1
|
El-Sayed ZA, El-Owaidy R, Hussein SM, Hossam D, El-Sawi IH, Adel A, Almalky M, Elshebiny E, Ismaeel AY, Osman NS, Shoman W, Abdel Hafez MA, Ibrahim MAF, Salama AAB, Sobh A. Physicians' knowledge and practice concerning diagnosis and management of anaphylaxis: The situation in Egypt. Afr J Emerg Med 2021; 11:464-470. [PMID: 34765433 PMCID: PMC8567155 DOI: 10.1016/j.afjem.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/06/2021] [Accepted: 07/12/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Early recognition of an anaphylaxis event is crucial for instituting lifesaving management. We sought to explore knowledge and practice towards anaphylaxis in a sample of physicians from ten Egyptian governorates. Methods An eighteen question-based questionnaire was developed by expert allergists to evaluate the knowledge and practice towards anaphylaxis, based on the World Allergy Organization guidelines for the assessment and management of anaphylaxis. The questionnaires were distributed, and the answered forms collected via emails, and data were tabulated, and analysed. Results In this cross-sectional study, a total of 242 physicians completed the survey (183 (75.6%) paediatricians, 32 (13.2%) internists, 22 (9.1%) intensivists and five (2.1%) anaesthetists). Only 91 participants (37.6%) identified all the four proposed anaphylaxis clinical scenarios while 70, 45 and 36 identified three, two and one scenario, respectively. Loss of consciousness and abdominal symptoms were not recognised as possible presentations of anaphylaxis by 64.5% and 80.2% of the participants, respectively. Epinephrine was considered the first line treatment by 98 (40.5%), corticosteroids by 77 (31.8%) and antihistamines by 25 (10.3%). 75 (31%) responders identified the right dose of epinephrine while 119 (49.2%) identified the proper route. Concerning practice, 83 physicians (39.2%) used epinephrine for all cases of anaphylaxis, 88 (41.5%) used it for refractory cases only whereas 41 (19.3%) did not use epinephrine at all. Discussion Our survey shows that the knowledge of Egyptian physicians and their practice towards anaphylaxis are still inadequate. The current situation reinforces the need to disseminate and encourage the adoption of the international guidelines for anaphylaxis diagnosis and treatment.
Collapse
Affiliation(s)
- Zeinab Awad El-Sayed
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Rasha El-Owaidy
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
- Corresponding author.
| | | | - Dina Hossam
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Ihab H. El-Sawi
- Department of Pediatrics, Alexandria University, Alexandria, Egypt
| | - Ahmad Adel
- Department of Pediatrics, Suez General Hospital, Suez, Egypt
| | | | - Emad Elshebiny
- Department of Internal Medicine, Rheumatology and Immunology Division, Faculty of Medicine, Menoufia University, Egypt
| | - Ahmed Yehia Ismaeel
- Department of Internal Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Naglaa S. Osman
- Pediatric Allergy, Immunology and Rheumatology Unit, Department of Pediatrics, Assiut University, Faculty of Medicine, Assiut, Egypt
| | - Walaa Shoman
- Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
| | | | | | | | - Ali Sobh
- Department of Pediatrics, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| |
Collapse
|
2
|
Daniels L, Barker S, Chang YS, Chikovani T, DunnGalvin A, Gerdts JD, Gerth Van Wijk R, Gibbs T, Villarreal-Gonzalez RV, Guzman-Avilan RI, Hanna H, Hossny E, Kolotilina A, Ortega Martell JA, Pacharn P, de Lira Quezada CE, Sibanda E, Stukus D, Tham EH, Venter C, Gonzalez-Diaz SN, Levin ME, Martin B, Munblit D, Warner JO. Harmonizing allergy care-integrated care pathways and multidisciplinary approaches. World Allergy Organ J 2021; 14:100584. [PMID: 34820045 PMCID: PMC8591185 DOI: 10.1016/j.waojou.2021.100584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 01/14/2023] Open
Abstract
There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.
Collapse
Affiliation(s)
- Lydia Daniels
- Faculty of Medicine, Imperial College London, London, UK
| | - Sally Barker
- Faculty of Medicine, Imperial College London, London, UK
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Tinatin Chikovani
- Department of Immunology, Tbilisi State Medical University, Tbilisi, Georgia
| | - Audrey DunnGalvin
- Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Roy Gerth Van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Trevor Gibbs
- Association for Medical Education in Europe (AMEE), Dundee, Scotland, UK
- Independant Consultant in Primary Care and Medical Education, UK
| | - Rosalaura V. Villarreal-Gonzalez
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Rosa I. Guzman-Avilan
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Anastasia Kolotilina
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Punchama Pacharn
- Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cindy E. de Lira Quezada
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Elopy Sibanda
- Asthma, Allergy and Immune Dysfunction Clinic, Twin Palms Medical Centre, Harare, Zimbabwe
- Department of Pathology, Medical School, National University of Science and Technology, Bulawayo, Zimbabwe
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth Huiwen Tham
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Colorado, USA
| | - Sandra N. Gonzalez-Diaz
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Michael E. Levin
- Division of Paediatric Allergy, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Bryan Martin
- Division of Allergy and Immunology, Department of Otolaryngology, The Ohio State University, Columbus, OH, USA
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Solov'ev Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - John O. Warner
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
- Corresponding author. Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, SW3 6LY, UK.
| |
Collapse
|
3
|
Jain PD, Gupta RS, Chadha AS, Warren CM, Rao VV, Putcha UK. Knowledge, attitude, and practices of medical clinicians regarding food allergy and anaphylaxis in Hyderabad, India. Ann Allergy Asthma Immunol 2020; 125:560-564. [PMID: 32619591 DOI: 10.1016/j.anai.2020.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Food allergy (FA) is a chronic condition of emerging global concern. Surveys have been conducted in numerous countries to assess physician knowledge, attitude, and practices (KAP) pertaining to FA and anaphylaxis, and substantial deficits in their KAP were identified. OBJECTIVE To assess the KAP of medical clinicians in Hyderabad, India, with respect to FA and anaphylaxis. METHODS A regionally representative sample of 570 physicians including 113 general practitioners, 123 pediatricians, 110 pulmonologists, 113 dermatologists, and 111 gastroenterologists were recruited from all major institutions in Hyderabad, India. A validated questionnaire was used to assess their KAP. RESULTS Overall, 90% of questions were correctly answered and differences emerged with respect to specific items, namely the following: (1) the lateral thigh being the preferred location for epinephrine administration (P = .001); (2) a positive skin prick test or radioallergosorbent test is sufficient for FA diagnosis (P = .04); and (3) the appropriate epinephrine dose for a 27-kg child (P = .006). Approximately 95% of the participants in each group were confident in their ability to care for patients with FA, yet 91% desired additional periodic FA training sessions. CONCLUSION Survey findings suggest that although FA knowledge among South Indian clinicians seems high across all major specialties who care for patients with FA, there are differences in the level of knowledge among them, which in turn reflects the differences in attitude and approach toward their patients. These FA care providers still desire to further participate in continuing medical education efforts in the field of food allergy. Efforts to provide periodic training and education for all FA clinical care providers remain vital in South India.
Collapse
Affiliation(s)
- Priyanka D Jain
- Division of Pathology and Microbiology, National Institute of Nutrition, Hyderabad, India
| | - Ruchi S Gupta
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Avneet S Chadha
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher M Warren
- Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vishnu V Rao
- National Institute of Medical Statistics, New Dehli, India
| | - Uday K Putcha
- Division of Pathology and Microbiology, National Institute of Nutrition, Hyderabad, India
| |
Collapse
|
4
|
DunnGalvin A, Treneva M, Pampura A, Grebenko A, Makatsori M, Munblit D. Quality of life associated with maternal anxiety disorder in Russian children and adolescents with food allergy. Pediatr Allergy Immunol 2020; 31:78-84. [PMID: 31562786 DOI: 10.1111/pai.13130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/05/2019] [Accepted: 09/18/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Food allergy negatively impacts the quality of life (QoL) and has been associated with increased maternal anxiety. There is currently a lack of data assessing QoL of food-allergic children and adolescents in Russia. We aimed to evaluate the performance of the Food Allergy Quality of Life Questionnaire (FAQLQ) measures in a Russian sample of children, adolescents, and mothers and to investigate association between child QoL and maternal general anxiety. METHODS FAQLQ and Food Allergy Independent Measures (FAIM) were translated to Russian to be completed by participants. Mothers also filled the General Anxiety Disorder (GAD-7) questionnaire. Reliability, construct, and discriminant validity of the FAQLQs and association between FAQLQ scores and general anxiety were assessed. RESULTS A total of 142 participants completed FAQLQ and FAIM. In total, 126 mothers completed GAD-7 questionnaire. All FAQLQs showed excellent internal consistency (α > 0.94). The means for the FAQLQ-PF, FAQLQ-CF, and FAQLQ-TF varied according to the number of foods avoided, severity of symptoms, and FAIM and GAD scores (ηp2 0.40 P < .001). One in 5 mothers had GAD-7 score indicative of moderate-to-severe anxiety. Association strength between GAD and FAQLQ increased with age. GAD score was associated with FAQLQ-PF score, controlling for multiple confounders. CONCLUSION The FAQLQ showed good reliability and validity in Russian. This study identified number of foods avoided and reported reaction severity being associated with greater QoL impairment in Russian children and adolescents affected by food allergy. The significant association found between general anxiety in parents and QoL in children and adolescents has practice, screening, and resource implications.
Collapse
Affiliation(s)
- Audrey DunnGalvin
- School of Applied Psychology, University College Cork, Cork City, Ireland.,Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Marina Treneva
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University, Moscow, Russia
| | - Alexander Pampura
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Melina Makatsori
- Specialist Allergy and Clinical Immunology Department, RNTNE Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Department of Paediatrics, Imperial College London, London, UK.,The In-VIVO Global Network, an Affiliate of the World Universities Network (WUN), USA.,Solov'ev Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| |
Collapse
|
5
|
Rachid O, Simons KJ, Rawas-Qalaji M. In Vivo Evaluation of Taste-Masked Fast-Disintegrating Sublingual Tablets of Epinephrine Microcrystals. AAPS PharmSciTech 2018; 19:3886-3894. [PMID: 30324360 DOI: 10.1208/s12249-018-1171-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/29/2018] [Indexed: 01/21/2023] Open
Abstract
In community settings, IM injection of 0.3 mg epinephrine (Epi) using an auto-injector is the drug of choice for treatment of anaphylaxis. Previously, a taste-masking (TM) formulation of fast-disintegrating sublingual tablets (FDSTs) was developed in our lab. Also, Epi was micronized (Epi-MC) successfully and reduced the previously achieved bioequivalent sublingual Epi dose to 0.3 mg IM injection by half using non-taste-masked fast-disintegrating sublingual tablets (TM-FDSTs). Our objective for this study was to evaluate the sublingual absorption of Epi-MC using TM-FDST. These sublingual Epi tablets have potential for out-of-hospital treatment of anaphylaxis and are suitable for human studies. TM-FDSTs containing Epi-MC were manufactured by direct compression. The rate and extent of Epi absorption from our developed 20 mg Epi-MC-TM-FDSTs (n = 5) were evaluated in rabbits and compared to the previous result from 20 mg Epi-MC in non-TM-FDSTs and EpiPen® auto-injector. Blood samples were collected over 1 h, and Epi concentrations were measured using HPLC with electrochemical detection. Mean ± SEM AUC0-1 h and Cmax from 20 mg Epi-MC-TM-FDSTs (733 ± 78 ng/ml/min and 30 ± 8 ng/ml) and 20 mg Epi-MC-non-TM-FDSTs (942 ± 109 ng/ml/min and 38 ± 4 ng/ml) were not significantly different (p > 0.05) from each other or from EpiPen® (592 ± 50 ng/ml/min and 28 ± 3 ng/ml) but were significantly higher (p < 0.05) than endogenous Epi after placebo FDSTs (220 ± 32 ng/ml/min and 8 ± 1 ng/ml). Mean ± SD Tmax was not significantly different (p > 0.05) among all formulations. Epi-MC-TM-FDSTs formulation improved Epi absorption twofold and reduced the required bioequivalent dose by 50%, similar to results obtained using non-TM-FDSTs. The incorporation of TM excipients did not interfere with the absorption of Epi-MC.
Collapse
Affiliation(s)
- Ousama Rachid
- College of Pharmacy, Qatar University, P.O.Box 2713, Doha, Qatar
| | - Keith J Simons
- Faculty of Pharmacy, University of Manitoba, 429-750 McDermot Ave, Winnipeg, Manitoba, R3E 0T5, Canada
| | - Mutasem Rawas-Qalaji
- College of Pharmacy, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, Florida, 33328, USA.
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, Florida, 33328, USA.
| |
Collapse
|