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Koumaki D, Koumaki V, Boumpoucheropoulos S, Katoulis A, Laguda B. Childhood Acute Urticaria and Seasonal Patterns Presenting in the Emergency Department of a Teaching Hospital in London, United Kingdom. Pediatr Emerg Care 2022; 38:e385-e386. [PMID: 34986591 DOI: 10.1097/pec.0000000000002297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize the clinical presentation, possible trigger factors and seasonality of acute urticaria (AU) in children referred to the emergency department in a teaching hospital in London, United Kingdom. METHODS This was a retrospective descriptive study. One hundred and sixty-three consecutive patients younger than 18 years with the diagnosis of AU who attended accident and emergency department from January 2018 until January 2020 at Chelsea and Westminster Hospital in London, United Kingdom, were included in the study. Descriptive statistics were performed using IBM SPSS 25. RESULTS In total, 163 patients younger than 18 years, 82 (50.3%) boys and 81 (49.7%) girls. The median age of patients with AU was 4 years (interquartile range, 6 years). In 120 of (73.6%) 163 patients, there was no clear trigger of AU, in 17 (10.4%) of 163 patients, upper respiratory infection was considered as a potential trigger of AU, followed by food in 14 (8.6%) cases, medications in 9 (5.5%) cases, hymenoptera sting in 1 (0.6%) case, and contact urticaria 2 (1.2%) cases. Seventeen (10.4%) of the patients were admitted into the hospital as a result of their urticaria. The majority of AU urticaria cases were reported in autumn with 76 (46.6%) cases with most of AU cases occurring in November (34/163, 20.9%). CONCLUSIONS A total of 163 cases of AU were identified between January 2018 and January 2020. A seasonal trend of AU in autumn was observed. Respiratory infections were found to be the most commonly associated potential trigger of AU cases.
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Affiliation(s)
- Dimitra Koumaki
- From the Paediatric Dermatology Department, Chelsea and Westminster NHS Foundation TRUST, London, United Kingdom
| | | | | | - Alexander Katoulis
- 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens, Medical School, "Attikon" General University Hospital, Athens, Greece
| | - Bisola Laguda
- From the Paediatric Dermatology Department, Chelsea and Westminster NHS Foundation TRUST, London, United Kingdom
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Yiğit RE, Cavkaytar O, Besli GE, Arga M. Do Pediatric Emergency Physicians Comply With Guideline Recommendations in Management of Patients With Acute Urticaria? Pediatr Emerg Care 2021; 37:407-412. [PMID: 34043307 DOI: 10.1097/pec.0000000000002327] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the level of knowledge and practical preferences of pediatricians regarding acute urticaria (AU) management and to assess the effects of training provided in accordance with the current urticaria guideline recommendations on pediatricians who work in the pediatric emergency department (PED). METHODS A theoretical training was provided to pediatricians regarding the diagnosis and treatment of AU in line with current urticaria guideline recommendations. Before the training, pediatricians completed a 10-item questionnaire. This prospective study assesses their treatment approaches in patients admitted to PED because of AU during the 6-month period before and the 1-year period after training. RESULTS Four hundred seventeen children in the pretraining and 1085 children in the posttraining periods were treated for AU in PED. Forty-eight pediatricians participated in the training. According to their questionnaire responses, 35% of them used only H1 antihistamine (AH) treatment, 50% used second-generation H1 AH (2nd-GAH) as AHs, 75% preferred the oral route of administration, and 85.4% did not administer systemic corticosteroid (sCS) to all patients. Comparing the practice approaches of the pediatricians in the pretraining and posttraining periods, first-generation H1 antihistamine (1st-GAH) preference rate decreased from 68.4% to 30.3% and the sCS preference rate decreased from 58.5% to 25.7%, while the 2nd-GAH preference rate increased from 31.7% to 69.7% (P < 0.001 for all). No treatments were prescribed for 10.8% of patients before the training and 3% after the training during discharge at home (P < 0.05). Comparing the home treatment choices of the pediatricians in the pretraining and posttraining periods, 1st-GAH preference rate decreased from 11.5% to 5%, while the 2nd-GAH preference rate increased from 78.7% to 91.5% (for both parameters, P < 0.001). CONCLUSIONS Practical treatment preferences of pediatricians in the treatment of children with AU differ considerably from both current guideline recommendations and their own theoretical knowledge, and training can enhance pediatricians' compliance with current guideline recommendations.
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Affiliation(s)
| | | | - Gulser Esen Besli
- Department of Pediatric Emergency, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
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Arga M, Cavkaytar Ö, Emeksiz HC. A randomized controlled trial of adding intravenous corticosteroids to H1 antihistamines in patients with acute urticaria. Am J Emerg Med 2020; 45:592-593. [PMID: 33358900 DOI: 10.1016/j.ajem.2020.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mustafa Arga
- Istanbul Medeniyet University, Faculty of Medicine, Department of Pediatric Allergy and Immunology, Istanbul, Turkey.
| | - Özlem Cavkaytar
- Istanbul Medeniyet University, Faculty of Medicine, Department of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Hamdi Cihan Emeksiz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Pediatric Endocrinology, Istanbul, Turkey
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Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review. Pediatr Emerg Care 2017; 33:278-286. [PMID: 28355170 DOI: 10.1097/pec.0000000000000557] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs. METHODS The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. RESULTS Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. CONCLUSIONS This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.
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Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, Sheikh J, Weldon D, Zuraw B, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133:1270-7. [DOI: 10.1016/j.jaci.2014.02.036] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
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Nowak R, Farrar JR, Brenner BE, Lewis L, Silverman RA, Emerman C, Hays DP, Russell WS, Schmitz N, Miller J, Singer E, Camargo CA, Wood J. Customizing Anaphylaxis Guidelines for Emergency Medicine. J Emerg Med 2013; 45:299-306. [DOI: 10.1016/j.jemermed.2013.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/02/2013] [Accepted: 01/18/2013] [Indexed: 11/27/2022]
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Russell WS, Farrar JR, Nowak R, Hays DP, Schmitz N, Wood J, Miller J. Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice. World J Emerg Med 2013; 4:98-106. [PMID: 25215101 PMCID: PMC4129832 DOI: 10.5847/wjem.j.issn.1920-8642.2013.02.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 05/02/2013] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations. METHODS This was an online anonymous survey of a random sample of EM health providers in US EDs. RESULTS Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended. CONCLUSIONS This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.
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Affiliation(s)
- W. Scott Russell
- Pediatric Emergency Department, Medical University of South Carolina, Charleston, SC 29425, USA
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, USA
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Jacobs TS, Greenhawt MJ, Hauswirth D, Mitchell L, Green TD. A survey study of index food-related allergic reactions and anaphylaxis management. Pediatr Allergy Immunol 2012; 23:582-9. [PMID: 22625658 DOI: 10.1111/j.1399-3038.2012.01315.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Initial food-allergic reactions are often poorly recognized and under-treated. METHODS Parents of food-allergic children were invited to complete an online questionnaire, designed with Kids with Food Allergies Foundation, about their children's first food-allergic reactions resulting in urgent medical evaluation. RESULTS Among 1361 reactions, 76% (95% CI 74-79%) were highly likely to represent anaphylaxis based on NIAID/FAAN criteria. Only 34% (95% CI 31-37%) of these were administered epinephrine. In 56% of these, epinephrine was administered by emergency departments; 20% by parents; 9% by paramedics; 8% by primary care physicians; and 6% by urgent care centers. In 26% of these, epinephrine was given within 15 min of the onset of symptoms; 54% within 30 min; 82% within 1 h; and 93% within 2 h. Factors associated with a decreased likelihood of receiving epinephrine for anaphylaxis included age <12 months, milk and egg triggers, and symptoms of abdominal pain and/or diarrhea. Epinephrine was more likely to be given to asthmatic children and children with peanut or tree nut ingestion prior to event. Post-treatment, 42% of reactions likely to represent anaphylaxis were referred to allergists, 34% prescribed and/or given epinephrine auto-injectors, 17% trained to use epinephrine auto-injectors, and 19% given emergency action plans. Of patients treated with epinephrine, only half (47%) were prescribed epinephrine auto-injectors. CONCLUSIONS Only one-third of initial food-allergic reactions with symptoms of anaphylaxis were recognized and treated with epinephrine. Fewer than half of patients were referred to allergists. There is still a need to increase education and awareness about food-induced anaphylaxis.
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Affiliation(s)
- Tammy S Jacobs
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
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Ricci G, Giannetti A, Belotti T, Dondi A, Bendandi B, Cipriani F, Masi M. Allergy is not the main trigger of urticaria in children referred to the emergency room. J Eur Acad Dermatol Venereol 2011; 24:1347-8. [PMID: 20337828 DOI: 10.1111/j.1468-3083.2010.03634.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urticaria is the disease that has the highest impact on quality of life and requires the most visits to the emergency room. OBJECTIVE To investigate the clinical presentation of acute urticaria in children referred to the paediatric emergency room of our hospital and to define possible related aetiologies. METHODS We included 814 children consecutively referred to the emergency room between January 2006 and December 2007 with a diagnosis of acute urticaria, isolated or associated with other clinical symptoms. RESULTS Only 2.0% of the cases studied were associated with severe clinical pictures. In 437 cases (53.7%), the cause of urticaria was not determined. The infections of the respiratory tract were the most frequently suspected aetiological factor. The diagnosis of allergic urticaria is more defined, but belongs to a minority group (10.8%). The first level treatment includes the use of non-sedating oral H1-antihistamine. CONCLUSION The children with urticaria are frequently referred to the paediatric emergency room, but only in a few cases were associated with severe clinical manifestations or allergy. The evidence of an inverse relationship between the number of accesses and the patients' age may be explained by the higher prevalence of this disease in early childhood and possibly also by a higher concern of the parents of the younger patients.
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Affiliation(s)
- G Ricci
- Department of Pediatric, University of Bologna, Bologna, Italy.
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Zonfrillo MR, Nelson KA, Durbin DR. Emergency physicians' knowledge and provision of child passenger safety information. Acad Emerg Med 2011; 18:145-51. [PMID: 21314773 DOI: 10.1111/j.1553-2712.2010.00971.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES While physicians provide discharge instructions to patients and families following emergency department (ED) visits, injury prevention information may not be routinely included in these instructions. This study assessed emergency physicians' knowledge and provision of child passenger safety (CPS) information to patients following motor vehicle crashes (MVCs). METHODS This study was both a survey of emergency physician knowledge and provision of CPS information and an examination of frequency of CPS information in discharge instructions at a single institution. Members of the American Academy of Pediatrics (AAP) Section on Emergency Medicine were invited to participate in the survey. Respondents were asked about their provision of CPS information to patients and knowledge of national AAP CPS recommendations. The institutional ED medical record chart review assessed the frequency of written CPS information for patients of MVC-related visits who were discharged home. RESULTS There were 317 survey respondents from 1,024 eligible physicians, of whom 43 began but did not complete the survey. The data analyzed are from the 274 who completed the survey. While 85% (95% confidence interval [CI] = 81% to 89%) of physicians believed that CPS information should be included in discharge instructions, only 36% (95% CI = 31% to 42%) correctly answered all knowledge questions. Of the 51 self-identified division/department chiefs, 15 (29.4%; 95% CI = 16.9% to 41.9%) reported that their EDs routinely provide CPS information in discharge instructions for pediatric passengers in MVCs. For the medical record review, of the 152 randomly selected MVC visits, 13 (8.6%; 95% CI = 4.1% to 13.0%) had documented CPS information in the discharge instructions. Patients with documented CPS information were younger, but there were no significant differences in race, sex, or maximum abbreviated injury scale score between patients with versus without CPS information. CONCLUSIONS While emergency physicians value the use of CPS information in discharge instructions following MVCs, they do not have adequate knowledge of, nor do they regularly disseminate, this information.
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Affiliation(s)
- Mark R Zonfrillo
- Division of Emergency Medicine, Children's Hospital of Philadelphia, PA, USA.
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Ferrer M, Morais-Almeida M, Guizova M, Khanferyan R. Evaluation of treatment satisfaction in children with allergic disease treated with an antihistamine: an international, non-interventional, retrospective study. Clin Drug Investig 2010; 30:15-34. [PMID: 19995095 DOI: 10.2165/11530910-000000000-00000] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES Histamine H(1)-receptor antagonists (antihistamines) have been shown to be efficacious and safe in children and are recommended as first-line treatment for the symptoms of allergic rhinitis and urticaria. No published study to date has directly compared satisfaction with the different antihistamines in children in a real-life clinical setting. This study aimed to investigate parent and physician satisfaction with the efficacy and tolerability of oral antihistamine treatment in children and to compare satisfaction between levocetirizine and the other antihistamines used by children in this cohort. METHODS This was an international Observational Survey in Children with Allergic Rhinitis (OSCAR). Children aged 2-12 years, with a history of an allergic condition leading to a consultation, were enrolled from 424 primary-care/specialist allergy clinics across Bulgaria, India, Portugal, Romania, Russia, South Korea and Spain. At the consultation, parents and physicians of eligible children completed questionnaires evaluating their satisfaction with specific antihistamines currently employed for management of the child's allergic condition, as well as their intention for future use of that treatment. Parents' satisfaction scores for efficacy, tolerability and global satisfaction with the antihistamine used were primary study outcomes, while physicians' satisfaction scores for the same measures were secondary outcomes. Other secondary outcomes were parents' rating of the impact of the antihistamine treatment on their child's sleep and school performance, and parents' and physicians' willingness to use/recommend the same antihistamine in the future. RESULTS A total of 4581 patients were enrolled; 3048 (66.5%) had allergic rhinitis (55.9% persistent allergic rhinitis and 44.1% intermittent allergic rhinitis), and 663 (14.5%) had urticaria as primary conditions. Additionally, 2465 patients (53.8%) suffered from other allergic diseases, including allergic asthma (33.3%), atopic dermatitis (17.6%), food allergy (5.3%), other allergies (5.0%) and drug hypersensitivity (2.0%). Parents' and physicians' satisfaction scores were closely concordant and demonstrated significantly greater global satisfaction for the second-generation antihistamines than for the first-generation antihistamines. Levocetirizine (n = 2339) and fexofenadine (n = 42) generally scored highest for efficacy, tolerability and global satisfaction, as well as for impact on the child's ability to function at school, quality of school activities and quality of sleep. Furthermore, >97% of parents and physicians indicated their desire to continue or recommend the use of levocetirizine in the future. Somnolence, the most commonly reported adverse event in this survey, was observed predominantly in patients treated with first-generation antihistamines. Among second-generation antihistamines, reports of somnolence were most frequent in the cetirizine group. CONCLUSION Second-generation antihistamines have a better risk:benefit ratio than first-generation antihistamines, indicating that the latter should be avoided or their use limited in children whenever possible. Levocetirizine and fexofenadine were perceived by parents and physicians to produce significantly higher treatment satisfaction than the majority of the other antihistamines with respect to overall efficacy and tolerability, and impact on the child's sleep and school activities. The newer antihistamine levocetirizine seems to be a preferred and appropriate future treatment choice for children with allergic diseases.
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Affiliation(s)
- Marta Ferrer
- Department of Allergy, Clinica Universidad de Navarra Medical School, 31080 Pamplona, Spain.
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Abstract
PURPOSE To determine the rate, immediate treatment, and outpatient management for anaphylaxis in patients receiving care in a pediatric emergency department (ED). METHODS This is a retrospective cross-sectional descriptive study of patients (21 years or younger) who received care for anaphylaxis for a 5-year period in the ED of the Children's Hospital of Alabama in Birmingham, AL, which has an annual census of 55,000. The diagnostic criteria for anaphylaxis were symptoms and/or signs involving 2 or more organ systems (dermatologic, respiratory, gastrointestinal, and cardiovascular), hypotension for age, 1 organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine. RESULTS There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) patients who had involvement of two or more organ systems. There were 66 (64%) males and 33 (27%) patient visits that resulted in hospitalization. The most common organ system involvement was dermatologic in 121 (98%), followed by respiratory in 101 (81%), gastrointestinal in 33 (27%), and cardiovascular in 11 (9%). Medical interventions include 69 patients treated with intramuscular epinephrine (56%; either in pre-hospital setting and/or during ED visit), 97 patients treated with corticosteroids (79%), 114 patients treated with H1 and/or H2 antihistamine (93%), 15 patients treated with intravenous fluid bolus (12%), and 37 patients treated with albuterol nebulization (30%). Food was the most common inciting allergen (in 45 or 36% of patients). Among the foods that were listed as causing reactions were peanuts, shellfish, milk, ice cream, fruit, nuts, and fried chicken. Compared with ED care-only patients, the hospitalized patients had a significantly greater rate of cardiovascular system involvement and of receiving more ED interventions. Of 91 ED care-only patients, autoinjection epinephrine was prescribed to 63% and referral to an allergist was recommended to 33%. Patients treated with intramuscular epinephrine had a significantly greater rate of hospitalization and of receiving more ED interventions compared with patients who were not treated with epinephrine. There were no patient deaths. CONCLUSIONS This study is the first to describe the management of anaphylaxis in a pediatric ED. The results revealed opportunities for improvement. Although our ED treatment and outpatient management of patients with anaphylaxis did not meet the recommended standards of care with regard to administration of intramuscular epinephrine, prescribing autoinjection epinephrine, or referral to an allergist for all patients who had a diagnosis of anaphylaxis, we do report a higher concordance with published recommendations than those reported in previous studies performed in adults.
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Mistry RD, Weisz K, Scott HF, Alpern ER. Emergency management of pediatric skin and soft tissue infections in the community-associated methicillin-resistant Staphylococcus aureus era. Acad Emerg Med 2010; 17:187-93. [PMID: 20370748 DOI: 10.1111/j.1553-2712.2009.00652.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. METHODS This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. RESULTS In total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections. CONCLUSIONS Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.
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Affiliation(s)
- Rakesh D Mistry
- Department of Pediatrics and the Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Kruszewski J. Leki przeciwhistaminowe w leczeniu alergicznego nieżytu nosa – uaktualnienie 2008/2009. Otolaryngol Pol 2009; 63:5-10. [DOI: 10.1016/s0030-6657(09)70180-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The fine article, "First Attack of Acute Urticaria in a Pediatric Emergency Department" by Liu et at, which appeared in the June issue of Pediatrics and Neonatology prompted me to submit comments and a review on the subject of urticaria in children, because this is indeed a pediatric problem that is frequently seen in clinical practice.
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Abstract
PURPOSE OF REVIEW The present review serves to address urticaria - both acute and chronic - as well as the differential diagnosis of urticarial syndromes in the pediatric population. We also wish to update the reader on progress in the pathophysiology, diagnosis and treatment of urticaria. RECENT FINDINGS Acute and chronic urticaria represent syndromes caused by a variety of triggers. Recent literature continues to describe subtypes of urticaria that may be differentially responsive to particular therapies. Recent associations highlight the need to fully evaluate patients for allergic and infectious triggers of urticaria. It is important to distinguish idiopathic urticaria from related conditions such as anaphylaxis, systemic conditions and autoimmune urticaria. Although antihistamines remain a cornerstone of therapy, particular urticaria subtypes may also respond to novel therapies such as omalizumab. Chronic urticaria has a significant impact on a patient's quality of life. SUMMARY Urticaria is a common condition. Our understanding of distinct urticaria subtypes differentially responsive to targeted therapies continues to increase. Due to the myriad of triggers that may cause urticaria, careful individualized patient assessment is necessary to exclude potential etiologies prior to a diagnosis of idiopathic urticaria.
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