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Olabarri M, Sanz N, Gonzalez-Peris S, Vazquez P, Gonzalez-Posada A, Diez N, Vinuesa A, Benito J, Mintegi S. Characteristics of Pediatric Emergency Department Presentations of Anaphylaxis in Spain. Pediatr Emerg Care 2023; 39:755-759. [PMID: 37650818 DOI: 10.1097/pec.0000000000003039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This study aimed to identify the triggers of pediatric anaphylaxis in Spain and to analyze the circumstances of the episode. METHODS Planned secondary analysis of a prospective observational multicenter study endorsed by the Spanish Society of Pediatric Emergencies including children aged younger than 18 years diagnosed with anaphylaxis in 7 Spanish pediatric emergency departments (EDs) between 2016 and 2018. We analyzed factors related to the anaphylaxis episode and its management. RESULTS Four hundred fifty-three cases were registered, happening mainly at home (295 [65.1%]), school (65 [14.3%]), and street (61 [13.5%]). The median age was 5 years, 143 (31.6%) had previous episodes, and 165 (36.4%) had previously been prescribed an epinephrine autoinjector, used in 40 (24.2% of those prescribed). Two thirds were well-appearing when arriving to the pediatric ED. Food was the trigger in 396 (87.4%). In 349 with a single food involved, the most frequent were milk (108 [30.4%]), nuts (103 [29.0%]), hen's egg (40 [11.3%]), and fish (31 [8.7%]), with variations related to the age of the child. CONCLUSIONS Food, especially milk and nuts, are responsible for most anaphylaxis diagnosed in Spanish pediatric EDs. Consideration should be given to improving health education due to the low use of epinephrine autoinjectors.
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Affiliation(s)
- Mikel Olabarri
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Nuria Sanz
- Pediatric Emergency Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | | | - Paula Vazquez
- Pediatric Emergency Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Nuria Diez
- Department of Pediatrics, Río Hortega University Hospital, Valladolid, Spain
| | - Ana Vinuesa
- Department of Pediatrics, Basurto University Hospital - Basque Country University, Bilbao, Spain
| | - Javier Benito
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
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Saretta F, Giovannini M, Pessina B, Barni S, Liccioli G, Sarti L, Tomei L, Fazi C, Pegoraro F, Valleriani C, Ricci S, Azzari C, Novembre E, Mori F. Venom immunotherapy protocols in the pediatric population: how to choose? Front Pediatr 2023; 11:1192081. [PMID: 37744438 PMCID: PMC10512975 DOI: 10.3389/fped.2023.1192081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/05/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Mattia Giovannini
- Department of Health Sciences, University of Florence, Florence, Italy
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Camilla Fazi
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | | | - Silvia Ricci
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Chiara Azzari
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Elio Novembre
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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Duffey H, Leonard J, Mistry RD. Variation in diagnosis and management of allergic reactions among emergency medicine and allergy immunology providers. Allergy Asthma Proc 2023; 44:51-58. [PMID: 36719699 DOI: 10.2500/aap.2023.44.220088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Children with anaphylaxis often emergently present for treatment. Providers' adherence to the principles of optimal management according to the most recent national guidelines is unknown. Objective: To assess the variation in management approaches for allergic reactions and anaphylaxis between allergy/immunology (AI) and emergency medicine (EM) providers. Methods: This was a cross-sectional survey study of AI and EM providers in the University of Colorado affiliated hospitals and Colorado Asthma and Allergy Society. The survey consisted of six cases of patients with allergic reactions, with four cases that represented patients with anaphylaxis that resolved by the time of discharge. For each vignette, the participants were asked about preferred initial therapy, adjunctive therapies, monitoring, outpatient prescription medications, and discharge instructions provided. Survey derivation and validation was accomplished by a multidisciplinary team of experts by using a modified Delphi process. Results: A total of 413 clinicians were contacted, of whom 194, (47%) responded, including 69 pediatric EM, 50 general EM, and 49 AI providers, and 26 did not identify a provider type. There were no statistically significant differences in correct recognition of anaphylaxis between the AI and EM providers. For each case, statistically significant differences were noted in the use of corticosteroids during and after resolution of anaphylaxis: AI providers reported giving fewer prescriptions than did the EM providers for corticosteroids in all cases of anaphylaxis (p < 0.001). The AI providers were less likely to prescribe scheduled antihistamines than were the EM providers in half of the cases (p < 0.02). Conclusion: Across the specialties, there were high rates of recognition of epinephrine as first-line treatment for anaphylaxis. The majority of the EM providers prescribed scheduled corticosteroids and antihistamines after resolution of anaphylaxis, whereas most of the AI providers did not prescribe scheduled corticosteroids. Analysis of the current data suggests against the routine use of corticosteroids in the management of anaphylaxis, particularly continued use after resolution of symptoms. AI involvement in the creation of EM and hospital protocols for allergic reactions could improve overall care.
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Affiliation(s)
- Hannah Duffey
- From the Department of Dermatology, University of Utah, Salt Lake City, Utah, and
| | - Jan Leonard
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Rakesh D Mistry
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
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Triage Grading and Correct Diagnosis Are Critical for the Emergency Treatment of Anaphylaxis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121794. [PMID: 36553239 PMCID: PMC9776430 DOI: 10.3390/children9121794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022]
Abstract
Introduction: Anaphylaxis is one of the most frequent and misdiagnosed emergencies in the pediatric emergency department (PED). We aimed to assess which factors play a major role for a correct diagnosis and an appropriate therapy. Methods: We reviewed the records of children discharged with a diagnosis of anaphylaxis or an allergic reaction over 11 years from 3 hospitals in the Bologna city area. Results: One hundred and sixteen cases matched the criteria (0.03% of the total admittances) and were divided according to the patients’ symptoms at arrival: active acute patients [AP], n = 50, or non-acute patients ([NAP], n = 66). At the patients’ discharge, anaphylaxis was diagnosed in 39 patients (33.6%). Some features seemed to favor a correct diagnosis: active symptoms at arrival (AP vs. NAP, p < 0.01), high-priority triage code (p < 0.01), and upper airway involvement (p < 0.01). Only 14 patients (12.1%), all in the AP group, received epinephrine, that was more likely administered to patients recognized to have anaphylaxis (p < 0.01) and with cardiovascular, respiratory, or persistent gastrointestinal symptoms (p < 0.02), as confirmed by logistic regression analysis. Conclusions: Anaphylaxis is still under-recognized and under-treated. Correct triage coding and a proper diagnosis seem to foster an appropriate treatment. Physicians often prefer third-line interventions. Specific training for nurses and physicians might improve the management of this disease.
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Nunes FA, Zanini F, Braga CDS, da Silva AL, Fernandes FR, Solé D, Wandalsen GF. Incidence, triggering factors, symptoms, and treatment of anaphylaxis in a pediatric hospital. World Allergy Organ J 2022; 15:100689. [PMID: 36092951 PMCID: PMC9421393 DOI: 10.1016/j.waojou.2022.100689] [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: 03/15/2022] [Revised: 06/27/2022] [Accepted: 08/02/2022] [Indexed: 11/08/2022] Open
Abstract
Objective Assess the incidence of anaphylaxis in the emergency room (ER) of a private pediatric hospital in the city of São Paulo, Brazil, and describe associated factors. Method This was a cross-sectional, retrospective, and observational study based on the medical records of patients from 0 to 18 years old seen at the emergency unit during the years of 2016–2019, who had a diagnosis potentially related to anaphylaxis according to ICD-10. All medical records were individually reviewed for the presence of compatible signs and symptoms that identified “possible” cases of anaphylaxis. Cases were considered probable anaphylaxis when medical history was compatible and indicative of anaphylaxis in the opinion of at least 2 allergists. Results The incidence of anaphylaxis was 0.013%. Among the 56 patients identified (mean age 4.2 years), food was the most predominant suspected factor (53%), followed by unknown factors (32%), and drugs (12.5%). All patients presented with cutaneous symptoms, 74% with respiratory, and 53% with gastrointestinal. Allergic disease as a comorbidity was found in 39% of the children and 11% had a history of previous anaphylaxis. There were neither cases of syncope or shock, nor deaths. Intramuscular (IM) adrenaline was prescribed in 37.5% of cases. Conclusions The incidence of anaphylaxis was low when compared to the worldwide incidence. The severity of most cases was mild, cutaneous symptoms were predominant, and food was the suspected trigger most frequently associated with reactions.
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Jiang N, Xu W, Huang H, Hou X, Xiang L. Anaphylaxis in Chinese Children with Pollen Sensitization: Triggers, Clinical Presentation, and Acute Management. J Asthma Allergy 2022; 15:633-643. [PMID: 35603012 PMCID: PMC9122664 DOI: 10.2147/jaa.s363113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Pollen sensitization is increasing in children. However, there is little evidence regarding the characteristics of anaphylaxis in individuals with pollen sensitization. Patients and Methods We conducted a retrospective study of patients with anaphylaxis combined with pollen sensitization who attended an allergy department in a tertiary children’s hospital from 2014 to 2021. Results A total of 157 anaphylaxis events in 108 patients were analyzed; the mean age at the reaction was 5.8 ± 4.17 years. A total of 99.1% (107/108) of the patients came from northern China. The most common sensitizing pollen was mugwort (93.5%,101/108), followed by ragweed (68.5%, 74/108) and birch (40.7%, 44/108). A total of 76.9% (83/108) of the patients showed polysensitization to pollen. Allergic rhinitis/conjunctivitis was the most common comorbidity (87.0%, 94/108). Children with severe anaphylaxis were more likely to have a history of recurrent urticaria (16.1% vs 3.9%, p = 0.028). The most frequently implicated foods were fruits/vegetables (22.3%, 35/157), followed by wheat (8.9%, 14/157) and milk (8.3%, 13/157), and the most common fruit allergen was peach (n = 7). Of 14% (22/157) exercise-induced reactions, 63.6% (14/22) occurred in pollen season. Skin symptoms were the most frequent (86.0%, 135/157) symptoms, followed by respiratory (73.9%, 116/157) and gastrointestinal (21%, 33/157) symptoms. Regarding acute management, only 7.4% of the patients were treated with epinephrine. Conclusion Our findings revealed the characteristics of anaphylaxis in children with pollen sensitization. Fruits/vegetables accounted for a substantial percentage of anaphylaxis triggers. The suboptimal use of epinephrine highlights the need for educational programs promoting the use of epinephrine.
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Affiliation(s)
- Nannan Jiang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Wei Xu
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Huijie Huang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Xiaoling Hou
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
| | - Li Xiang
- Department of Allergy, Beijing Children′s Hospital, Capital Medical University, National Center for Children′s Health; Key Laboratory of Major Diseases in Children, Ministry of Education; National Clinical Research Center for Respiratory Diseases, Beijing, People’s Republic of China
- Correspondence: Li Xiang, Department of Allergy, Beijing Children’s Hospital, Capital Medical University, National Center for Children′s Health, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, People’s Republic of China, Tel +861059616934, Fax +861059616934, Email
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Baseggio Conrado A, Patel N, Turner PJ. Global patterns in anaphylaxis due to specific foods: A systematic review. J Allergy Clin Immunol 2021; 148:1515-1525.e3. [PMID: 33940057 PMCID: PMC8674817 DOI: 10.1016/j.jaci.2021.03.048] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/12/2021] [Accepted: 03/19/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND There are increasing global data relating to prevalence of food allergy and food-induced anaphylaxis; however, this is often based on surrogate measures of sensitization rather than objective symptoms at food challenge. In terms of protecting food-allergic consumers from reactions, to our knowledge, there has been no global survey assessing geographic differences in the proportion of anaphylaxis triggered by specific foods. OBJECTIVE We sought to identify common triggers for food-induced anaphylaxis and how these vary from country to country. METHODS Systematic review of relevant reports published between January 2010 and November 2020. Results were reported following PRISMA guidelines. Publications were screened and data extracted by 2 independent reviewers, and the risk of bias was assessed. RESULTS Sixty-five studies (encompassing 41 countries and all 6 regions as defined by the Food and Agriculture Organization of the United Nations) were included. Significant regional variations in the most common triggers of food anaphylaxis were seen; however, in general, there was good agreement between local legislative requirements for allergen disclosure and the most common allergens for each region or nation. CONCLUSIONS Local legislation for allergen disclosure generally reflects those allergens commonly responsible for food anaphylaxis. Cow's milk and crustaceans appear to cause a higher proportion of anaphylaxis compared to peanut in some regions.
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Affiliation(s)
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom; Department of Paediatrics and Child Health, University of Sydney, Sydney, Australia.
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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.
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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
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Pecoraro L, Infante S, Fuentes-Aparicio V, Cabrera-Freitag P, Antonucci N, Alvarez-Perea A. IgE-mediated fish allergy in pediatric age: Does canned tuna have a chance for tolerance? Pediatr Allergy Immunol 2021; 32:1114-1117. [PMID: 33605499 DOI: 10.1111/pai.13481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Luca Pecoraro
- Department of Medicine, University of Verona, Verona, Italy.,Pediatric Clinic, ASST Mantua, Mantua, Italy
| | - Sonsoles Infante
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Victoria Fuentes-Aparicio
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Paula Cabrera-Freitag
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Nadia Antonucci
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alberto Alvarez-Perea
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
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Management of Anaphylaxis During the SARS-CoV-2 Pandemic. CURRENT TREATMENT OPTIONS IN ALLERGY 2021; 8:88-96. [PMID: 33723499 PMCID: PMC7946336 DOI: 10.1007/s40521-021-00284-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/21/2022]
Abstract
Purpose of Review Management of anaphylaxis during the SARS-CoV-2 pandemic should consider local infection rates so as to not burden local ED at times of pandemic, while also protecting patients from infection risks and progression of anaphylaxis. In this review, we identify a treatment strategy for anaphylaxis that balances the risks versus benefits of ED versus home management in this unprecedented time. Recent Findings Physicians and patients have had to adapt new approaches to medical care during the SARS-CoV-2 pandemic due to restricted access to health care facilities. Telemedicine has substituted in-person visits, and such a drastic change in the patient care paradigm presents a need to revise the acute management of anaphylaxis. Summary Physicians should utilize telemedicine during this time to engage in shared decision-making with patients and their families to devise an anaphylaxis plan of management that emphasizes home care when symptoms are mild with an exception for ED care if a patient has had severe, near-fatal anaphylaxis episodes in the past. Previous anaphylaxis recommendations should remain in place despite the pandemic, including prompt use of epinephrine when needed, avoidance of known allergens, training of patients and their caregivers, and carrying of epinephrine autoinjector devices at all times to remain prepared in the event of an anaphylaxis episode. Supplementary Information The online version contains supplementary material available at 10.1007/s40521-021-00284-0.
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Cardenas-Morales M, Hernandez-Trujillo V. Infant Anaphylaxis: A Diagnostic Challenge. Curr Allergy Asthma Rep 2021; 21:12. [PMID: 33624161 DOI: 10.1007/s11882-021-00990-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Infant anaphylaxis has been increasing in incidence; however, significant gaps in the literature remain. The aim of this article is to review the most recent literature pertaining to infant anaphylaxis and discuss recent findings related to epidemiology, diagnosis, management, and prevention. RECENT FINDINGS There is no accurate report of the incidence and prevalence of anaphylaxis in infancy. Food is the most common trigger for infant anaphylaxis reported. The diagnosis of anaphylaxis in infants is often missed, and, even when the diagnosis is made, epinephrine continues to be under-utilized. An epinephrine autoinjector with a shorter needle and lower dose is now available for infants. Concise criteria specifically focusing on infant anaphylaxis is needed to streamline its diagnosis and management. Diagnosis is underrecognized in infants leading to improper treatment. When the diagnosis is made, epinephrine continues to be under-utilized and under-prescribed in infants.
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Affiliation(s)
| | - Vivian Hernandez-Trujillo
- Allergy and Immunology Care Center of South Florida, Miami, FL, USA.,Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA
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12
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The Challenge of Establishing the Burden of Anaphylaxis: Some Recent Trends. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00257-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Anaphylaxis and alternative medicine: an unexpected association. Curr Opin Allergy Clin Immunol 2020; 20:470-473. [DOI: 10.1097/aci.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Gamboa-Antiñolo FM. The essential measures to improve the management of anaphylaxis. AIMS MEDICAL SCIENCE 2020. [DOI: 10.3934/medsci.2020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Le M, Gabrielli S, De Schryver S, Ben-Shoshan M. Management Strategies Of Idiopathic Anaphylaxis In The Emergency Room: Current Perspectives. Open Access Emerg Med 2019; 11:249-263. [PMID: 31802955 PMCID: PMC6830385 DOI: 10.2147/oaem.s200342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background Idiopathic anaphylaxis (IA) is a diagnosis of exclusion and represents a major diagnostic and management challenge. There are no current guidelines for diagnosis and management of IA. We aim to present a systematic review of the literature on adult and pediatric IA. Methods We conducted a systematic review of original articles published in the past 22 years regarding diagnosis and management strategies of adult and pediatric IA. Results The current proposed diagnostic approach and treatment regimens are based on a few small studies. Future large-scale studies are required. IA is a diagnosis of exclusion and should be made only after extensive evaluation excludes potential anaphylaxis triggers as well as non-allergic conditions with a similar presentation. There is currently no diagnostic consensus for IA. Furthermore, the current proposed treatment regimens are limited and rely on prophylactic treatment with antihistamines and prednisone for patients with frequent episodes. However, daily treatment with systemic steroids has well-recognized serious adverse effects. More recently, the use of biologics was suggested to benefit patients with IA, although the optimal management protocol is not yet established. Conclusion Future studies are needed to optimize diagnosis and treatment strategies in adult and pediatric cases of IA. Omalizumab may be a promising novel therapeutic option for adult and pediatric IA.
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Affiliation(s)
- Michelle Le
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
| | - Sofianne Gabrielli
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
| | - Sarah De Schryver
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada
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Ramsey NB, Guffey D, Anagnostou K, Coleman NE, Davis CM. Epidemiology of Anaphylaxis in Critically Ill Children in the United States and Canada. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2241-2249. [PMID: 31051271 PMCID: PMC8411990 DOI: 10.1016/j.jaip.2019.04.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anaphylaxis is a rapid-onset, multisystem, and potentially fatal hypersensitivity reaction with varied reports of prevalence, incidence, and mortality. There are limited cases reported of severe and/or fatal pediatric anaphylaxis. OBJECTIVE This study describes the largest cohort of intensive care unit pediatric anaphylaxis admissions with a comprehensive analysis of identified triggers, clinical and demographic information, and probability of death. METHODS We describe the epidemiology of pediatric anaphylaxis admissions to North American pediatric intensive care units (PICUs) that were prospectively enrolled in the Virtual Pediatric Systems database from 2010 to 2015. One hundred thirty-one PICUs in North America (United States and Canada) were queried for anaphylaxis International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes from the Virtual Pediatric Systems database from 2010 to 2015 in the United States and Canada. One thousand nine hundred eighty-nine patients younger than 18 years were identified out of 604,279 total number of patients admitted to a PICU in the database during this time frame. RESULTS The primary outcome was mortality, which was compared with patient and admission data using Fisher exact test. Secondary outcomes (intubation, length of stay, mortality risk scores, systolic blood pressure, and pupillary reflex) were analyzed using the Kruskal-Wallis test or Wilcoxon rank-sum test, as appropriate. One thousand nine hundred eighty-nine patients with an anaphylaxis International Classification of Diseases code were identified in the database. One percent of patients died because of critical anaphylaxis. Identified triggers for fatal cases were peanuts, milk, and blood products. Peanuts were the most common trigger. Children were mostly male when younger than 13 years, and mostly female when 13 years and older. Average length of stay was 2 days. There was a higher proportion of Asian patients younger than 2 years or when the trigger was food. CONCLUSIONS This is the largest study to describe pediatric critical anaphylaxis cases in North America and identifies food as the most common trigger. Death occurs in 1% of cases, with intubation occurring most commonly in the first hour. The risk for intensive care unit admission in children underscores the serious nature of anaphylaxis in this population.
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Affiliation(s)
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Katherine Anagnostou
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Nana E Coleman
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Carla M Davis
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas.
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Cohen N, Capua T, Pivko-Levy D, Ben-Shoshan M, Rimon A, Benor S. Improved diagnosis and treatment of anaphylaxis in a pediatric emergency department (2013-2018). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2882-2884.e2. [PMID: 31078760 DOI: 10.1016/j.jaip.2019.04.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/21/2019] [Accepted: 04/29/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Neta Cohen
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tali Capua
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dikla Pivko-Levy
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Ayelet Rimon
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Benor
- Allergy and Clinical Immunology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
PURPOSE OF REVIEW Gain of function KIT mutations are detected in clonal mast cell diseases, namely mastocytosis and monoclonal mast cell activation syndrome. Timely diagnosis and treatment of these disorders are crucial because of their association with severe and life-threatening anaphylaxis. KIT mutations also have implications for targeted therapies of mast cell disorders. This review article strives to serve as an overview of the role of clonal mast cell disorders in anaphylaxis while elucidating current and future therapies. RECENT FINDINGS Clonal mast cell disease has been increasingly diagnosed in patients with severe hymenoptera allergy and those with recurrent unexplained anaphylaxis. The current state of knowledge of the epidemiology, pathophysiology, diagnosis, and treatment of mastocytosis with a particular focus on anaphylaxis and its triggers which are described in this context. Novel and forthcoming treatments are discussed including the relevance of KIT mutation status. This review provides an overview of the role of KIT mutations in mastocytosis and anaphylaxis, and highlights emerging therapies for mastocytosis, targeting these mutations.
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Affiliation(s)
- Elise Coulson
- Department of Internal Medicine, Division of Allergy and Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Suite H-2100, PO Box 442, Ann Arbor, MI, 48106-0442, USA
| | - Sherry Zhou
- Department of Internal Medicine, Division of Allergy and Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Suite H-2100, PO Box 442, Ann Arbor, MI, 48106-0442, USA
| | - Cem Akin
- Department of Internal Medicine, Division of Allergy and Immunology, University of Michigan, 24 Frank Lloyd Wright Drive, Suite H-2100, PO Box 442, Ann Arbor, MI, 48106-0442, USA.
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Klingebiel C, Chantran Y, Arif‐Lusson R, Ehrenberg AE, Östling J, Poisson A, Liabeuf V, Agabriel C, Birnbaum J, Porri F, Sarrat A, Apoil P, Vivinus M, Garnier L, Chiriac AM, Caimmi D, Bourrain J, Demoly P, Guez S, Boralevi F, Lovato B, Palussière C, Leroy S, Bourrier T, Giovannini‐Chami L, Gouitaa M, Aferiat‐Derome A, Charpin D, Sofalvi T, Cabon‐Boudard I, Massabie‐Bouchat Y, Hofmann B, Bonardel N, Dron‐Gonzalvez M, Sterling B, Carsin A, Vivinus S, Poitevin B, Nicolau L, Liautard G, Soler C, Mezouar S, Annesi‐Maesano I, Mège J, Lidholm J, Vitte J. Pru p 7 sensitization is a predominant cause of severe, cypress pollen‐associated peach allergy. Clin Exp Allergy 2019; 49:526-536. [DOI: 10.1111/cea.13345] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 11/11/2018] [Accepted: 12/12/2018] [Indexed: 12/21/2022]
Affiliation(s)
| | - Yannick Chantran
- UPMC Univ Paris 06 INSERM UMRS 938 Centre de Recherche Saint‐Antoine, team “Immune System, Neuroinflammation and Neurodegenerative Diseases” Hôpital Saint‐Antoine Sorbonne Universités Paris France
- Immunology Department AP‐HP Saint‐Antoine Hospital Paris France
| | - Rihane Arif‐Lusson
- Aix‐Marseille Univ IRD APHM MEPHI IHU Méditerranée Infection Marseille France
| | | | | | - Alain Poisson
- Service de Pneumo‐Allergologie Hôpital Saint Joseph Marseille France
| | - Valérie Liabeuf
- Aix‐Marseille Univ APHM, Hôpital Timone Service de Dermatologie‐Vénéréologie Marseille France
| | - Chantal Agabriel
- Aix‐Marseille Univ APHM, Hôpital Timone Service de Pédiatrie Multidisciplinaire Marseille France
| | - Joëlle Birnbaum
- Service de Pneumologie et Allergologie CH du Pays d'Aix Aix‐en‐Provence France
| | - Françoise Porri
- Service de Pneumo‐Allergologie Hôpital Saint Joseph Marseille France
| | - Anne Sarrat
- Laboratoire d'Immunologie et Immunogénétique GH Pellegrin CHU Bordeaux Bordeaux France
| | - Pol‐André Apoil
- Institut Fédératif de Biologie Hôpital Purpan, CHU Toulouse Toulouse France
| | - Mylène Vivinus
- Laboratoire d'Immunologie Hôpital de l'Archet CHU Nice Nice France
| | - Lorna Garnier
- Laboratoire d'Immunologie CH Lyon Sud CHU Lyon Pierre‐Bénite France
| | - Anca Mirela Chiriac
- Département de pneumologie et addictologie CHU Montpellier Hôpital Arnaud‐de‐Villeneuve Univ Montpellier Montpellier France
- Sorbonne Universités INSERM UMRS 1136 IPLESP, team EPAR Paris France
| | - Davide‐Paolo Caimmi
- Département de pneumologie et addictologie CHU Montpellier Hôpital Arnaud‐de‐Villeneuve Univ Montpellier Montpellier France
- Sorbonne Universités INSERM UMRS 1136 IPLESP, team EPAR Paris France
| | - Jean‐Luc Bourrain
- Département de pneumologie et addictologie CHU Montpellier Hôpital Arnaud‐de‐Villeneuve Univ Montpellier Montpellier France
| | - Pascal Demoly
- Département de pneumologie et addictologie CHU Montpellier Hôpital Arnaud‐de‐Villeneuve Univ Montpellier Montpellier France
- Sorbonne Universités INSERM UMRS 1136 IPLESP, team EPAR Paris France
| | - Stéphane Guez
- Unité d'allergologie, GH Pellegrin, CHU Bordeaux Bordeaux France
| | - Franck Boralevi
- Unité de Dermatologie Pédiatrique Hôpital Pellegrin‐Enfants, CHU Bordeaux Bordeaux France
| | | | | | - Sylvie Leroy
- Service de Pneumologie Hôpital Pasteur CHU Nice Nice France
| | | | | | - Marion Gouitaa
- Aix‐Marseille Univ APHM, Hôpital Nord Service de Pneumologie Marseille France
| | | | - Denis Charpin
- Aix‐Marseille Univ APHM, Hôpital Timone Unité de Pneumologie Marseille France
| | - Tünde Sofalvi
- Aix‐Marseille Univ APHM, Hôpital Nord Service de Pneumologie Marseille France
| | - Isabelle Cabon‐Boudard
- Aix‐Marseille Univ APHM, Hôpital Timone Service de Chirurgie Pédiatrique Marseille France
| | | | | | | | | | - Benoît Sterling
- Medical Office Marseille France
- Aix‐Marseille Univ APHM, Hôpital Timone Service de Pneumo‐Pédiatrie Marseille France
| | - Ania Carsin
- Aix‐Marseille Univ APHM, Hôpital Timone Service de Pneumo‐Pédiatrie Marseille France
| | - Serge Vivinus
- Service de Pneumologie Hôpital Pasteur CHU Nice Nice France
| | | | | | | | | | - Soraya Mezouar
- Aix‐Marseille Univ IRD APHM MEPHI IHU Méditerranée Infection Marseille France
| | | | - Jean‐Louis Mège
- Aix‐Marseille Univ IRD APHM MEPHI IHU Méditerranée Infection Marseille France
| | | | - Joana Vitte
- Aix‐Marseille Univ IRD APHM MEPHI IHU Méditerranée Infection Marseille France
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Barni S, Mori F, Giovannini M, de Luca M, Novembre E. In situ simulation in the management of anaphylaxis in a pediatric emergency department. Intern Emerg Med 2019; 14:127-132. [PMID: 29948834 DOI: 10.1007/s11739-018-1891-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/06/2018] [Indexed: 12/13/2022]
Abstract
Anaphylaxis is a potentially life-threatening, rapid-onset hypersensitive reaction, usually treated in the emergency department (ED). Failure to recognize anaphylaxis leads to under-treatment with epinephrine and even when correctly diagnosed, epinephrine is not always administered. In addition, often patients who are treated in the ED are not referred for allergy work-up. Simulation is a tool that increases exposure to events in a safe environment, allowing trainers to develop skills without harming patients. The main purpose of our study was to determine whether in situ simulation training increases the frequency of epinephrine use. The secondary aim was to observe whether simulation modifies the number of children investigated over the years before and after the setting up of the simulation training. All patients with anaphylaxis referred to the Pediatric Emergency Department (PED) of the Anna Meyer Children's Hospital from 2004 to 2010 [pre-simulation (PRE-s) period], and from 2011 to 2016 [post-simulation (POST-s) period], were retrospectively included in this observational study. Simulation was carried out using a high-fidelity patient simulator mannequin (SimBaby, Laerdal Medical, Inc, Stavanger, NY). The diagnosis of anaphylaxis was based on the EAACI guidelines. The use of epinephrine significantly increased (p < 0.05) between the PRE-s and POST-s time periods: 2.4% versus 10% patients, respectively. During the two time periods, we also observed a significant increase (p = 0.011) in the number of patients who underwent a complete allergy work-up: 36% versus 51% patients, respectively. According to our results, the in situ simulation program improved the correct management of anaphylaxis in terms of prompt use of epinephrine, and it also led to a higher number of patients being referred to the allergy unit for evaluation.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Marco de Luca
- Simulation and Risk Management Unit, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
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When is epinephrine prescribed for anaphylaxis? Ann Allergy Asthma Immunol 2018; 122:339-340. [PMID: 30529549 DOI: 10.1016/j.anai.2018.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/16/2018] [Accepted: 11/26/2018] [Indexed: 11/21/2022]
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Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Campbell RL. National trends in emergency department visits and hospitalizations for food-induced anaphylaxis in US children. Pediatr Allergy Immunol 2018; 29:538-544. [PMID: 29663520 DOI: 10.1111/pai.12908] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Food is the leading cause of anaphylaxis in children seen in emergency departments in the United States, yet data on emergency department visits and hospitalizations related to food-induced anaphylaxis are limited. The objective of our study was to examine national time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations. METHODS We conducted an observational study using a national administrative claims database from 2005 through 2014. Participants were younger than 18 years with an emergency department visit or hospitalization for food-induced anaphylaxis. Outcome measures of our study included time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations, including observations (in an emergency department or a hospital unit), inpatient admissions, and intensive care unit admissions. RESULTS During the study period, participants had 7310 food-induced anaphylaxis-related emergency department visits. Emergency department visits for food-induced anaphylaxis increased by 214% (P < .001); the highest rates were in infants and toddlers (age 0-2 years). Rates of emergency department visits significantly increased in all age-groups, with the highest increase in adolescents (age 13-17 years: 413%; P < .001). Peanuts accounted for the highest rates (5.85 per 100 000 in 2014) followed by tree nuts/seeds (4.62 per 100 000 in 2014). The greatest increase in rates of emergency department visits for food-induced anaphylaxis occurred with tree nuts/seeds (373.0% increase during the study period). CONCLUSIONS The incidence of food-induced anaphylaxis has significantly increased over time in children of all ages. Food-induced anaphylaxis in children is an important national public health concern.
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Affiliation(s)
- Megan S Motosue
- Division of Allergic Diseases, Mayo Clinic, Rochester, MN, USA
| | - M Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
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Cohen N, Capua T, Pivko D, Ben-Shoshan M, Benor S, Rimon A. Trends in the diagnosis and management of anaphylaxis in a tertiary care pediatric emergency department. Ann Allergy Asthma Immunol 2018; 121:348-352. [PMID: 29981442 DOI: 10.1016/j.anai.2018.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/05/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Underdiagnosis of anaphylaxis is a major concern in the pediatric emergency department (PED), leading to failure to administer and prescribe intramuscular epinephrine treatment. OBJECTIVE To examine the clinical features, triggers, and management of anaphylaxis in the PED, with a special focus on the rate of cases diagnosed and treated correctly over time, and to compare correctly diagnosed and misdiagnosed cases. METHODS All records of patients presenting to a tertiary care PED between 2013 and 2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed. RESULTS The rate of anaphylaxis increased from 0.1% between 2013 and 2014 and 0.24% between 2015 and 2016. Symptoms such as breathing difficulties and wheezing were found significantly less among misdiagnosed patients compared with patients correctly diagnosed with anaphylaxis. Food was the most common causative agent in both of the study periods (88% in 2013-2014 and 91% in 2015-2016), with milk (20% in 2013-2014 and 28% in 2015-2016) and tree nuts (23.1% in 2013-2014 and 23.7% in 2015-2016 as the most prevalent identified triggers. Intramuscular epinephrine treatment in the prehospital and hospital settings and the automatic epinephrine injector prescription rate did not change significantly throughout the study. Referral to an allergist increased from 68% in 2013 to 2014 to 90% in 2015 to 2016. CONCLUSION The rate of visits attributable to anaphylaxis in our PED doubled during the study period, with milk allergy as the most common trigger. Most cases of misdiagnosed and undertreated anaphylaxis had no respiratory signs and symptoms. Novel methods to improve recognition of anaphylaxis and adherence to treatment guidelines are needed.
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Affiliation(s)
- Neta Cohen
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Tali Capua
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dikla Pivko
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Shira Benor
- Allergy and Clinical Immunology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ayelet Rimon
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
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de Gier S, Verhoeckx K. Insect (food) allergy and allergens. Mol Immunol 2018; 100:82-106. [PMID: 29731166 DOI: 10.1016/j.molimm.2018.03.015] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/19/2018] [Indexed: 12/21/2022]
Abstract
Insects represent an alternative for meat and fish in satisfying the increasing demand for sustainable sources of nutrition. Approximately two billion people globally consume insects. They are particularly popular in Asia, Latin America, and Africa. Most research on insect allergy has focussed on occupational or inhalation allergy. Research on insect food safety, including allergenicity, is therefore of great importance. The objective of this review is to provide an overview of cases reporting allergy following insect ingestion, studies on food allergy to insects, proteins involved in insect allergy including cross-reactive proteins, and the possibility to alter the allergenic potential of insects by food processing and digestion. Food allergy to insects has been described for silkworm, mealworm, caterpillars, Bruchus lentis, sago worm, locust, grasshopper, cicada, bee, Clanis bilineata, and the food additive carmine, which is derived from female Dactylopius coccus insects. For cockroaches, which are also edible insects, only studies on inhalation allergy have been described. Various insect allergens have been identified including tropomyosin and arginine kinase, which are both pan-allergens known for their cross-reactivity with homologous proteins in crustaceans and house dust mite. Cross-reactivity and/or co-sensitization of insect tropomyosin and arginine kinase has been demonstrated in house dust mite and seafood (e.g. prawn, shrimp) allergic patients. In addition, many other (allergenic) species (various non-edible insects, arachnids, mites, seafoods, mammals, nematoda, trematoda, plants, and fungi) have been identified with sequence alignment analysis to show potential cross-reactivity with allergens of edible insects. It was also shown that thermal processing and digestion did not eliminate insect protein allergenicity. Although purified natural allergens are scarce and yields are low, recombinant allergens from cockroach, silkworm, and Indian mealmoth are readily available, giving opportunities for future research on diagnostic allergy tests and vaccine candidates.
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Affiliation(s)
- Steffie de Gier
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kitty Verhoeckx
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands; TNO, Zeist, The Netherlands.
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When nutrition and allergy collide: the rise of anaphylaxis to plant foods. Curr Opin Allergy Clin Immunol 2018; 17:338-343. [PMID: 28858913 DOI: 10.1097/aci.0000000000000387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Interest in nutrition is increasing, but in the world of internet health gurus, whilst the nutritional benefits of fruits and vegetables are extolled, wheat is often vilified. This review will assess the positive nutritional effects of plant foods in relation to allergy prevention, the effectiveness of gluten-avoidance and the likelihood of anaphylaxis to fruits and vegetables. RECENT FINDINGS Although the numbers of people who report gluten sensitivity is rising, hard evidence of mass sensitivity to gluten is scant. Also, the avoidance of wheat containing foods could lead to nutritional imbalance and effects on the gut microbiome. The evidence that fruits and vegetables have a protective effect on the development of allergy is inconsistent, although fruit juices may promote beneficial changes to gut microflora. Fruits and vegetables can cause severe allergic reactions, especially due to the presence of lipid transfer proteins, but this is not just a Mediterranean phenomenon, and not limited to peaches. SUMMARY These findings emphasise the importance of a keeping an open mind about reported reactions to plant foods, to ensure the correct diagnosis is made and nutrition is optimised to prevent any adverse effects of avoidance on the gut microbiome.
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Schatz M, Sicherer SH, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:328-352. [PMID: 29397373 DOI: 10.1016/j.jaip.2017.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022]
Abstract
An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
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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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Castells M. Diagnosis and management of anaphylaxis in precision medicine. J Allergy Clin Immunol 2017; 140:321-333. [PMID: 28780940 DOI: 10.1016/j.jaci.2017.06.012] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is the most severe and frightening of the allergic reactions, placing patients at high risk and demanding prompt recognition and immediate management by health care providers. Yet because its symptoms imitate those of other diseases, such as asthma and urticaria, current data suggest that its diagnosis is often missed, with underuse of tryptase measurement; its treatment is delayed, with little use of epinephrine; and its underlying cause or causes are poorly investigated. Deaths from anaphylaxis are difficult to investigate because of miscoding. Surprisingly, patients treated with new and powerful chemotherapy agents and humanized mAbs present with nonclassical symptoms of anaphylaxis, and patients may present with unrecognized clonal mast cell disorders with KIT mutations may present as Hymenoptera-induced or idiopathic anaphylaxis. The goal of this review is to recognize the presentations of anaphylaxis with the description of its current phenotypes, to provide new insight and understanding of its mechanisms and causes through its endotypes, and to address its biomarkers for broad clinical use. Ultimately, the aim is to empower allergists and heath care providers with new tools that can help alleviate patients' symptoms, preventing and protecting them against anaphylaxis.
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Affiliation(s)
- Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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