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Paolino G, Carugno A, Frontera A, Rongioletti F, Malagoli P, Foti A, Brianti P, Guida S, Germiniasi F, Bianchi VG, Raponi F, Sena P, Narcisi A, Costanzo A, Mercuri SR, Valenti M. Arrhythmias and other cardiovascular diseases in young patients (<40 years) with moderate/severe atopic dermatitis: A multicentric study in northern Italy. J Eur Acad Dermatol Venereol 2024. [PMID: 38940515 DOI: 10.1111/jdv.20184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 05/27/2024] [Indexed: 06/29/2024]
Affiliation(s)
- G Paolino
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute, San Raffaele, Milan, Italy
| | - A Carugno
- Dermatology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
- PhD Program in Molecular and Translational Medicine (DIMET), University of Milano-Bicocca, Milan, Italy
| | - A Frontera
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - F Rongioletti
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute, San Raffaele, Milan, Italy
| | - P Malagoli
- Dermatology Unit, Azienda Ospedaliera San Donato Milanese, Milan, Italy
| | - A Foti
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - P Brianti
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - S Guida
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute, San Raffaele, Milan, Italy
| | - F Germiniasi
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute, San Raffaele, Milan, Italy
| | - V G Bianchi
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - F Raponi
- Dermatology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - P Sena
- Dermatology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - A Narcisi
- Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - A Costanzo
- Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - S R Mercuri
- Unit of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute, San Raffaele, Milan, Italy
| | - M Valenti
- Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Wahid HH, Anahar FN, Isahak NH, Mohd Zoharodzi J, Mohammad Khoiri SNL, Mohamad Zainal NH, Kamarudin N, Ismail H, Mustafa Mahmud MIA. Role of Platelet Activating Factor as a Mediator of Inflammatory Diseases and Preterm Delivery. THE AMERICAN JOURNAL OF PATHOLOGY 2024; 194:862-878. [PMID: 38403163 DOI: 10.1016/j.ajpath.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/16/2024] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
Nearly 70% of preterm deliveries occur spontaneously, and the clinical pathways involved include preterm labor and preterm premature rupture of membranes. Prediction of preterm delivery is considered crucial due to the significant effects of preterm birth on health and the economy at both the personal and community levels. Although similar inflammatory processes occur in both term and preterm delivery, the premature activation of these processes or exaggerated inflammatory response triggered by infection or sterile factors leads to preterm delivery. Platelet activating factor (PAF) is a phosphoglycerylether lipid mediator of inflammation that is implicated in infections, cancers, and various chronic diseases and disorders including cardiovascular, renal, cerebrovascular, and central nervous system diseases. In gestational tissues, PAF mediates the inflammatory pathways that stimulate the effector mechanisms of labor, including myometrial contraction, cervical dilation, and fetal membrane rupture. Women with preterm labor and preterm premature rupture of membranes have increased levels of PAF in their amniotic fluid. In mice, the intrauterine or intraperitoneal administration of carbamyl PAF activates inflammation in gestational tissues, thereby eliciting preterm delivery. This review summarizes recent research on PAF as an important inflammatory mediator in preterm delivery and in other inflammatory disorders, highlighting its potential value for prediction, intervention, and prevention of these diseases.
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Affiliation(s)
- Hanan H Wahid
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia.
| | - Fatin N Anahar
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Nurul H Isahak
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Juwairiyah Mohd Zoharodzi
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Siti N L Mohammad Khoiri
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Nurul H Mohamad Zainal
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, University of Putra Malaysia, Selangor, Malaysia
| | - Norhidayah Kamarudin
- Department of Pathology, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Hamizah Ismail
- Department of Obstetrics & Gynaecology, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
| | - Mohammed I A Mustafa Mahmud
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University, Pahang, Malaysia
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3
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Lappe BL, Scovronick N, D’Souza RR, Manangan A, Chang HH, Ebelt S. Associations of pollen and cardiovascular disease morbidity in Atlanta during 1993-2018. Environ Epidemiol 2024; 8:e296. [PMID: 38617427 PMCID: PMC11008638 DOI: 10.1097/ee9.0000000000000296] [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: 10/02/2023] [Accepted: 01/25/2024] [Indexed: 04/16/2024] Open
Abstract
Background Pollen exposure is associated with substantial respiratory morbidity, but its potential impact on cardiovascular disease (CVD) remains less understood. This study aimed to investigate the associations between daily levels of 13 pollen types and emergency department (ED) visits for eight CVD outcomes over a 26-year period in Atlanta, GA. Methods We acquired pollen data from Atlanta Allergy & Asthma, a nationally certified pollen counting station, and ED visit data from individual hospitals and the Georgia Hospital Association. We performed time-series analyses using quasi-Poisson distributed lag models, with primary analyses assessing 3-day (lag 0-2 days) pollen levels. Models controlled for temporally varying covariates, including air pollutants. Results During 1993-2018, there were 1,573,968 CVD ED visits. Most pairwise models of the 13 pollen types and eight CVD outcomes showed no association, with a few exceptions potentially due to chance. Conclusion We found limited evidence of the impact of pollen on cardiovascular morbidity in Atlanta. Further study on pollen exposures in different climactic zones and exploration of pollen-pollution mixture effects is warranted.
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Affiliation(s)
- Brooke L. Lappe
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rohan R. D’Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arie Manangan
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Vaz-Rodrigues R, Mazuecos L, Villar M, Contreras M, Artigas-Jerónimo S, González-García A, Gortázar C, de la Fuente J. Multi-omics analysis of zebrafish response to tick saliva reveals biological processes associated with alpha-Gal syndrome. Biomed Pharmacother 2023; 168:115829. [PMID: 37922649 DOI: 10.1016/j.biopha.2023.115829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023] Open
Abstract
The alpha-Gal syndrome (AGS) is a tick-borne allergy. A multi-omics approach was used to determine the effect of tick saliva and mammalian meat consumption on zebrafish gut transcriptome and proteome. Bioinformatics analysis using R software was focused on significant biological and metabolic pathway changes associated with AGS. Ortholog mapping identified highly concordant human ortholog genes for the detection of disease-enriched pathways. Tick saliva treatment increased zebrafish mortality, incidence of hemorrhagic type allergic reactions and changes in behavior and feeding patterns. Transcriptomics analysis showed downregulation of biological and metabolic pathways correlated with anti-alpha-Gal IgE and allergic reactions to tick saliva affecting blood circulation, cardiac and vascular smooth muscle contraction, behavior and sensory perception. Disease enrichment analysis revealed downregulated orthologous genes associated with human disorders affecting nervous, musculoskeletal, and cardiovascular systems. Proteomics analysis revealed suppression of pathways associated with immune system production of reactive oxygen species and cardiac muscle contraction. Underrepresented proteins were mainly linked to nervous and metabolic human disorders. Multi-omics data revealed inhibition of pathways associated with adrenergic signaling in cardiomyocytes, and heart and muscle contraction. Results identify tick saliva-related biological pathways supporting multisystemic organ involvement and linking α-Gal sensitization with other illnesses for the identification of potential disease biomarkers.
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Affiliation(s)
- Rita Vaz-Rodrigues
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain
| | - Lorena Mazuecos
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain
| | - Margarita Villar
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain; Biochemistry Section, Faculty of Science and Chemical Technologies, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
| | - Marinela Contreras
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain
| | - Sara Artigas-Jerónimo
- Biochemistry Section, Faculty of Science and Chemical Technologies, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
| | - Almudena González-García
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain
| | - Christian Gortázar
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain
| | - José de la Fuente
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain; Department of Veterinary Pathobiology, Centre for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74078, USA.
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Schuler CF, O’Shea KM, Troost JP, Kaul B, Launius CM, Cannon J, Manthei DM, Freigeh GE, Sanders GM, Hogan SP, Lukacs NW, Baker JR. Transepidermal water loss rises before food anaphylaxis and predicts food challenge outcomes. J Clin Invest 2023; 133:e168965. [PMID: 37402149 PMCID: PMC10425212 DOI: 10.1172/jci168965] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUNDFood allergy (FA) is a growing health problem requiring physiologic confirmation via the oral food challenge (OFC). Many OFCs result in clinical anaphylaxis, causing discomfort and risk while limiting OFC utility. Transepidermal water loss (TEWL) measurement provides a potential solution to detect food anaphylaxis in real time prior to clinical symptoms. We evaluated whether TEWL changes during an OFC could predict anaphylaxis onset.METHODSPhysicians and nurses blinded to the TEWL results conducted and adjudicated the results of all 209 OFCs in this study. A study coordinator measured TEWL throughout the OFC and had no input on the OFC conduct. TEWL was measured 2 ways in 2 separate groups. First, TEWL was measured using static, discrete measurements. Second, TEWL was measured using continuous monitoring. Participants who consented provided blood samples before and after the OFCs for biomarker analyses.RESULTSTEWL rose significantly (2.93 g/m2/h) during reactions and did not rise during nonreacting OFCs (-1.00 g/m2/h). Systemic increases in tryptase and IL-3 were also detected during reactions, providing supporting biochemical evidence of anaphylaxis. The TEWL rise occurred 48 minutes earlier than clinically evident anaphylaxis. Continuous monitoring detected a significant rise in TEWL that presaged positive OFCs, but no rise was seen in the OFCs that resulted in no reaction, providing high predictive specificity (96%) for anaphylaxis against nonreactions 38 minutes prior to anaphylaxis onset.CONCLUSIONSDuring OFCs, a TEWL rise anticipated a positive clinical challenge. TEWL presents a monitoring modality that may predict food anaphylaxis and facilitate improvements in OFC safety and tolerability.
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Affiliation(s)
- Charles F. Schuler
- Division of Allergy and Clinical Immunology, Department of Internal Medicine
- Mary H. Weiser Food Allergy Center
| | - Kelly M. O’Shea
- Division of Allergy and Clinical Immunology, Department of Internal Medicine
- Mary H. Weiser Food Allergy Center
| | | | | | | | - Jayme Cannon
- Mary H. Weiser Food Allergy Center
- Michigan Nanotechnology Institute for the Biomedical Sciences, and
| | - David M. Manthei
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - George E. Freigeh
- Division of Allergy and Clinical Immunology, Department of Internal Medicine
| | - Georgiana M. Sanders
- Division of Allergy and Clinical Immunology, Department of Internal Medicine
- Mary H. Weiser Food Allergy Center
| | - Simon P. Hogan
- Mary H. Weiser Food Allergy Center
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas W. Lukacs
- Mary H. Weiser Food Allergy Center
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - James R. Baker
- Division of Allergy and Clinical Immunology, Department of Internal Medicine
- Mary H. Weiser Food Allergy Center
- Michigan Nanotechnology Institute for the Biomedical Sciences, and
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Calogiuri G, Savage MP, Congedo M, Nettis E, Mirizzi AM, Foti C, Vacca A, Kounis NG. Is Adrenaline Always the First Choice Therapy of Anaphylaxis? An Allergist-cardiologist Interdisciplinary Point of View. Curr Pharm Des 2023; 29:2545-2551. [PMID: 37877509 DOI: 10.2174/0113816128257514231019165809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023]
Abstract
Worldwide, adrenaline is considered the first choice therapy in the international guidelines for the management of anaphylaxis. However, the heart and cardiovascular apparatus are strongly involved in anaphylaxis; for that reason, there are some cardiac conditions and certain anaphylaxis patterns that make epinephrine use problematic without adequate heart monitoring. The onset of Kounis syndrome, takotsubo cardiopathy, or the paradoxical anaphylaxis require great attention in the management of anaphylaxis and adrenaline administration by clinicians, who should be aware of the undervalued evolution of anaphylaxis and the potential cardiologic complications of epinephrine administration. Numerous case reports and studies describe the unexpected onset of cardiac diseases following epinephrine treatment, despite the latter being the recommended therapy for anaphylaxis. Our review suggests that future anaphylaxis guidelines should incorporate cardiovascular specialists since the treatment of Kounis syndrome or takotsubo cardiopathy requires cardiologist skills.
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Affiliation(s)
| | - Michael P Savage
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, USA
| | | | - Eustachio Nettis
- Department of Emergency and Organ Transplantation, School and Chair of Allergy and Clinical Immunology, University of Bari "Aldo Moro", Bari, Italy
| | | | - Caterina Foti
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine 'G. Baccelli', University of Bari "Aldo Moro", Bari, Italy
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Patras 26221, Greece
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Rabkin SW, Tang JKK. Clozapine-induced Myocarditis: Pathophysiologic Mechanisms and Implications for Therapeutic Approaches. Curr Mol Pharmacol 2023; 16:60-70. [PMID: 35152873 DOI: 10.2174/1874467215666220211094910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/19/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022]
Abstract
Clozapine, a superior treatment for treatment-resistant schizophrenia can cause potentially life-threatening myocarditis and dilated cardiomyopathy. While the occurrence of this condition is well known, its molecular mechanisms are unclear and may be multifactorial. Putative mechanisms warrant an in-depth review not only from the perspective of toxicity but also for understanding the molecular mechanisms of the adverse cardiac effects of clozapine and the development of novel therapeutic approaches. Clozapine-induced cardiac toxicity encompasses a diverse set of pathways, including (i) immune modulation and proinflammatory processes encompassing an IgEmediated (type I hypersensitivity) response and perhaps a cytokine release syndrome (ii) catecholaminergic activation (iii) induction of free radicals and oxidative stress (iv) activation of cardiomyocyte cell death pathways, including apoptosis, ischemia through impairment in coronary blood flow via changes in endothelial production of NO and vasoconstriction induced by norepinephrine as well as other factors released from cardiac mast cells. (v) In addition, an extensive examination of the effects of clozapine on non-cardiac cellular proteins demonstrates that clozapine can impair enzymes involved in cellular metabolism, such as pyruvate kinase, mitochondrial malate dehydrogenase, and other proteins, including α-enolase, triosephosphate isomerase and cofilin, which might explain clozapine-induced reductions in myocardial energy generation for cell viability as well as contractile function. Pharmacologic antagonism of these cellular protein effects may lead to the development of strategies to antagonize the cardiac damage induced by clozapine.
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Affiliation(s)
- Simon W Rabkin
- Division of Cardiology, University of British Columbia, Vancouver, B.C., Canada
| | - Jacky K K Tang
- Division of Cardiology, University of British Columbia, Vancouver, B.C., Canada
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Abstract
PURPOSE OF REVIEW Anaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management. RECENT FINDINGS Data from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data. SUMMARY The most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.
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Affiliation(s)
- Maria Teresa Ventura
- Unit of Geriatric Immunoallergology, University of Bari Medical School, Bari, Italy
| | - Elisa Boni
- Allergologia e Autoimmunità LUM, Maggiore Hospital, AUSL Bologna, Italy
| | - Luis Taborda-Barata
- UBIAir – Clinical & Experimental Lung Centre, University of Beira Interior, Covilhã and CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- Department of Immunoallergology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Hubert Blain
- Department of Geriatrics, Montpellier University Hospital, MUSE, Montpellier, France
| | - Jean Bousquet
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- University Hospital Montpellier, France
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Gao S, Liu K, Ku W, Wang D, Wake H, Qiao H, Teshigawara K, Nishibori M. Histamine induced high mobility group box-1 release from vascular endothelial cells through H1 receptor. Front Immunol 2022; 13:930683. [PMID: 36275732 PMCID: PMC9583674 DOI: 10.3389/fimmu.2022.930683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background Systemic allergic reaction is characterized by vasodilation and vascular leakage, which causes a rapid, precipitous and sustained decrease in arterial blood pressure with a concomitant decrease of cardiac output. Histamine is a major mediator released by mast cells in allergic inflammation and response. It causes a cascade of inflammation and strongly increases vascular permeability within minutes through its four G-protein-coupled receptors (GPCRs) on endothelial cells. High mobility group box-1 (HMGB1), a nonhistone chromatin-binding nuclear protein, can be actively secreted into the extracellular space by endothelial cells. HMGB1 has been reported to exert pro-inflammatory effects on endothelial cells and to increase vascular endothelial permeability. However, the relationship between histamine and HMGB1-mediated signaling in vascular endothelial cells and the role of HMGB1 in anaphylactic-induced hypotension have never been studied. Methods and results EA.hy 926 cells were treated with different concentrations of histamine for the indicated periods. The results showed that histamine induced HMGB1 translocation and release from the endothelial cells in a concentration- and time-dependent manner. These effects of histamine were concentration-dependently inhibited by d-chlorpheniramine, a specific H1 receptor antagonist, but not by H2 or H3/4 receptor antagonists. Moreover, an H1-specific agonist, 2-pyridylethylamine, mimicked the effects of histamine, whereas an H2-receptor agonist, 4-methylhistamine, did not. Adrenaline and noradrenaline, which are commonly used in the clinical treatment of anaphylactic shock, also inhibited the histamine-induced HMGB1 translocation in endothelial cells. We therefore established a rat model of allergic shock by i.v. injection of compound 48/80, a potent histamine-releasing agent. The plasma HMGB1 levels in compound 48/80-injected rats were higher than those in controls. Moreover, the treatment with anti-HMGB1 antibody successfully facilitated the recovery from compound 48/80-induced hypotension. Conclusion Histamine induces HMGB1 release from vascular endothelial cells solely through H1 receptor stimulation. Anti-HMGB1 therapy may provide a novel treatment for life-threatening systemic anaphylaxis.
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Affiliation(s)
- Shangze Gao
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing, China
| | - Keyue Liu
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Wenhan Ku
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Dengli Wang
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hidenori Wake
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Handong Qiao
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kiyoshi Teshigawara
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiro Nishibori
- Department of Translational Research and Drug Development, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- *Correspondence: Masahiro Nishibori,
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Combined Treatment with KV Channel Inhibitor 4-Aminopyridine and either γ-Cystathionine Lyase Inhibitor β-Cyanoalanine or Epinephrine Restores Blood Pressure, and Improves Survival in the Wistar Rat Model of Anaphylactic Shock. BIOLOGY 2022; 11:biology11101455. [PMID: 36290359 PMCID: PMC9598754 DOI: 10.3390/biology11101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
Simple Summary Allergic diseases are presenting a constant increase all over the world and caused by such different substances as food, drugs, and pollens. Anaphylactic shock is the more severe complication of allergy which can induce death if the treatment is not administered immediately. Some patients do not respond to the recommended treatment, intra venous or intramuscular epinephrine. The pathophysiology of anaphylactic shock is still under investigation. The mediators released after the activation of mast cells and basophiles act on endothelial cells and smooth muscle cells, inducing the vasodilation responsible for hypotension and shock. Nitric oxide and hydrogen sulphide are both intracellular mediators that induce vasodilation. The role of potassium voltage dependent channels is suspected. We aimed to demonstrate the ability of a blocker of potassium voltage dependent channels, 4-aminopyridine, alone or in combination with inhibitors of cystathionine γ-lyase to restore blood pressure and improve survival in an ovalbumin rat anaphylactic shock model. The blockade of potassium voltage dependent channels alone or combined with inhibitors of cystathionine γ-lyase, dl-propargylglycine, or β-cyanoalanine restored blood pressure and improved survival. These findings suggest possible investigative treatment pathways for research concerning epinephrine-refractory anaphylactic shock in patients. Abstract The mechanism of anaphylactic shock (AS) remains incompletely understood. The potassium channel blocker 4-aminopyridine (4-AP), the inhibitors of cystathionine γ-lyase (ICSE), dl-propargylglycine (DPG) or β-cyanoalanine (BCA), and the nitric oxide (NO) synthase produce vasoconstriction and could be an alternative for the treatment of AS. The aim of this study was to demonstrate the ability of L-NAME, ICSE alone or in combination with 4-AP to restore blood pressure (BP) and improve survival in ovalbumin (OVA) rats AS. Experimental groups included non-sensitized Wistar rats (n = 6); AS (n = 6); AS (n = 10 per group) treated i.v. with 4-AP (AS+4-AP), epinephrine (AS+EPI), AS+DPG, AS+BCA, or with L-NAME (AS+L-NAME); or AS treated with drug combinations 4-AP+DPG, 4-AP+BCA, 4-AP+L-NAME, or 4-AP+EPI. AS was induced by i.v. OVA (1 mg). Treatments were administered i.v. one minute after AS induction. Mean arterial BP (MAP), heart rate (HR), and survival were monitored for 60 min. Plasma levels of histamine, prostaglandin E2 (PGE2) and F2 (PGF2α), leukotriene B4 and C4, angiotensin II, vasopressin, oxidative stress markers, pH, HCO3, PaO2, PaCO2, and K+ were measured. OVA induced severe hypotension and all AS rats died. Moreover, 4-AP, 4-AP+EPI, or 4-AP+BCA normalized both MAP and HR and increased survival. All sensitized rats treated with 4-AP alone or with 4-AP+BCA survived. The time-integrated MAP “area under the curve” was significantly higher after combined 4-AP treatment with ICSE. Metabolic acidosis was not rescued and NO, ICSE, and Kv inhibitors differentially alter oxidative stress and plasma levels of anaphylactic mediators. The AS-induced reduction of serum angiotensin II levels was prevented by 4-AP treatment alone or in combination with other drugs. Further, 4-AP treatment combined with EPI or with BCA also increased serum PGF2α, whereas only the 4-AP+EPI combination increased serum LTB4. Serum vasopressin and angiotensin II levels were increased by 4-AP treatment alone or in combination with other drugs. Moreover, 4-AP alone and in combination with inhibition of cystathionine γ-lyase or EPI normalizes BP, increases serum vasoconstrictor levels, and improves survival in the Wistar rat model of AS. These findings suggest possible investigative treatment pathways for research into epinephrine-refractory anaphylactic shock in patients.
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11
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Sharma S, Zaher S, Rodrigues PRS, Davies LC, Edkins S, Strang A, Chakraborty M, Watkins WJ, Andrews R, Parkinson E, Angelopoulos N, Moet L, Shepherd F, Davies KMM, White D, Oram S, Siddall K, Keeping V, Simpson K, Faggian F, Bray M, Bertorelli C, Bell S, Collis RE, McLaren JE, Labeta M, O'Donnell VB, Ghazal P. mSep: investigating physiological and immune-metabolic biomarkers in septic and healthy pregnant women to predict feto-maternal immune health - a prospective observational cohort study protocol. BMJ Open 2022; 12:e066382. [PMID: 36115679 PMCID: PMC9486348 DOI: 10.1136/bmjopen-2022-066382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Maternal sepsis remains a leading cause of death in pregnancy. Physiological adaptations to pregnancy obscure early signs of sepsis and can result in delays in recognition and treatment. Identifying biomarkers that can reliably diagnose sepsis will reduce morbidity and mortality and antibiotic overuse. We have previously identified an immune-metabolic biomarker network comprising three pathways with a >99% accuracy for detecting bacterial neonatal sepsis. In this prospective study, we will describe physiological parameters and novel biomarkers in two cohorts-healthy pregnant women and pregnant women with suspected sepsis-with the aim of mapping pathophysiological drivers and evaluating predictive biomarkers for diagnosing maternal sepsis. METHODS AND ANALYSIS Women aged over 18 with an ultrasound-confirmed pregnancy will be recruited to a pilot and two main study cohorts. The pilot will involve blood sample collection from 30 pregnant women undergoing an elective caesarean section. Cohort A will follow 100 healthy pregnant women throughout their pregnancy journey, with collection of blood samples from participants at routine time points in their pregnancy: week 12 'booking', week 28 and during labour. Cohort B will follow 100 pregnant women who present with suspected sepsis in pregnancy or labour and will have at least two blood samples taken during their care pathway. Study blood samples will be collected during routine clinical blood sampling. Detailed medical history and physiological parameters at the time of blood sampling will be recorded, along with the results of routine biochemical tests, including C reactive protein, lactate and white blood cell count. In addition, study blood samples will be processed and analysed for transcriptomic, lipidomic and metabolomic analyses and both qualitative and functional immunophenotyping. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Wales Research Ethics Committee 2 (SPON1752-19, 30 October 2019). TRIAL REGISTRATION NUMBER NCT05023954.
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Affiliation(s)
- Simran Sharma
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
| | - Summia Zaher
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
| | - Patrícia R S Rodrigues
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Luke C Davies
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Sarah Edkins
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Angela Strang
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - W John Watkins
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
| | - Robert Andrews
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Edward Parkinson
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Nicos Angelopoulos
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Linda Moet
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Freya Shepherd
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Kate Megan Megan Davies
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Daniel White
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Shaun Oram
- Department of Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Kate Siddall
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Vikki Keeping
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Kathryn Simpson
- Department of Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Federica Faggian
- Department of Microbiology, University Hospital of Wales, Cardiff, UK
| | - Maryanne Bray
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Claire Bertorelli
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Sarah Bell
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Department of Anaesthesia and Critical Care, University of Wales Cardiff, Cardiff, UK
| | - Rachel E Collis
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - James E McLaren
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Mario Labeta
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Valerie B O'Donnell
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Peter Ghazal
- Project Sepsis, Systems Immunity Research Institute, Cardiff University Cardiff Institute of Infection and Immunity, Cardiff, UK
- Cardiff Division of Infection and Immunity, Cardiff University, Cardiff, UK
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Zeng R, Wang J, Liang Z, Zhang J, Wang Z, Xu C, Dong L. Association of atopic diseases with atrial fibrillation risk: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:877638. [PMID: 36110420 PMCID: PMC9468366 DOI: 10.3389/fcvm.2022.877638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
Abstract
Background Atopic diseases and atrial fibrillation (AF) seem to share an underlying inflammatory pathology. To date, some population-based studies have explored the relationship between the two. We aimed to conduct a meta-analysis to examine the role of atopic condition in AF risk. Methods All relevant observational studies in PubMed and EMBASE databases up to November 2021 were searched. In RevMan 5.3, we used random-effects or fixed-effects models to pool the effect sizes of hazard ratio (HR), odds ratio (OR) and their corresponding 95% confidence intervals (95% CI). In addition, I2 and Cochran Q test were used to evaluate the heterogeneity. Results A total of 2488 records were retrieved. After screening according to the predetermined criteria, 6 cohort studies and 2 case-control studies were included in this meta-analysis. Herein, the meta-analysis of 6 cohort studies suggested that atopic diseases potentially increased the AF risk with the pooled HR of 1.26 (95%CI,1.14–1.39), while the pooled effect size (OR, 1.04; 95%CI,0.74–1.46) of 2 case-control studies was not statistically significant. Based on the types of atopic diseases, further subgroup analyses of 6 cohort studies revealed that asthma, allergic rhinitis, and atopic dermatitis all potentially increased the risk of subsequent AF with the pooled HR of 1.41 (n = 4; 95%CI, 1.25–1.58), 1.12 (n = 1; 95%CI,1.10–1.14) and 1.06 (n = 3; 95%CI, 1.01–1.12), respectively. Conclusion This meta-analysis demonstrated that patients with atopic diseases have a higher risk of developing AF, particularly those with asthma.
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Affiliation(s)
- Rong Zeng
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jing Wang
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ziting Liang
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jintao Zhang
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zihan Wang
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Changjuan Xu
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Liang Dong
- Department of Respiratory, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Shandong University, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- *Correspondence: Liang Dong,
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Pollen Exposure and Cardiopulmonary Health Impacts in Adelaide, South Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159093. [PMID: 35897462 PMCID: PMC9331296 DOI: 10.3390/ijerph19159093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/22/2022]
Abstract
(1) Background: Limited research has suggested that cardiopulmonary health outcomes should be considered in relation to pollen exposure. This study sets out to test the relationship between pollen types (grasses, trees, weeds) and cardiovascular, lower respiratory and COPD health outcomes using 15 years (2003–2017) of data gathered in Adelaide, South Australia; (2) Methods: A time-series analysis by months was conducted using cardiopulmonary data from hospital admissions, emergency presentations and ambulance callouts in relation to daily pollen concentrations in children (0–17) for lower respiratory outcomes and for adults (18+). Incidence rate ratios (IRR) were calculated over lags from 0 to 7 days; (3) Results: IRR increases in cardiovascular outcomes in March, May, and October were related to grass pollen, while increases in July, November, and December were related to tree pollen. IRRs ranged from IRR 1.05 (95% confidence interval (CI) 1.00–1.10) to 1.25 (95% CI 1.12–1.40). COPD increases related to grass pollen occurred only in May. Pollen-related increases were observed for lower respiratory outcomes in adults and in children; (4) Conclusion: Notable increases in pollen-related associations with cardiopulmonary outcomes were not restricted to any one season. Prevention measures for pollen-related health effects should be widened to consider cardiopulmonary outcomes.
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Assadi RR, Sadhu S, Fatima F, Bhat R, Shivappa P. Retrospective Analysis of Thalassemia Patients in Secondary Care Hospital: Ras Al Khaimah, United Arab Emirates. Adv Biomed Res 2022; 11:53. [PMID: 35982867 PMCID: PMC9379903 DOI: 10.4103/abr.abr_302_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/11/2021] [Accepted: 02/12/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Roomiyah Riyaz Assadi
- Department of Internal Medicine, RAK Medical and Health Sciences University, RAK, UAE
| | - Shria Sadhu
- Department of Internal Medicine, RAK Medical and Health Sciences University, RAK, UAE
| | - Farzeen Fatima
- Department of Internal Medicine, RAK Medical and Health Sciences University, RAK, UAE
| | - Raghavendra Bhat
- Department of Internal Medicine, RAK Medical and Health Sciences University, RAK, UAE
| | - Pooja Shivappa
- Department of Internal Medicine, RAK Medical and Health Sciences University, RAK, UAE,Address for correspondence: Dr. Pooja Shivappa, Department of Basic Sciences, RAK Medical and Health Sciences University, RAK, UAE. E-mail:
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Micaletto S, Ruetzler K, Bruesch M, Schmid-Grendelmeier P. Honey bee venom re-challenge during specific immunotherapy: prolonged cardio-pulmonary resuscitation allowed survival in a case of near fatal anaphylaxis. Allergy Asthma Clin Immunol 2022; 18:44. [PMID: 35655287 PMCID: PMC9164337 DOI: 10.1186/s13223-022-00687-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases. CASE PRESENATION We report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min. CONCLUSION This intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.
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Affiliation(s)
- Sara Micaletto
- Allergy Unit, Dept. of Dermatology, University Hospital and University of Zürich, Zurich, Switzerland.
| | - Kurt Ruetzler
- Institute for Anesthesiology, University Hospital and University of Zürich, Zurich, Switzerland.,Cleveland Clinic, Anesthesiology Institute, Departments of Outcomes Research and General Anesthesia, Cleveland, OH, USA
| | - Martin Bruesch
- Institute for Anesthesiology, University Hospital and University of Zürich, Zurich, Switzerland
| | - Peter Schmid-Grendelmeier
- Allergy Unit, Dept. of Dermatology, University Hospital and University of Zürich, Zurich, Switzerland
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Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review. J Clin Med 2022; 11:jcm11102811. [PMID: 35628936 PMCID: PMC9143688 DOI: 10.3390/jcm11102811] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 12/17/2022] Open
Abstract
The aim of the present study is to describe pharmacological characteristics of drug-related allergies and anaphylaxis leading to the emergency department (ED). An 8-year post hoc analysis on the MEREAFaPS Study database was performed (2012−2019). Subjects who experienced drug-related hypersensitivity leading to an ED visit were selected. Logistic regression analyses were used to estimate the reporting odds ratios (RORs) of drug-related allergies and anaphylaxis adjusting for sex, age classes, and ethnicity. In addition, a systematic review of observational studies evaluating drug-related hypersensitivity reactions leading to ED visits in outpatients was performed. Out of 94,073 ED visits, 14.4% cases were drug-related allergies and 0.6% were anaphylaxis. Females accounted for 56%. Multivariate logistic regression showed a higher risk of drug-related allergy among males and all age classes < 65 years, while a higher risk of anaphylaxis was observed for females (ROR 1.20 [1.01−1.42]) and adults (ROR 2.63 [2.21−3.14]). The systematic review included 37 studies. ED visits related to allergy and anaphylaxis ranged from 0.004% to 88%, and drug-related allergies and anaphylaxis ranged from 0.007% to 88%. Both in our analysis and in primary studies, antibacterials, analgesics, and radiocontrast agents were identified as the most common triggers of hypersensitivity.
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Oulehri W, Collange O, Tacquard C, Bellou A, Graff J, Charles AL, Geny B, Mertes PM. Impaired Myocardial Mitochondrial Function in an Experimental Model of Anaphylactic Shock. BIOLOGY 2022; 11:730. [PMID: 35625458 PMCID: PMC9139016 DOI: 10.3390/biology11050730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/07/2022]
Abstract
Anaphylactic shock (AS) is associated with a profound vasodilation and cardiac dysfunction. The cellular mechanisms underlying AS-related cardiac dysfunction are unknown. We hypothesized that myocardial mitochondrial dysfunction may be associated with AS cardiac dysfunction. In controls and sensitized Brown Norway rats, shock was induced by ovalbumin i.v bolus, and abdominal aortic blood flow (ABF), systemic mean arterial pressure (MAP), and lactatemia were measured for 15 min. Myocardial mitochondrial function was assessed with the evaluation of mitochondrial respiration, oxidative stress production by reactive oxygen species (ROS), reactive nitrogen species (RNS), and the measurement of superoxide dismutases (SODs) activity. Oxidative damage was assessed by lipid peroxidation. The mitochondrial ultrastructure was assessed using transmission electronic microscopy. AS was associated with a dramatic drop in ABF and MAP combined with a severe hyperlactatemia 15 min after shock induction. CI-linked substrate state (197 ± 21 vs. 144 ± 21 pmol/s/mg, p < 0.05), OXPHOS activity by complexes I and II (411 ± 47 vs. 246 ± 33 pmol/s/mg, p < 0.05), and OXPHOS activity through complex II (316 ± 40 vs. 203 ± 28 pmol/s/mg, p < 0.05) were significantly impaired. ROS and RNS production was not significantly increased, but SODs activity was significantly higher in the AS group (11.15 ± 1.02 vs. 15.50 ± 1.40 U/mL/mg protein, p = 0.02). Finally, cardiac lipid peroxidation was significantly increased in the AS group (8.50 ± 0.67 vs. 12.17 ± 1.44 µM/mg protein, p < 0.05). No obvious changes were observed in the mitochondrial ultrastructure between CON and AS groups. Our experimental model of AS results in rapid and deleterious hemodynamic effects and was associated with a myocardial mitochondrial dysfunction with oxidative damage and without mitochondrial ultrastructural injury.
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Affiliation(s)
- Walid Oulehri
- Pôle Anesthésie, Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France; (W.O.); (O.C.); (C.T.)
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
| | - Olivier Collange
- Pôle Anesthésie, Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France; (W.O.); (O.C.); (C.T.)
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
| | - Charles Tacquard
- Pôle Anesthésie, Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France; (W.O.); (O.C.); (C.T.)
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Academy of Medical Sciences, Guangdong General People Hospital, Guangzhou 510060, China;
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Global Healthcare Network & Research Innovation Institute LLC, Brookline, MA 02446, USA
| | - Julien Graff
- Faculté de Médecine de Strasbourg, Institut d’Histologie, Service Central de Microscopie Électronique, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France;
| | - Anne-Laure Charles
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
- Service de Physiologie et d’Explorations Fonctionnelles, Pôle de Pathologie Thoracique, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France
| | - Bernard Geny
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
- Service de Physiologie et d’Explorations Fonctionnelles, Pôle de Pathologie Thoracique, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France
| | - Paul-Michel Mertes
- Pôle Anesthésie, Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg, France; (W.O.); (O.C.); (C.T.)
- Faculté de Médecine de Strasbourg, UR 3072 Institut de Physiologie, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Université de Strasbourg, 67091 Strasbourg, France; (A.-L.C.); (B.G.)
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Lim S, Leach SB. ECG of the Month. J Am Vet Med Assoc 2022; 260:1-4. [PMID: 35482561 DOI: 10.2460/javma.21.01.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | - Stacey B Leach
- 1BluePearl Pet Hospital, New Braunfels, TX.,2Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO
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Gaudio FG, Johnson DE, DiLorenzo K, Anderson A, Musi M, Schimelpfenig T, Leemon D, Blair-Smith C, Lemery J. Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis. Wilderness Environ Med 2022; 33:75-91. [PMID: 35120856 DOI: 10.1016/j.wem.2021.11.009] [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: 02/03/2021] [Revised: 10/01/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.
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Affiliation(s)
- Flavio G Gaudio
- Department of Emergency Medicine, New York Presbyterian-Weill Cornell Medicine, New York, NY.
| | | | - Kelly DiLorenzo
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Arian Anderson
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Martin Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Drew Leemon
- National Outdoor Leadership School, Lander, WY
| | | | - Jay Lemery
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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20
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Sagliocco O, Betelli M. Comment on Fierro et al. Severe Hypotension, Bradycardia and Asystole after Sugammadex Administration in an Elderly Patient. Medicina 2021, 57, 79. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010122. [PMID: 35056430 PMCID: PMC8778466 DOI: 10.3390/medicina58010122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/26/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Orlando Sagliocco
- Intensive Care Unit, Bolognini Hospital, ASST Bergamo Est, 24068 Seriate, Italy
- Correspondence:
| | - Mauro Betelli
- Internal Medicine Department, Bolognini Hospital, ASST Bergamo Est, 24068 Seriate, Italy;
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21
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Clemen B, Nwosu I, Chukwuka N, Cordeiro NL, Ibeson E, Gulati A, Ayzenberg S, Weindorf B. Recognizing Kounis Syndrome: A Report of Type 2 Kounis Syndrome and a Brief Review of Management. Cureus 2021; 13:e19712. [PMID: 34934576 PMCID: PMC8684398 DOI: 10.7759/cureus.19712] [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] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.
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Affiliation(s)
- Britney Clemen
- Internal Medicine, Maimonides Medical Center, New York City, USA
| | - Ifeanyi Nwosu
- Internal Medicine, Maimonides Medical Center, New York City, USA
| | | | | | - Emeka Ibeson
- Internal Medicine, Maimonides Medical Center, New York City, USA
| | - Amit Gulati
- Internal Medicine, Maimonides Medical Center, New York City, USA
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22
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Castagnoli R, Giovannini M, Mori F, Barni S, Pecoraro L, Arasi S, Saretta F, Mastrorilli C, Liotti L, Caminiti L, Sturm GJ, Marseglia GL, Novembre E. Unusual Reactions to Hymenoptera Stings: Current Knowledge and Unmet Needs in the Pediatric Population. Front Med (Lausanne) 2021; 8:717290. [PMID: 34901051 PMCID: PMC8661053 DOI: 10.3389/fmed.2021.717290] [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: 05/30/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Hymenoptera stings are generally well-tolerated and usually cause limited local reactions, characterized by self-resolving erythema and edema associated with pain. However, Hymenoptera stings can induce immediate and delayed hypersensitivity reactions. In addition to these manifestations, unusual reactions to Hymenoptera stings have been reported. The latter are defined as unusual because of their atypical characteristics. They may differ from classical hypersensitivity reactions due to the stings' particular localization and the unusual involvement of one or more specific organs. Although unusual reactions to Hymenoptera stings are infrequent, it is essential for clinicians to know the possible related clinical manifestations. Here, we review the available literature and propose a diagnostic and management algorithm. At present, there are no defined guidelines for most of the unusual reactions to Hymenoptera stings, which should be managed in a tailored way according to the specifical clinical manifestations presented by the patients. Further studies are needed to better define these conditions and the underlying pathogenetic mechanisms to improve the diagnostic and therapeutic approach.
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Affiliation(s)
- Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Luca Pecoraro
- Department of Medicine, University of Verona, Policlinico GB Rossi, Verona, Italy.,Pediatric Unit, ASST Mantua, Mantua, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Lucia Liotti
- Department of Pediatrics, Salesi Children's Hospital, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age "Gaetano Barresi," Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Gunter Johannes Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria.,Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Gian Luigi Marseglia
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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23
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Kounis syndrome associated with COVID-19 infection: cause or coincidence? COR ET VASA 2021. [DOI: 10.33678/cor.2021.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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24
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Ahuja V, Sharma H, Singla V. Imipenem-induced paroxysmal supraventricular tachycardia in a sepsis patient. J Anaesthesiol Clin Pharmacol 2021; 37:293-294. [PMID: 34349383 PMCID: PMC8289649 DOI: 10.4103/joacp.joacp_409_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/06/2020] [Accepted: 03/14/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Vanita Ahuja
- Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Harjit Sharma
- Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Vaishali Singla
- Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
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25
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Yuste-Montalvo A, Fernandez-Bravo S, Oliva T, Pastor-Vargas C, Betancor D, Goikoetxea MJ, Laguna JJ, López JA, Alvarez-Llamas G, Cuesta-Herranz J, Martin-Lorenzo M, Esteban V. Proteomic and Biological Analysis of an In Vitro Human Endothelial System in Response to Drug Anaphylaxis. Front Immunol 2021; 12:692569. [PMID: 34248989 PMCID: PMC8269062 DOI: 10.3389/fimmu.2021.692569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022] Open
Abstract
Anaphylaxis is a life-threatening systemic hypersensitivity reaction. During anaphylaxis, mediator release by effector cells causes endothelial barrier breakdown, increasing vascular permeability and leakage of fluids, which may lead to tissue edema. Although endothelial cells (ECs) are key players in this context, scant attention has been paid to the molecular analysis of the vascular system, and further analyses of this cell type are necessary, especially in humans. The protein expression pattern of human microvascular ECs was analyzed in response to sera from anaphylactic patients (EC-anaphylaxis) and sera from non-allergic subjects (EC-control) after 2 hours of contact. Firstly, a differential quantitative proteomic analysis of the protein extracts was performed by mass spectrometry using an isobaric labeling method. Second, the coordinated behavior of the identified proteins was analyzed using systems biology analysis (SBA). The proteome of the EC-anaphylaxis system showed 7,707 proteins, of which 1,069 were found to be significantly altered between the EC-control and EC-anaphylaxis groups (p-value < 0.05). Among them, a subproteome of 47 proteins presented a high rate of change (|ΔZq| ≥ 3). This panel offers an endothelial snapshot of the anaphylactic reaction. Those proteins with the highest individual changes in abundance were hemoglobin subunits and structural support proteins. The interacting network analysis of this altered subproteome revealed that the coagulation and complement systems are the main biological processes altered in the EC-anaphylactic system. The comprehensive SBA resulted in 5,512 functional subcategories (biological processes), 57 of which were significantly altered between EC-control and EC-anaphylaxis. The complement system, once again, was observed as the main process altered in the EC system created with serum from anaphylactic patients. Findings of the current study further our understanding of the underlying pathophysiological mechanisms operating in anaphylactic reactions. New target proteins and relevant signaling pathways operating in the in vitro endothelial-serum system have been identified. Interestingly, our results offer a protein overview of the micro-EC-anaphylaxis environment. The relevance of the coagulation, fibrinolytic, contact and complement systems in human anaphylaxis is described. Additionally, the untargeted high-throughput analysis used here is a novel approach that reveals new pathways in the study of the endothelial niche in anaphylaxis.
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Affiliation(s)
- Alma Yuste-Montalvo
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Sergio Fernandez-Bravo
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Tamara Oliva
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Carlos Pastor-Vargas
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Red de ASMA, REACCIONES ADVERSAS Y ALÉRGICAS (ARADyAL), Instituto de Salud Carlos III, Madrid, Spain.,Department of Biochemistry and Molecular Biology, Universidad Complutense de Madrid, Madrid, Spain
| | - Diana Betancor
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Department of Allergy, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - María José Goikoetxea
- Red de ASMA, REACCIONES ADVERSAS Y ALÉRGICAS (ARADyAL), Instituto de Salud Carlos III, Madrid, Spain.,Department of Allergy and Clinic Immunology, IdiSNA, Clínica Universidad de Navarra, Pamplona, Spain
| | - José Julio Laguna
- Red de ASMA, REACCIONES ADVERSAS Y ALÉRGICAS (ARADyAL), Instituto de Salud Carlos III, Madrid, Spain.,Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
| | - Juan Antonio López
- Cardiovascular Proteomics Laboratory, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Gloria Alvarez-Llamas
- Inmunoallergy and Proteomics Laboratory, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, UAM, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Cuesta-Herranz
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Red de ASMA, REACCIONES ADVERSAS Y ALÉRGICAS (ARADyAL), Instituto de Salud Carlos III, Madrid, Spain.,Department of Allergy, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Marta Martin-Lorenzo
- Inmunoallergy and Proteomics Laboratory, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, UAM, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Vanesa Esteban
- Allergy and Inmunology Department, Instituto de Investigaciones Sanitarias (ISS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Red de ASMA, REACCIONES ADVERSAS Y ALÉRGICAS (ARADyAL), Instituto de Salud Carlos III, Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
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26
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Long B, Gottlieb M. Emergency medicine updates: Anaphylaxis. Am J Emerg Med 2021; 49:35-39. [PMID: 34052784 DOI: 10.1016/j.ajem.2021.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Anaphylaxis is a potentially deadly condition that requires emergent therapy. While frequently treated in the emergency department (ED), recent evidence updates may improve the diagnosis and management of this condition. OBJECTIVE This paper evaluates key evidence-based updates concerning the diagnosis and management of anaphylaxis for the emergency clinician. DISCUSSION The presentation of anaphylaxis can vary. Current diagnostic criteria can be helpful when evaluating patients for anaphylaxis, though multiple criteria exist. While the most common causes of anaphylaxis include medications, insect venom, and foods, recent literature has identified an IgE antibody response to mammalian galactose alpha-1,3-galactose, known as alpha-gal anaphylaxis. Epinephrine is the first-line therapy and is given in doses of 0.01 mg/kg (up to 0.5 mg in adults) intramuscularly (IM) in the anterolateral thigh. Intravenous (IV) epinephrine administration is recommended in patients refractory to IM epinephrine and IV fluids, or those with cardiovascular collapse. Antihistamines and glucocorticoids should not delay administration of epinephrine and do not demonstrate a significant reduction in risk of biphasic reactions. Biphasic reactions may affect 1-7% of patients with anaphylaxis. Risk factors for biphasic reaction include severe initial presentation and repeated doses of epinephrine. Disposition of patients with anaphylaxis requires consideration of several factors. CONCLUSIONS Emergency clinicians must be aware of current updates in the evaluation and management of this disease.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Increased Risk of Atrial Fibrillation in Patients with Atopic Triad: A Nationwide Population-Based Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3422-3430.e5. [PMID: 33965590 DOI: 10.1016/j.jaip.2021.04.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite a sharp increase in the global prevalence of allergy over the past decade, the relation between multiple atopic conditions and atrial fibrillation (AF) has not been fully elucidated. OBJECTIVE To determine whether there is an association between atopic diseases and AF and to examine the effect of multiple atopic diseases on the incidence of AF. METHODS This retrospective population-based study used the database from the 2009 National Health Insurance Services-Health Screening Cohort in Korea. A total of 6,748,564 subjects without a previous history of AF were included in the final analysis and observed until 2017. The atopic triad included asthma, allergic rhinitis, and atopic dermatitis. A total of 1,168,196 subjects (17.3%) with at least one atopic disease were classified as the atopic group. The primary outcome was new-onset AF. RESULTS During a median 7.2 ± 1.0 years of follow-up, 136,253 subjects were given the new diagnosis of AF (30,300 in the atopic group and 105,953 in the nonatopic group). The incidence of AF was 3.63/1000 person-years in the atopic group and 2.64/1000 person-years in the nonatopic group. The risk for AF showed a positive correlation with the number of diseases in the atopic triad (adjusted hazard ratio [aHR], 95% confidence interval [CI]: one disease: aHR = 1.15, CI, 1.14-1.17; two diseases: aHR = 1.34, CI, 1.31-1.38; and three diseases: aHR = 1.35, CI, 1.11-1.66; P for trend < .001). CONCLUSIONS The atopic triad of asthma, allergic rhinitis, and atopic dermatitis was associated with an increased risk for AF. Moreover, multiple atopic conditions have a higher risk for AF.
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PGE2 deficiency predisposes to anaphylaxis by causing mast cell hyperresponsiveness. J Allergy Clin Immunol 2020; 146:1387-1396.e13. [DOI: 10.1016/j.jaci.2020.03.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/22/2020] [Accepted: 03/31/2020] [Indexed: 12/12/2022]
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29
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A reversal of fortune: A case of cardiovascular collapse following protamine sulfate infusion. HeartRhythm Case Rep 2020; 6:322-324. [PMID: 32577386 PMCID: PMC7300346 DOI: 10.1016/j.hrcr.2020.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Anti-Anaphylactic Activity of Isoquercitrin (Quercetin-3-O-β-d-Glucose) in the Cardiovascular System of Animals. Biomedicines 2020; 8:biomedicines8060139. [PMID: 32486018 PMCID: PMC7345749 DOI: 10.3390/biomedicines8060139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
Effects of isoquercitrin (IQ) on anaphylactic responses were examined in cardiovascular systems of experimental animals. In pithed rats, IQ at 30 and 100 mg/kg (intravenous) significantly blunted both the initial hypertensive and the ensuing hypotensive responses during anaphylaxis. Death rate and tachycardia were also significantly inhibited after the same IQ doses in these rats. In isolated guinea pig hearts, IQ infusion at 30–100 μg/mL markedly reduced anaphylaxis-related coronary flow decrease, contractile force change, and heart rate responses (both tachycardia and arrhythmia). Cardiac histamine and creatine kinase releases were similarly diminished by IQ during anaphylaxis in the isolated guinea pig hearts. In two different isolated guinea pig vasculatures, the pulmonary artery and mesenteric arterial bed, anaphylactic vasoconstriction was reduced by IQ 30 and 100 μg/mL. It was observed that IQ had a marked inhibitory effect on histamine release from rat mast cells, and this mechanism was suggested as the major anti-anaphylactic mechanism. Direct inhibition of histamine-induced muscle contraction did not seem to be relevant, but IQ treatment successfully repressed intracellular calcium influx/depletion in mast cells. Overall, this study provided evidence for the beneficial effect of IQ on cardiac anaphylaxis, thus suggesting its potential applications in the treatment and prevention of related diseases.
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Regateiro FS, Marques ML, Gomes ER. Drug-Induced Anaphylaxis: An Update on Epidemiology and Risk Factors. Int Arch Allergy Immunol 2020; 181:481-487. [PMID: 32396909 DOI: 10.1159/000507445] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/23/2020] [Indexed: 11/19/2022] Open
Abstract
Drug hypersensitivity is one of the most frequent causes of anaphylaxis, particularly in adults and in hospitalized patients. Drug-induced anaphylaxis (DIA) is also associated with more severe outcomes than other anaphylaxis triggers, and drugs are responsible for the majority of deaths due to anaphylaxis. We here review the current knowledge on the incidence, prevalence, drugs involved, mortality, and mortality risk factors for DIA. The incidence of both anaphylaxis and DIA seems to be increasing worldwide. Antibiotics and analgesics are the most frequently reported triggers of DIA. However, the importance of other drug groups should be taken into account, especially in particular settings (e.g., peri-operative and oncology). The identification of risk factors, geographical variables, and drugs associated with higher risk for DIA may improve the outcomes of this entity.
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Affiliation(s)
- Frederico S Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, .,Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal, .,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal,
| | - Maria Luís Marques
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Rebelo Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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32
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Chapsa M, Roensch H, Langner M, Beissert S, Bauer A. Predictors of severe anaphylaxis in Hymenoptera venom allergy: The importance of absence of urticaria and angioedema. Ann Allergy Asthma Immunol 2020; 125:72-77. [PMID: 32199978 DOI: 10.1016/j.anai.2020.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/08/2020] [Accepted: 03/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Severe anaphylaxis (SA) in Hymenoptera venom allergy has been associated with a number of risk factors. However, the effect of several of those risk factors on the severity of anaphylaxis is poorly defined. OBJECTIVE To evaluate risk factors for SA in Hymenoptera venom allergy. METHODS We evaluated data from 500 patients who were referred to our department for the diagnosis of Hymenoptera venom allergy during a period of 11 years to identify risk factors for SA. RESULTS Six significant risk factors for SA were identified (P < .05): short interval from sting to reaction, absence of urticaria or angioedema (U/A) during anaphylaxis, older age, male sex, elevation of baseline serum tryptase (BST) level, and diagnosis of systemic mastocytosis. Moreover, elevation in BST level was significantly associated with the absence of U/A and older age. No association could be established between SA and comorbidities, concurrent cardiovascular medication, or the severity of the systemic reaction during the initiation of venom immunotherapy. CONCLUSION Apart from BST and older age, male sex, short interval from sting to reaction, and absence of U/A are also risk factors for SA. The association between elevated BST level and SA was largely confined to those who had an absence of U/A after field sting, possibly because of the higher risk of concurrent systemic mastocytosis. Patients with an SA after a field sting do not have an elevated risk of systemic reactions during the initiation of venom immunotherapy compared with patients with mild anaphylaxis; therefore, additional preventive measures are not necessary.
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Affiliation(s)
- Maria Chapsa
- Dermatology Clinic, University Hospital Dresden, Dresden, Germany.
| | | | - Mathias Langner
- Dermatology Clinic, University Hospital Dresden, Dresden, Germany
| | - Stefan Beissert
- Dermatology Clinic, University Hospital Dresden, Dresden, Germany
| | - Andrea Bauer
- Dermatology Clinic, University Hospital Dresden, Dresden, Germany
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33
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Ingebrigtsen TS, Marott JL, Vestbo J, Nordestgaard BG, Lange P. Coronary heart disease and heart failure in asthma, COPD and asthma-COPD overlap. BMJ Open Respir Res 2020; 7:7/1/e000470. [PMID: 33371008 PMCID: PMC7011896 DOI: 10.1136/bmjresp-2019-000470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/22/2019] [Accepted: 12/10/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION We investigated risk of coronary heart disease and heart failure in phenotypes of obstructive airway disease. METHODS Among 91 692 participants in the Copenhagen General Population Study, 42 058 individuals were classified with no respiratory disease, and 11 988 individuals had different phenotypes of obstructive airways disease: asthma with early onset or late-onset, chronic obstructive pulmonary disease (COPD) with forced expiratory volume in one second (FEV1) above or below 50% of predicted value (%p) or asthma-COPD overlap (ACO). RESULTS During a mean follow-up of 5.7 years we registered 3584 admissions for coronary heart disease and 1590 admissions for heart failure. Multivariable Cox regression analyses of time to first admission were used with a two-sided p value of 0.05 as significance level. Compared with no respiratory disease the highest risks of coronary heart disease and heart failure were observed in ACO with late-onset asthma and FEV1 <50% p, HR=2.2 (95% CI 1.6 to 3.0), and HR=2.9 (95% CI 2.0 to 4.3), respectively. In COPD with FEV1 above 50% p the HRs were 1.3 (95% CI 1.2 to 1.5) for coronary heart disease and 1.9 (95% CI 1.6 to 2.3) for heart failure. Asthma associated with increased risks of coronary heart disease and heart failure, however, in asthma without allergy the HR was 1.1 (95% CI 0.7 to 1.6) for coronary heart disease while individuals with allergy had an HR of 1.4 (95% CI 1.1 to 1.6). CONCLUSIONS Risks of coronary heart disease and heart failure were increased in asthma, COPD and ACO. In asthma, the risk of coronary heart disease depended on presence of allergy. We suggest that cardiovascular risk factors should be assessed systematically in individuals with obstructive airway disease with the potential to facilitate targeted treatments.
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Affiliation(s)
- Truls Sylvan Ingebrigtsen
- Respiratory Section, Department of Internal Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Jacob Louis Marott
- The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Frederiksberg, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Børge Grønne Nordestgaard
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Frederiksberg, Denmark.,Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lange
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark .,The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Frederiksberg, Denmark.,Medical department O, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Section of Epidemiology, Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Tacquard C, Oulehri W, Collange O, Garvey LH, Nicoll S, Tuzin N, Geny B, Mertes PM. Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock. Clin Exp Allergy 2019; 50:383-390. [DOI: 10.1111/cea.13540] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/28/2019] [Accepted: 11/10/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Charles Tacquard
- Department of anesthesia and intensive care Hôpitaux Universitaires de Strasbourg Nouvel Hôpital Civil Strasbourg France
- Groupe Méthode en Recherche Clinique Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil Strasbourg France
| | - Walid Oulehri
- Department of anesthesia and intensive care Hôpitaux Universitaires de Strasbourg Nouvel Hôpital Civil Strasbourg France
- EA 3072, Fédération de Médecine Translationnelle, Faculté de Médecine Université de Strasbourg Strasbourg France
| | - Olivier Collange
- Department of anesthesia and intensive care Hôpitaux Universitaires de Strasbourg Nouvel Hôpital Civil Strasbourg France
- EA 3072, Fédération de Médecine Translationnelle, Faculté de Médecine Université de Strasbourg Strasbourg France
| | - Lene H. Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Susan Nicoll
- Department of Anaesthesia Christchurch Hospital Christchurch New Zealand
| | - Nicolas Tuzin
- Groupe Méthode en Recherche Clinique Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil Strasbourg France
| | - Bernard Geny
- EA 3072, Fédération de Médecine Translationnelle, Faculté de Médecine Université de Strasbourg Strasbourg France
| | - Paul M. Mertes
- Department of anesthesia and intensive care Hôpitaux Universitaires de Strasbourg Nouvel Hôpital Civil Strasbourg France
- EA 3072, Fédération de Médecine Translationnelle, Faculté de Médecine Université de Strasbourg Strasbourg France
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Kounis Syndrome as First Manifestation of Allergic Sensitization. Case Rep Med 2019; 2019:6317956. [PMID: 31341482 PMCID: PMC6614985 DOI: 10.1155/2019/6317956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/24/2023] Open
Abstract
Mast cells are abundant in the heart, among myocardial fibers, around coronary arteries, within arterial intima and intramural vessels, and in atherosclerotic plaques. Their mediators can be released during anaphylaxis and be responsible for acute coronary syndrome. This condition has been described as Kounis syndrome (KS). We report three cases of acute myocardial ischemia, which fulfill the definition for KS. In Cases 1 and 2, the association of intense chest pain with acute urticaria after an allergenic contact (wasp sting and betalactam antibiotic administration, respectively) was suspected to be an attack of angina related to an allergic reaction. No signs of an allergic reaction were observed in Case 3, but only the history of a wasp sting suggested its relationship to loss of consciousness and heart ischemia when hypersensitivity to venom was ascertained. These cases strongly recommend measurement of anaphylactic biomarkers, such as tryptase, during acute coronary syndromes to detect the possible involvement of an allergic reaction. Conversely, measurement of cardiac biomarkers during anaphylaxis, even without obvious signs of myocardial ischemia, might identify patients at risk of myocardial injury.
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Abusnina W, Shehata M, Abouzid M, Price M, Zeid F. Kounis syndrome secondary to gadolinium contrast agent. Proc (Bayl Univ Med Cent) 2019; 32:253-255. [PMID: 31191145 DOI: 10.1080/08998280.2019.1581319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 12/16/2022] Open
Abstract
Cases of coronary artery spasm secondary to contrast agent use are rarely reported. Herein, we report the case of a 53-year-old woman who developed chest pain, dyspnea, and bradycardia and quickly become unresponsive after magnetic resonance imaging of the brain. A heart monitor showed ST elevation, and an electrocardiogram showed ST elevations in leads II, III, aVF, V3, and V4 and ST segment depression in lead I. Urgent left heart catheterization revealed no evidence of obstructive coronary artery disease or pulmonary embolism. A few days later, she was discharged from the hospital with no symptoms. A type I variant of Kounis syndrome was diagnosed.
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Affiliation(s)
- Waiel Abusnina
- Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Mena Shehata
- Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Mahmoud Abouzid
- Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Malesa Price
- Department of Family Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Fuad Zeid
- Department of Pulmonary Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
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Farhat E, Tegg E, Mohammed S, Grzechnik E, Favaloro EJ. Not as sweet as honey: A rare case of an apparent factor V "inhibitor" in association with bee sting anaphylaxis. Am J Hematol 2018; 93:965-970. [PMID: 29675861 DOI: 10.1002/ajh.25121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Elisabeth Farhat
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Elizabeth Tegg
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Elzbieta Grzechnik
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Emmanuel J. Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
- Sydney Centres for Thrombosis and Haemostasis; Westmead NSW Australia
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Tsoupras A, Lordan R, Zabetakis I. Inflammation, not Cholesterol, Is a Cause of Chronic Disease. Nutrients 2018; 10:E604. [PMID: 29757226 PMCID: PMC5986484 DOI: 10.3390/nu10050604] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 12/17/2022] Open
Abstract
Since the Seven Countries Study, dietary cholesterol and the levels of serum cholesterol in relation to the development of chronic diseases have been somewhat demonised. However, the principles of the Mediterranean diet and relevant data linked to the examples of people living in the five blue zones demonstrate that the key to longevity and the prevention of chronic disease development is not the reduction of dietary or serum cholesterol but the control of systemic inflammation. In this review, we present all the relevant data that supports the view that it is inflammation induced by several factors, such as platelet-activating factor (PAF), that leads to the onset of cardiovascular diseases (CVD) rather than serum cholesterol. The key to reducing the incidence of CVD is to control the activities of PAF and other inflammatory mediators via diet, exercise, and healthy lifestyle choices. The relevant studies and data supporting these views are discussed in this review.
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Affiliation(s)
- Alexandros Tsoupras
- Department of Biological Sciences, University of Limerick, V94 T9PX Limerick, Ireland.
| | - Ronan Lordan
- Department of Biological Sciences, University of Limerick, V94 T9PX Limerick, Ireland.
| | - Ioannis Zabetakis
- Department of Biological Sciences, University of Limerick, V94 T9PX Limerick, Ireland.
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Risk Factors and Cofactors for Severe Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Yang X, Feng X, Duan F, Wang Z, Raut MS, Swain B. Neostigmine-induced coronary spasm: Beware of Kounis syndrome. J Anaesthesiol Clin Pharmacol 2018; 34:123-124. [PMID: 29643637 PMCID: PMC5885428 DOI: 10.4103/joacp.joacp_268_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Xiaofei Yang
- Department of Cardiovascular Medicine, Shanxi Sencond Provincal People's Hospital, Xi'an, P.C 710005, China
| | - Xiaozhi Feng
- Department of Internal Medicine, Yanan University Affiliated Hospital, Xi'an, Shanxi, 716000, China
| | - Feiru Duan
- Xi'an Medicine University, Traditional Chinese Internal Medicine, Gaoxin District Campus, Xi'an Medicine University, 710075, Xi'an, Provence Shanxi, China
| | - Zhiyong Wang
- The Second Affiliated Hospital of Xi'an Jiaotong University, Traditional Chinese Medicine Department, Xi'an, Provence Shanxi, China, 710004, China
| | - Monish S Raut
- Department of Cardiac, AnesthesiologySir Ganga Ram Hospital, New Delhi, India
| | - Baryon Swain
- Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Tritt A, Gabrielli S, Zahabi S, Clarke A, Moisan J, Eisman H, Morris J, Restivo L, Shand G, Ben-Shoshan M. Short- and long-term management of cases of venom-induced anaphylaxis is suboptimal. Ann Allergy Asthma Immunol 2018; 121:229-234.e1. [PMID: 29656144 DOI: 10.1016/j.anai.2018.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Venom-induced anaphylaxis (VIA) accounts for severe reactions. However, little is known about the short- and long-term management of VIA patients. OBJECTIVE To assess the short- and long-term management of VIA. METHODS Using a national anaphylaxis registry (C-CARE), we identified VIA cases presenting to emergency departments in Montreal and to emergency medical services (EMSs) in western Quebec over a 4-year period. Data were collected on clinical characteristics, triggers, and management. Consenting patients were contacted annually regarding long-term management. Univariate and multivariate logistic regressions were used to identify factors associated with epinephrine use, allergist assessment, and administration of immunotherapy. RESULTS Between June 2013 and May 2017, 115 VIA cases were identified. Epinephrine was administered to 63.5% (95% confidence interval [CI], 53.9%-72.1%) of all VIA cases by a health care professional. Treatment of reactions without epinephrine was more likely in reactions occurring at home and in nonsevere cases (no hypotension, hypoxia, or loss of consciousness). Among 48 patients who responded to a follow-up questionnaire, 95.8% (95% CI, 84.6%-99.3%) were prescribed epinephrine auto-injector, 68.8% (95% CI, 53.6%-80.9%) saw an allergist who confirmed the allergy in 63.6% of cases, and 81.0% of those with positive testing were administered immunotherapy. Among cases with follow-up, seeing an allergist was less likely in patients with known ischemic heart disease. CONCLUSION Almost 30% of patients with suspected VIA did not see an allergist, only two thirds of those seeing an allergist had allergy confirmation, and almost one fifth of those with confirmed allergy did not receive immunotherapy. Educational programs are needed to bridge this knowledge-to-action gap.
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Affiliation(s)
- Ashley Tritt
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Sofianne Gabrielli
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sarah Zahabi
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ann Clarke
- Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jocelyn Moisan
- Regional Medical Director of Emergency Medical Services of Outaouais, Outaouais, Quebec, Canada
| | - Harley Eisman
- Department of Emergency Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Judy Morris
- Department of Emergency Medicine, Sacre-Coeur Hospital, Montreal, Quebec, Canada
| | - Lea Restivo
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Greg Shand
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
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Fiorito G, Vlaanderen J, Polidoro S, Gulliver J, Galassi C, Ranzi A, Krogh V, Grioni S, Agnoli C, Sacerdote C, Panico S, Tsai MY, Probst-Hensch N, Hoek G, Herceg Z, Vermeulen R, Ghantous A, Vineis P, Naccarati A. Oxidative stress and inflammation mediate the effect of air pollution on cardio- and cerebrovascular disease: A prospective study in nonsmokers. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2018; 59:234-246. [PMID: 29114965 DOI: 10.1002/em.22153] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/29/2017] [Accepted: 10/08/2017] [Indexed: 05/17/2023]
Abstract
Air pollution is associated with a broad range of adverse health effects, including mortality and morbidity due to cardio- and cerebrovascular diseases (CCVD), but the molecular mechanisms involved are not entirely understood. This study aims to investigate the involvement of oxidative stress and inflammation in the causal chain, and to identify intermediate biomarkers that are associated retrospectively with the exposure and prospectively with the disease. We designed a case-control study on CCVD nested in a cohort of 18,982 individuals from the EPIC-Italy study. We measured air pollution, inflammatory biomarkers, and whole-genome DNA methylation in blood collected up to 17 years before the diagnosis. The study sample includes all the incident CCVD cases among former- and never-smokers, with available stored blood sample, that arose in the cohort during the follow-up. We identified enrichment of altered DNA methylation in "ROS/Glutathione/Cytotoxic granules" and "Cytokine signaling" pathways related genes, associated with both air pollution (multiple comparisons adjusted p for enrichment ranging from 0.01 to 0.03 depending on pollutant) and with CCVD risk (P = 0.04 and P = 0.03, respectively). Also, Interleukin-17 was associated with higher exposure to NO2 (P = 0.0004), NOx (P = 0.0005), and CCVD risk (OR = 1.79; CI 1.04-3.11; P = 0.04 comparing extreme tertiles). Our findings indicate that chronic exposure to air pollution can lead to oxidative stress, which in turn activates a cascade of inflammatory responses mainly involving the "Cytokine signaling" pathway, leading to increased risk of CCVD. Inflammatory proteins and DNA methylation alterations can be detected several years before CCVD diagnosis in blood samples, being promising preclinical biomarkers. Environ. Mol. Mutagen. 59:234-246, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Giovanni Fiorito
- Italian Institute for Genomic Medicine (IIGM), Turin, Italy
- Department of Medical Sciences, University of Turin, Italy
| | - Jelle Vlaanderen
- Utrecht University, Institute for Risk Assessment Sciences, Environmental Epidemiology Division, Utrecht, Netherlands
| | | | - John Gulliver
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, UK
| | - Claudia Galassi
- Unit of Cancer Epidemiology, Città Della Salute e della Scienza University-Hospital and Center for Cancer Prevention (CPO), Turin, Italy
| | - Andrea Ranzi
- Environmental Health Reference Centre, Regional Agency for Prevention, Environment and Energy of Emilia-Romagna, Modena, Italy
| | - Vittorio Krogh
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Grioni
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudia Agnoli
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Carlotta Sacerdote
- Unit of Cancer Epidemiology, Città Della Salute e della Scienza University-Hospital and Center for Cancer Prevention (CPO), Turin, Italy
| | - Salvatore Panico
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Ming-Yi Tsai
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Nicole Probst-Hensch
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Gerard Hoek
- Utrecht University, Institute for Risk Assessment Sciences, Environmental Epidemiology Division, Utrecht, Netherlands
| | - Zdenko Herceg
- International Agency for Research on Cancer (IARC), Lyon, France
| | - Roel Vermeulen
- Utrecht University, Institute for Risk Assessment Sciences, Environmental Epidemiology Division, Utrecht, Netherlands
| | - Akram Ghantous
- International Agency for Research on Cancer (IARC), Lyon, France
| | - Paolo Vineis
- Italian Institute for Genomic Medicine (IIGM), Turin, Italy
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, UK
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Anaphylaxis in the Workplace. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Alvarez-Perea A, Tanno LK, Baeza ML. How to manage anaphylaxis in primary care. Clin Transl Allergy 2017; 7:45. [PMID: 29238519 PMCID: PMC5724339 DOI: 10.1186/s13601-017-0182-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022] Open
Abstract
Anaphylaxis is defined as a severe life-threatening generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or circulation problems. It presents with very different combinations of symptoms and apparently mild signs and can progress to fatal anaphylactic shock unpredictably. The difficulty in recognizing anaphylaxis is due, in part, to the variability of diagnostic criteria, which in turn leads to a delay in administration of appropriate treatment, thus increasing the risk of death. The use of validated clinical criteria can facilitate the diagnosis of anaphylaxis. Intramuscular epinephrine (adrenaline) is the medication of choice for the emergency treatment of anaphylaxis. Administration of corticosteroids and H1-antihistamines should not delay the administration of epinephrine, and the management of a patient with anaphylaxis should not end with the acute episode. Long-term management of anaphylaxis should include avoidance of triggers, following confirmation by an allergology study. Etiologic factors suspected in the emergency department often differ from the real causes of anaphylaxis. Evaluation of patients with a history of anaphylaxis should also include an assessment of personal data, such as age and comorbidities, which may increase the risk of severe reactions. Special attention should also be paid to co-factors, as these may easily confound the cause of the anaphylaxis. Patients experiencing anaphylaxis should administer epinephrine as soon as possible. Education (including the use of Internet and social media), written personalized emergency action plans, and self-injectable epinephrine have proven useful for the treatment of further anaphylaxis episodes.
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Affiliation(s)
- Alberto Alvarez-Perea
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Luciana Kase Tanno
- Hospital Sírio Libanês, São Paulo, Brazil
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier, France
- Pierre and Marie Curie Institute of Epidemiology and Public Health, Sorbonne Universités, Paris, France
| | - María L. Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
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Bambery B, Douglas T, Selgelid MJ, Maslen H, Giubilini A, Pollard AJ, Savulescu J. Influenza Vaccination Strategies Should Target Children. Public Health Ethics 2017; 11:221-234. [PMID: 30135702 PMCID: PMC6093440 DOI: 10.1093/phe/phx021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Strategies to increase influenza vaccination rates have typically targeted healthcare professionals (HCPs) and individuals in various high-risk groups such as the elderly. We argue that they should (instead or as well) focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies.
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Zhang T, Tanida M, Uchida K, Suzuki Y, Yang W, Kuda Y, Kurata Y, Tominaga M, Shibamoto T. Mouse Anaphylactic Hypotension Is Characterized by Initial Baroreflex Independent Renal Sympathoinhibition Followed by Sustained Renal Sympathoexcitation. Front Physiol 2017; 8:669. [PMID: 28936180 PMCID: PMC5594092 DOI: 10.3389/fphys.2017.00669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/23/2017] [Indexed: 01/14/2023] Open
Abstract
Aim: The hemodynamic response to mouse systemic anaphylaxis is characterized by an initial hypertension followed by sustained hypotension. However, the defense mechanisms of the sympathetic nervous system against this circulatory disturbance is not known. Here, we investigated the renal sympathetic nerve activity (RSNA) response to mouse systemic anaphylaxis, along with the roles of carotid sinus baroreceptor, vagal nerves and the transient receptor potential vanilloid type 1 channel (TRPV1). Methods: Male ovalbumin-sensitized C57BL/6N mice were used under pentobarbital anesthesia. RSNA, systemic arterial pressure (SAP) and heart rate (HR) were continuously measured for 60 min after the antigen injection. Results: Within 3 min after antigen injection, RSNA decreased along with a transient increase in SAP. Thereafter, RSNA showed a progressive increase during sustained hypotension. In contrast, HR continuously increased. Sinoaortic denervation, but not vagotomy, significantly attenuated the renal sympathoexcitation and tachycardia from 30 and 46 min, respectively, after antigen. The responses of RSNA, SAP and HR to anaphylaxis were not affected by pretreatment with a TRPV1 inhibitor, capsazepine, or by genetic knockout of TRPV1. Conclusion: The mouse systemic anaphylaxis causes a biphasic RSNA response with an initial baroreflex-independent decrease and secondary increase. The antigen-induced sympathoexcitation and tachycardia at the late stage are partly mediated by carotid sinus baroreceptors. Either vagal nerve or TRPV1 does not play any significant roles in the RSNA and HR responses in anesthetized mice.
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Affiliation(s)
- Tao Zhang
- Department of Physiology II, Kanazawa Medical UniversityUchinada, Japan.,Department of Colorectal and Hernia Surgery, The Fourth Affiliated Hospital of China Medical UniversityShenyang, China
| | - Mamoru Tanida
- Department of Physiology II, Kanazawa Medical UniversityUchinada, Japan
| | - Kunitoshi Uchida
- Division of Cell Signaling, Okazaki Institute for Integrative Bioscience, National Institute for Physiological Sciences, National Institutes of Natural SciencesOkazaki, Japan.,Department of Physiological Science and Molecular Biology, Fukuoka Dental CollegeFukuoka, Japan
| | - Yoshiro Suzuki
- Division of Cell Signaling, Okazaki Institute for Integrative Bioscience, National Institute for Physiological Sciences, National Institutes of Natural SciencesOkazaki, Japan
| | - Wei Yang
- Department of Physiology II, Kanazawa Medical UniversityUchinada, Japan.,Department of Infectious Disease, The Sheng Jing Hospital of China Medical UniversityShenyang, China
| | - Yuhichi Kuda
- Department of Physiology II, Kanazawa Medical UniversityUchinada, Japan
| | - Yasutaka Kurata
- Department of Physiology II, Kanazawa Medical UniversityUchinada, Japan
| | - Makoto Tominaga
- Division of Cell Signaling, Okazaki Institute for Integrative Bioscience, National Institute for Physiological Sciences, National Institutes of Natural SciencesOkazaki, Japan
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Rojas-Perez-Ezquerra P, Noguerado-Mellado B, Morales-Cabeza C, Zambrano Ibarra G, Datino Romaniega T. Atrial Fibrillation in Anaphylaxis. Am J Med 2017; 130:1114-1116. [PMID: 28601540 DOI: 10.1016/j.amjmed.2017.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/28/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The relationship between anaphylaxis and cardiovascular events has been reported in the past. While skin and respiratory symptoms are usually the most common and the first to appear, cardiovascular complications play a key role and represent the leading cause of death in anaphylaxis. METHODS We report 3 episodes of atrial fibrillation triggered by anaphylaxis. Allergy and cardiology studies were performed. In both patients, the etiological agent was identified: Anisakis simplex hypersensitivity and food allergy. RESULTS The heart is the source and target of chemical mediators released during an allergic reaction. In the heart, there are plenty of mast cells, and they are predominantly located around the coronary adventitia and in close contact with small vessels in the muscle wall. The release of mediators can influence ventricular function, heart rate, and coronary artery tone. Anaphylaxis can trigger any kind of arrhythmia. In these cases, the very interesting point of discussion was: which should be first, treating anaphylaxis or cardiac events? The other controversial point was the use of epinephrine, the first line of treatment for anaphylaxis. Recommendations about epinephrine in cardiac patients during an anaphylactic event are still a major dilemma. CONCLUSIONS We emphasize the importance of the priority of establishing protocols between cardiologist and allergist in treatment of cardiac complications during anaphylaxis, and we warn about the correct diagnosis of arrhythmias in anaphylaxis in order to treat them as soon as possible, to prevent other consequences and complications.
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Elicitors of severe allergic reactions - reports from allergists and emergency doctors. Allergol Select 2017; 1:14-20. [PMID: 30402597 PMCID: PMC6039994 DOI: 10.5414/alx01347e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 08/31/2010] [Indexed: 01/01/2023] Open
Abstract
Data from the anaphylaxis registry of German-speaking countries indicate that food is the most frequent elicitor of severe allergic reactions in children, insect venom is the most frequent elicitor in adults. The anaphylaxis registry considers data from patients of allergy centers. The aim of the present study was to collect data regarding elicitors, cofactors and the medical care of patients with severe allergic reactions seen by private practice allergists but also patients seen by emergency doctors. From June 2008 to December 2009 70 cases of severe allergic reactions from private practice allergists and 154 from emergency doctors in Berlin were registered. Our data show that the profile of elicitors differs among the reporting groups. The reported causes from allergists were severe reactions to food, insect venom and subcutaneous immunotherapy, the emergency doctors reported insect venom as the most frequent elicitor. Our data show that a systematic evaluation of severe allergic reactions can provide important data about elicitors and circumstances of anaphylaxis. Through a comparison with data from the anaphylaxis registry the analysis of the data from the emergency doctors will allow to determine how many patients with severe allergic reactions are seen by an allergist for further diagnostic work-up and subsequent therapy.
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