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Kraft MT, Coletta C, Mikhail I, Prince BT, Scherzer R, Eisner M, Mustillo P. The sensitivity of food allergy skin testing soon after food-induced anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1384-1386.e2. [PMID: 38316185 DOI: 10.1016/j.jaip.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Affiliation(s)
- Monica T Kraft
- Division of Allergy and Immunology, Department of Otolaryngology, the Ohio State University Wexner Medical Center, Columbus, Ohio.
| | | | - Irene Mikhail
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Benjamin T Prince
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Scherzer
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Mariah Eisner
- Biostatistics Resource, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter Mustillo
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Rukasin CRF, Rank MA, Park MA, Yee CI, Volcheck GW. A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00342-8. [PMID: 38580206 DOI: 10.1016/j.jaip.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Christine R F Rukasin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Claire I Yee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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Schroeder MJ, Kraft CT, Janis JE, Kraft MT. Diagnosis and Treatment of Perioperative Allergic Complications: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5734. [PMID: 38623441 PMCID: PMC11018239 DOI: 10.1097/gox.0000000000005734] [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: 12/06/2023] [Accepted: 02/23/2024] [Indexed: 04/17/2024]
Abstract
Background Reported drug allergies are commonly encountered by surgeons and can lead to uncertainty in selecting an appropriate agent due to concerns of associated risks with related and cross-reactive drugs. This uncertainty can ultimately lead to increased infection rates. Methods A literature review was conducted in PubMed using a combination of the terms "allergy," "allergic reaction," "anaphylaxis," and "surgery," "surgical," or "operating room" for articles published within the last 10 years. Publications identified with these search terms were then filtered for review articles, sorted by "best match," and a maximum of 100 articles were manually reviewed for each combination of search terms. Results Search results yielded 46,484 articles, 676 of which were ultimately included for manual review, based on selection criteria. Specifically, articles selected for inclusion focused on surgical allergic reactions that were either related to mechanism of action, causative agent for the allergic reaction, timing of allergic reaction, or recommendations for appropriate management. Conclusions Allergic reactions can be a common occurrence in the operative room. Knowledge of likely causative agents, timing of a reaction to various agents, and appropriate management in the immediate and delayed setting can improve outcomes and safety for plastic surgery patients.
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Affiliation(s)
- Michael J. Schroeder
- From the Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
| | | | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
| | - Monica T. Kraft
- Department of Otolaryngology, Division of Allergy and Immunology, Ohio State University, Columbus, Ohio
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Mayorga C, Çelik GE, Pascal M, Hoffmann HJ, Eberlein B, Torres MJ, Brockow K, Garvey LH, Barbaud A, Madrigal-Burgaleta R, Caubet JC, Ebo DG. Flow-based basophil activation test in immediate drug hypersensitivity. An EAACI task force position paper. Allergy 2024; 79:580-600. [PMID: 38084472 DOI: 10.1111/all.15957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 12/22/2023]
Abstract
Diagnosing immediate drug hypersensitivity reactions (IDHRs) can pose a significant challenge and there is an urgent need for safe and reliable tests. Evidence has emerged that the basophil activation test (BAT), an in vitro assay that mirrors the in vivo response, can be a complementary test for many drugs. In this position paper, members of Task Force (TF) "Basophil activation test in the evaluation of Drug Hypersensitivity Reactions" from the European Academy of Allergy and Clinical Immunology (EAACI) present the data from a survey about the use and utility of BAT in IDHRs in Europe. The survey results indicate that there is a great interest for using BAT especially for diagnosing IDHRs. However, there are still main needs, mainly in the standardization of the protocols. Subsequently consensus-based recommendations were formulated for: (i) Technical aspects of BAT in IDHRs including type of sample, management of drugs, flow cytometry protocols, interpretation of the results; and (ii) Drug-specific aspects that should be taken into account when performing BAT in relation to betalactams, neuromuscular blocking agents, fluoroquinolones, chlorhexidine, opioids, radio contrast media, chemotherapeutics, biological agents, nonsteroidal anti-inflammatory drugs, COVID vaccine, and excipients. Moreover, aspects in the evaluation of pediatric population have also been considered. All this indicates that BAT offers the clinician and laboratory a complementary tool for a safe diagnostic for IDHRs, although its place in the diagnostic algorithm depends on the drug class and patient population (phenotype, geography, and age). The standardization of BAT is important for generalizing this method beyond the individual laboratory.
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Affiliation(s)
- C Mayorga
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
| | - G E Çelik
- Department of chest disease, Division of Allergy & Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - M Pascal
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Immunology Department, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - H J Hoffmann
- Department of Clinical Medicine and Department of Clinical Immunology, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - B Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - M J Torres
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Medicine Department, Malaga University, Málaga, Spain
| | - K Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - L H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen and Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - A Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP.Sorbonne Université, Hôpital Tenon, Département de dermatologie et allergologie, Paris, France
| | - R Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - J C Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - D G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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Barbaud A, Garvey LH, Torres M, Laguna JJ, Arcolaci A, Bonadonna P, Scherer Hofmeier K, Chiriac AM, Cernadas J, Caubet JC, Brockow K. EAACI/ENDA position paper on drug provocation testing. Allergy 2024; 79:565-579. [PMID: 38155501 DOI: 10.1111/all.15996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
In drug hypersensitivity, drug provocation testing (DPT), also called drug challenge, is the gold standard for investigation. In recent years, risk stratification has become an important tool for adjusting the diagnostic strategy to the perceived risk, whilst still maintaining a high level of safety for the patient. Skin tests are recommended before DPT but may be omitted in low-risk patients. The task force suggests a strict definition of such low-risk patients in children and adults. Based on experience and evidence from studies of allergy to beta-lactam antibiotics, an algorithm on how to adjust DPT to the risk, and when to omit skin tests before DPT, is presented. For other antibiotics, non-steroidal anti-inflammatory drugs and other drugs, skin tests are poorly validated and DPT is frequently necessary. We recommend performing DPT with chemotherapeutics and biologicals to avoid unnecessary desensitization procedures and DPT with skin tests negative contrast media. We suggest DPT with anesthetics only in highly specialized centers. Specifics of DPT to proton pump inhibitors, anticonvulsants and corticosteroids are discussed. This position paper provides general recommendations and guidance on optimizing use of DPT, whilst balancing benefits with patient safety and optimizing the use of the limited available resources.
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Affiliation(s)
- Annick Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Tenon, Service de dermatologie et allergologie, Paris, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Torres
- Allergy Unit, Regional University Hospital of Malaga-IBIMA-UMA-ARADyAL, Malaga, Spain
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL, REI, Madrid, Spain
| | - Alessandra Arcolaci
- Immunology Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Kathrin Scherer Hofmeier
- Allergy and Dermatology, Cantonal Hospital Aarau, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Anca Mirela Chiriac
- Allergy Unit, University Hospital of Montpellier and IDESP, UMR UA11, Univ. Montpellier - INSERM, Montpellier, France
| | - Josefina Cernadas
- Hospital Lusíadas, Porto, Portugal
- Centro Hospitalar Universitário H. S. João, Porto, Portugal
| | - Jean Christoph Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Faculty of Medicine and Health, Munich, Germany
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Mertes PM, Tacquard C. Perioperative anaphylaxis: when the allergological work-up goes negative. Curr Opin Allergy Clin Immunol 2023; 23:287-293. [PMID: 37357801 DOI: 10.1097/aci.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis. RECENT FINDINGS Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup. SUMMARY When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Team EFS-INSERM U1255, EFS Grand-Est, Strasbourg, France
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Ebo DG, van der Poorten MLM, Hopkins PM. Suspected perioperative anaphylaxis: are we making the correct diagnosis? Br J Anaesth 2023:S0007-0912(23)00235-0. [PMID: 37271719 DOI: 10.1016/j.bja.2023.05.002] [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: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
We provide a commentary on aspects of a prospective study of the epidemiology of perioperative anaphylaxis in Japan (Japanese Epidemiologic Study for Perioperative Anaphylaxis [JESPA]). Accurate diagnosis of perioperative anaphylaxis is important for research but essential for clinical safety. We evaluate the diagnostic approach used in the JESPA study and caution against over-reliance on diagnostic tests that lack sensitivity and specificity when clinical data suggest an immediate perioperative hypersensitivity reaction is likely.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Banerji A. Best of drug and vaccine allergy 2022. Ann Allergy Asthma Immunol 2023; 130:143-144. [PMID: 36737153 DOI: 10.1016/j.anai.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Aleena Banerji
- Division of Rheumatology Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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