better cut-off (PPV: 83.0, 95% CI 73.8 to 90.0; NPV: 59.3, 95% CI 54.2 to 64.2).ConclusionAdmission probability for ED patients can be calculated using a prediction tool. Further research must show whether using this tool can improve patient flow in the ED.
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Dyer AA, Lau CH, Smith TL, Smith BM, Gupta RS. Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois. Ann Allergy Asthma Immunol 2015; 115:56-62. [PMID: 26123422 DOI: 10.1016/j.anai.2015.05.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/30/2015] [Accepted: 05/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rates of food-induced anaphylaxis among children remain uncertain. In addition, little is known about the demographics of children who have experienced food-induced anaphylaxis resulting in emergency department (ED) visits and/or subsequent hospitalizations. OBJECTIVES To evaluate trends in ED visits and hospital admissions due to food-induced anaphylaxis among Illinois children and to identify socioeconomic variation in trend distribution. METHODS Illinois hospital discharge data compiled by the Illinois Hospital Association were used to identify ED visits or hospitalizations for food-induced anaphylaxis in Illinois hospitals from 2008-2012. Data for children aged 0 to 19 years who were Illinois residents and received a diagnosis of food-induced anaphylaxis based on International Classification of Diseases, Ninth Revision, Clinical Modification codes (995.60 through 995.69) were included for analysis. RESULTS There was a significant increase in the rate of ED visits and hospital admissions due to food-induced anaphylaxis among children in Illinois during the 5-year period, with an annual percent increase of 29.1% from 6.3 ED visits and hospital admissions per 100,000 children in 2008 to 17.2 in 2012 (P < .001). Increases in visit frequency were observed for all study variables, including age, sex, race/ethnicity, insurance type, metropolitan status, hospital type, and allergenic food. Visits were most frequent each year for Asian children and children with private insurance. However, the annual percent increase in visits was most pronounced among Hispanic children (44.3%, P < .001) and children with public insurance (30.2%, P < .001). CONCLUSION ED visits and hospital admissions for food-induced anaphylaxis have increased during a 5-year period among children in Illinois, regardless of race/ethnicity and socioeconomic status.
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Affiliation(s)
- Ashley A Dyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Claudia H Lau
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Tracie L Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Bridget M Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare Edward J. Hines, Jr. Veterans Affairs Hospital, Hines, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ruchi S Gupta
- Center of Innovation for Complex Chronic Healthcare Edward J. Hines, Jr. Veterans Affairs Hospital, Hines, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Fleming JT, Clark S, Camargo CA, Rudders SA. Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 3:57-62. [PMID: 25577619 DOI: 10.1016/j.jaip.2014.07.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 06/16/2014] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Food-induced anaphylaxis (FIA) is potentially life threatening. Prompt administration of epinephrine is universally recommended by current treatment guidelines. OBJECTIVE To identify factors associated with early epinephrine treatment for FIA and to specifically examine the association between early epinephrine treatment and hospitalization. METHODS A chart review study conducted at Hasbro Children's Hospital/Rhode Island Hospital. By using the International Classification of Diseases, Ninth Revision codes, we identified all patients who presented to the emergency department with FIA between January 1, 2004, and December 31, 2009. Early epinephrine treatment was defined as receipt of epinephrine before arrival to the emergency department. The independent association between early epinephrine treatment and hospitalization was assessed using logistic regression. RESULTS Among the 384 emergency department visits for FIA identified during the study period, 234 patients received epinephrine (61%). Among this subset, most (164 [70%]) received early epinephrine treatment, whereas a smaller number of patients (70 [30%]) first received epinephrine in the emergency department (late treatment). Patients who received early epinephrine treatment were older (7.4 vs 4.3 years; P = .008), were more likely to have a known food allergy (66% vs 34%; P < .001), and were more likely to own an epinephrine autoinjector (80% vs 23%; P < .001). Patients treated early were less likely to be hospitalized (17% vs 43%; P < .001). After adjusting for age, sex, and race, the patients who received early epinephrine treatment remained at significantly decreased risk of hospitalization compared with those who received late epinephrine treatment (odds ratio 0.25 [95% CI, 0.12-0.49]). CONCLUSIONS In this population, early treatment of FIA with epinephrine was associated with significantly lower risk of hospitalization. Accordingly, this study supports the benefit of prompt administration of epinephrine for the treatment of FIA.
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Affiliation(s)
- Jude T Fleming
- Division of Asthma and Allergy, Department of Pediatrics, Hasbro Children's Hospital/Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medical College, New York, NY
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Division of Allergy/Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Susan A Rudders
- Division of Asthma and Allergy, Department of Pediatrics, Hasbro Children's Hospital/Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI.
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Greenhawt M, Weiss C, Conte ML, Doucet M, Engler A, Camargo CA. Racial and ethnic disparity in food allergy in the United States: a systematic review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:378-86. [PMID: 24565543 DOI: 10.1016/j.jaip.2013.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/11/2013] [Accepted: 04/17/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of food allergy is rising among US children. Little is known about racial/ethnic disparities in food allergy. OBJECTIVE We performed a systematic literature review to understand racial/ethnic disparities in food allergy in the United States. METHODS We searched PubMed/MEDLINE, Embase, and Scopus for original data about racial/ethnic disparities in the diagnosis, prevalence, treatment, or clinical course of food allergy or sensitization, with a particular focus on black (African American) race. Articles were analyzed by study methodology, racial/ethnic composition, food allergy definition, outcomes, summary statistic used, and covariate adjustment. RESULTS Twenty of 645 identified articles met inclusion criteria. The studies used multiple differing criteria to define food allergy, including self-report, sensitization assessed by serum food-specific IgE to selected foods without corroborating history, discharge codes, clinic chart review, and event-reporting databases. None used oral food challenge. In 12 studies, black persons (primarily children) had significantly increased adjusted odds of food sensitization or significantly higher proportion or odds of food allergy by self-report, discharge codes, or clinic-based chart review than white children. Major differences in study methodology and reporting precluded calculation of a pooled estimate of effect. CONCLUSION Sparse and methodologically limited data exist about racial/ethnic disparity in food allergy in the United States. Available data lack a common definition for food allergy and use indirect measures of allergy, not food challenge. Although data suggest an increased risk of food sensitization, self-reported allergy, or clinic-based diagnosis of food allergy among black children, no definitive racial/ethnic disparity could be found among currently available studies.
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Affiliation(s)
- Matthew Greenhawt
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, The University of Michigan Medical School and the University of Michigan Health System, Ann Arbor, Mich.
| | | | - Marisa L Conte
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Mich
| | - Marlie Doucet
- Oak Ridge Institute for Science and Education Fellow, Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Amy Engler
- Human Biology Department, Stanford University, Palo Alto, Calif
| | - Carlos A Camargo
- Department of Emergency Medicine and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol 2012; 12:389-99. [PMID: 22744267 DOI: 10.1097/aci.0b013e328355b7e4] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis published in early 2011 provide a global perspective on patient risk factors, triggers, clinical diagnosis, treatment, and prevention of anaphylaxis. In this 2012 Update, subsequently published, clinically relevant research in these areas is reviewed. RECENT FINDINGS Patient risk factors and co-factors that amplify anaphylaxis have been documented in prospective studies. The global perspective on the triggers of anaphylaxis has expanded. The clinical criteria for the diagnosis of anaphylaxis that are promulgated in the Guidelines have been validated. Some aspects of anaphylaxis treatment have been prospectively studied. Novel investigations of self-injectable epinephrine for treatment of anaphylaxis recurrences in the community have been performed. Progress has been made with regard to measurement of specific IgE to allergen components (component-resolved testing) that might help to distinguish clinical risk of future anaphylactic episodes to an allergen from asymptomatic sensitization to the allergen. New strategies for immune modulation to prevent food-induced anaphylaxis and new insights into subcutaneous immunotherapy to prevent venom-induced anaphylaxis have been described. SUMMARY Research highlighted in this Update strengthens the evidence-based recommendations for assessment, management, and prevention of anaphylaxis made in the WAO Anaphylaxis Guidelines.
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Anaphylaxis in the community setting: determining risk factors for admission. Ann Allergy Asthma Immunol 2012; 109:133-6. [PMID: 22840255 DOI: 10.1016/j.anai.2012.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 05/20/2012] [Accepted: 06/01/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the identification and management of anaphylaxis in an emergency department setting has been well studied, our understanding of the risk factors for admission in a community-based hospital is lacking. OBJECTIVE To determine the demographics and the predictors of hospitalization, in patients presenting with anaphylaxis to a community-based emergency department (ED). METHODS We performed a five-year retrospective chart review of all patients seen in the ED of Winthrop University Hospital, a community-based institution, with an International Classification of Diseases, 9(th)Edition code related to anaphylaxis. RESULTS Fifty-eight visits met inclusion criteria, of which 34% resulted in hospital admission (95% CI: 22-48%). Univariate predictors for admission included (1) the involvement of 2, 3, and 4 organ systems (26%, 55%, and 75%, respectively; P < .02); (2) gastrointestinal symptoms vs no symptoms (59% vs 24%, P < .02); (3) non-sting (ingested and other allergens) vs insect sting allergen (50% vs 12.5%, P < .005); and (4) a history of an ED visit for anaphylaxis vs none (67% vs 30%, P < .05). Multivariate analysis (logistic regression) confirmed non-sting allergens (p < 0.02) and number of organ systems involved (P < .05) as independent predictors of hospitalization. CONCLUSION In our study population, the involvement of multiple organ systems, particularly gastrointestinal involvement, a history of ED visits for anaphylaxis, and involvement of ingested or other allergens (non-sting) demonstrated higher admission rates.
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Kalogeromitros D, Makris MP, Chliva C, Sergentanis TN, Church MK, Maurer M, Psaltopoulou T. An internet survey on self-reported food allergy in Greece: clinical aspects and lack of appropriate medical consultation. J Eur Acad Dermatol Venereol 2012; 27:558-64. [PMID: 22348258 DOI: 10.1111/j.1468-3083.2012.04482.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Food allergy (FA) represents a common and worldwide disorder but in publications referring to FA the reported diagnosis is rarely confirmed. Consequently, the subjectively assessed FA may negatively affect the quality of life of patients and their families. OBJECTIVE We have conducted this internet survey in order to estimate the self-reported perception of FA in Greece. METHODS A standard anonymous questionnaire was posted for a 3-month period on http://www.in.gr, a Greek popular Internet portal. Each individual could participate only once. Participants were screened for the presence or history of FA by a key question and were then asked to provide information on symptoms, course and management. RESULTS A total of 3673 adult subjects (mean age 34.2 years, range 18-74, females 61.3%), reporting FA were included in analysis. Most reported reactions were related to fruits (14.9%), seafood (10.7%) and nuts (9.2%). The first episode occurred principally during the second (29.2%) and third (30.9%) decade within 3 h from consumption (82.2%). Predominant symptoms were urticaria and oral allergy syndrome (almost 25% each one). Nearly half of the participants sought no medical advice, while 31.4% asked for an allergist's consultation. Almost 21% of reactors were hospitalized; nuts, severity of symptoms (lower respiratory and/or cardiovascular), onset in lower age, previous exercise and concomitant alcohol and/or aspirin intake were positively associated with hospitalization. CONCLUSION Although FA causes severe anaphylactic episodes, almost 50% of individuals who experience symptoms perceived as FA do not seek medical advice. Awareness programmes must be carried out in order to increase consciousness about this potentially fatal medical condition.
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Affiliation(s)
- D Kalogeromitros
- Allergy Unit, 2nd Department Dermatology and Venereology, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece
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Ayuso R. Update on the diagnosis and treatment of shellfish allergy. Curr Allergy Asthma Rep 2011; 11:309-16. [PMID: 21494858 DOI: 10.1007/s11882-011-0198-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Shellfish allergy is a frequent, long-lasting, life-threatening disorder. As shellfish consumption increases, the number of allergic reactions to shellfish is expected to continue to rise as well. During the past decade, much has been learned about the allergens involved in shellfish allergy. Potential cross-reacting allergens between shellfish and other arthropods have been identified. As our knowledge of shellfish allergen improves, we will be able to develop more accurate methods of diagnosing shellfish allergy. In addition, extensive research is currently under way for the development of safer, more effective methods of managing shellfish hypersensitivity.
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Affiliation(s)
- Rosalía Ayuso
- Department of Medicine and Pediatrics, Mount Sinai School of Medicine, One Gustave L. Levy Place, ANBG 17-80, Box 1198, New York, NY 10029, USA.
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Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes. J Allergy Clin Immunol 2011; 129:162-8.e1-3. [PMID: 22018905 DOI: 10.1016/j.jaci.2011.09.018] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 07/16/2011] [Accepted: 09/20/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Anaphylaxis incidence is increasing. OBJECTIVE We sought to characterize anaphylaxis in children in an urban pediatric emergency department (PED). METHODS We performed a review of PED records for anaphylactic reactions over 5 years. RESULTS We identified 213 anaphylactic reactions in 192 children (97 male patients): 6 were infants, 20 had multiple reactions, and the median age was 8 years (age range, 4 months to 18 years). Sixty-two reactions were coded as anaphylaxis; 151 additional reactions met the second symposium anaphylaxis criteria. There was no increase in incidence over 5 years. The triggers included the following: foods, 71%; unknown, 15%; drugs, 9%; and "other," 5%. Food was more likely to be a trigger in multiple PED visits (P = .03). Epinephrine was administered in 169 (79%) reactions; in 58 (27%) reactions epinephrine was administered before arrival in the PED. Patients with Medicaid were less likely to receive epinephrine before arrival in the PED (P < .001). Twenty-eight (14.6%) patients were hospitalized, 9 in the intensive care unit. For 13 (6%) of the reactions, 2 doses of epinephrine were administered; 69% of the patients treated with 2 doses of epinephrine were hospitalized compared with 12% of the patients treated with a single dose (P < .001). Administration of both epinephrine doses before arrival to the PED was associated with a lower rate of hospitalization compared with epinephrine administration in the PED (P = .05). CONCLUSIONS Food is the main anaphylaxis trigger in the urban PED, although the International Classification of Diseases-ninth revision code for anaphylaxis is underused. Treatment with 2 doses of epinephrine is associated with a higher risk of hospitalization; epinephrine treatment before arrival to the PED is associated with a decreased risk. Children with Medicaid are less likely to receive epinephrine before arrival in the PED.
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Comparison of artificial neural networks with logistic regression for detection of obesity. J Med Syst 2011; 36:2449-54. [PMID: 21556898 DOI: 10.1007/s10916-011-9711-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
Abstract
Obesity is a common problem in nutrition, both in the developed and developing countries. The aim of this study was to classify obesity by artificial neural networks and logistic regression. This cross-sectional study comprised of 414 healthy military personnel in southern Iran. All subjects completed questionnaires on their socio-economic status and their anthropometric measures were measured by a trained nurse. Classification of obesity was done by artificial neural networks and logistic regression. The mean age±SD of participants was 34.4 ± 7.5 years. A total of 187 (45.2%) were obese. In regard to logistic regression and neural networks the respective values were 80.2% and 81.2% when correctly classified, 80.2 and 79.7 for sensitivity and 81.9 and 83.7 for specificity; while the area under Receiver-Operating Characteristic (ROC) curve were 0.888 and 0.884 and the Kappa statistic were 0.600 and 0.629 for logistic regression and neural networks model respectively. We conclude that the neural networks and logistic regression both were good classifier for obesity detection but they were not significantly different in classification.
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