Adults and children with anaphylaxis in the emergency room: why it is not recognized?

Allergy to Gibberellin-regulated proteins in an adolescent: A case of orange-induced anaphylaxis mediated by cofactors

This report is a case of anaphylaxis in an adolescent due to allergy to gibberellin-regulated proteins mediated by cofactors, in probable relation to a pollen/food allergy syndrome. It should also emphasizes the importance of obtaining a faithful clinical history, especially when it comes to adolescent patients as they tend to initiate toxic habits.

Development of a machine learning algorithm based on administrative claims data for identification of ED anaphylaxis patient visits

Background

Epidemiologic studies of anaphylaxis commonly rely on International Classification of Diseases (ICD) codes to identify anaphylaxis cases, which may lead to suboptimal epidemiologic classification.

Objective

We sought to develop and assess the accuracy of a machine learning algorithm using ICD codes and other administrative data compared with ICD code-only algorithms to identify emergency department (ED) anaphylaxis visits.

Methods

We conducted a retrospective review of ED visits from January 2013 to September 2017. Potential ED anaphylaxis visits were identified using 3 methods: anaphylaxis ICD diagnostic codes (method 1), ICD symptom-based codes with or without a code indicating an allergic trigger (method 2), and ICD codes indicating a potential allergic reaction only (method 3). A machine learning algorithm was developed from administrative data, and test characteristics were compared with ICD code-only algorithms.

Results

A total of 699 of 2191 (31.9%) potential ED anaphylaxis visits were classified as anaphylaxis. The sensitivity and specificity of method 1 were 49.1% and 87.5%, respectively. Method 1 used in combination with method 2 resulted in a sensitivity of 53.9% and a specificity of 68.7%. Method 1 used in combination with method 3 resulted in a sensitivity of 98.4% and a specificity of 15.1%. The sensitivity and specificity of the machine learning algorithm were 87.3% and 79.1%, respectively.

Conclusions

ICD coding alone demonstrated poor sensitivity in identifying cases of anaphylaxis, with venom-related anaphylaxis missing 96% of cases. The machine learning algorithm resulted in a better balance of sensitivity and specificity and improves upon previous strategies to identify ED anaphylaxis visits.

Direct Versus Indirect Query Performance of ICD-9/-10 Coding to Identify Anaphylaxis

BACKGROUND

Anaphylaxis is an often under =diagnosed, severe allergic event for which epidemiological data are sporadic. Researchers have leveraged administrative and claims data algorithms to study large databases of anaphylactic events; however, little longitudinal data analysis is available after transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

OBJECTIVE

Study longitudinal trends in anaphylaxis incidence using direct and indirect query methods.

METHODS

Emergency department (ED) and inpatient data were analyzed from a large state health care administration database from 2011 to 2020. Incidence was calculated using direct queries of anaphylaxis ICD-9-CM and ICD-10-CM codes and indirect queries using a symptom-based ICD-9-CM algorithm and forward mapped ICD-10-CM version to identify undiagnosed anaphylaxis episodes and to assess algorithm performance at the population level.

RESULTS

An average of 2.4 million inpatient and 7.5 million ED observations/y were analyzed. Using the direct query method, annual ED anaphylaxis cases increased steadily from 1,454 (2011) to 4,029 (2019) then declined to 3,341 in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. In contrast, inpatient cases remained relatively steady, with a slight decline after 2015 during the ICD version transition, until a significant drop occurred in 2020. Using the indirect queries, anaphylaxis cases increased markedly after the ICD transition year, especially involving drug-related anaphylaxis.

CONCLUSIONS

Nontypical drug associations with anaphylaxis episodes using the ICD-10-CM version of the algorithm suggest poor performance with drug-related codes. Further, the increased granularity of ICD-10-CM identified potential limitations of a previously validated symptom-based ICD-9-CM algorithm used to detect undiagnosed cases.

The Timely Administration of Epinephrine and Related Factors in Children with Anaphylaxis

Anaphylaxis is a severe allergic reaction that requires immediate recognition and intervention. This study investigated the factors related to the timely administration of epinephrine in cases of pediatric anaphylaxis. We performed a retrospective chart review of 107 patients who visited a pediatric emergency center with anaphylaxis between 2015 and 2017. In total, 76 patients received epinephrine injections. We analyzed factors including allergy history, anaphylaxis signs and symptoms, allergen sensitization, anaphylaxis triggers, and time of epinephrine injection. Anaphylactic patients who received epinephrine took a median of 50 min to arrive at the hospital, and patients who did not receive epinephrine took a median of 94 min. Epinephrine administration was significantly delayed by more than 60 min from symptom onset in patients <2 years old. Patients presenting with wheezing symptoms or history of bronchial asthma were significantly more likely to receive epinephrine within 60 min of symptoms onset, while patients with food allergen sensitization were significantly more likely to receive epinephrine within 30 min of hospital arrival. Wheezing, history of asthma, age (≥2 years old), food triggers, and food allergen sensitivity were significant factors for the rapid administration of epinephrine. An immediate diagnosis of anaphylaxis and a rapid administration of epinephrine are essential.

Effects of a standardized patient-based simulation in anaphylactic shock management for new graduate nurses

Background

Patients may be endangered if new graduate nurses cannot recognize and manage anaphylactic shock. Consequently, enhancing the new graduate nurses’ understanding of their roles and responsibilities during the rescue of a patient with anaphylactic shock is important. However, due to its inherent limitations, traditional classroom-based teaching makes it difficult to explore the potential of the students. Although popular simulation teaching has several notable advantages, it has not been proven to be effective in training inexperienced nurses on anaphylactic shock. We investigated the effect of a standardized patient-based simulation on the behaviors of new graduate nurses’ during anaphylactic shock rescue to identify an effective and safe method for contemporary nursing education.

Methods

Except for the ill or pregnant, all the new graduate nurses were included in the study as students to undergo a standardized patient-based simulation conducted in the clinical skills center of a general hospital. The simulation training was designed to teach students to recognize the signs and symptoms of anaphylactic shock, place the patient in the correct position, stop the ongoing intravenous infusion of the antibiotic which triggers the anaphylactic shock, restart an intravenous infusion on a new infusion apparatus, give 100% oxygen via a nasal cannula or mask, preserve airway patency, call the rapid response team, and correctly administer the medications prescribed by the clinicians. Before and after the training, the instructors evaluated each student’s skills and behaviors using a clinical competency evaluation list. After the training, all students completed the Chinese version of the Simulation Design Scale (SDS) to demonstrate their satisfaction with the program and then participated in semi-structured interviews with their instructors.

Results

All 104 graduate nurses had a significant improvement on the 6 competencies of the clinical competency evaluation list after the simulation training (P < 0.001). The SDS scores revealed that the students were highly satisfied with all the aspects of the simulation training (the 20 satisfaction rates were all above 90.00%). During the semi-structured interviews, most of the new graduate nurses reported that simulation training in the management of anaphylactic shock was critical and would guide them in clinical practice.

Conclusion

Simulation training in anaphylactic shock is a potentially viable and effective method for teaching new graduate nurses to manage clinical incidents.

Epinephrine in anaphylaxis: too little, too late

PURPOSE OF REVIEW

Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike.

RECENT FINDINGS

There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen.

SUMMARY

Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.

A Case Report of a 3-Year-Old Child With Anaphylactic Shock After a Diclofenac Suppository Confirmed by Serial Tryptase and a Basophil Activation Test

Diclofenac is one of the most commonly used non-steroidal anti-inflammatory drug (NSAID) agents for fever management by general practitioners. Anaphylaxis due to suppository of diclofenac sodium (Voltaren) is extremely rare in children. We report the case of a 3-year-old girl with anaphylactic shock after a diclofenac suppository with confirmation by serial tryptase and a basophil activation test.

The Study of Incidence and Characteristics of Patients with Eye-Related Chief Complaints at the Emergency Department of Thammasat University Hospital

Background

Patients with eye-related chief complaints could be diagnosed not only with eye diseases but also with noneye diseases. This study determines rates and characteristics of patients with eye-related chief complaints at the Emergency Department of Thammasat University Hospital.

Methods

The study design is a descriptive retrospective observational study of patients with eye-related chief complaints at the Emergency Department of Thammasat University Hospital in 2017. Demographic data, diagnosis, management, consultation, and disposition were recorded by chart review. Categorical data were reported by percentage.

Results

Of the 52081 patients, 704 (1.3%) presented with eye problems. 60% of the patients were males. Patients were classified into three groups which are traumatic eye disease, nontraumatic eye disease, and noneye disease. 75.9% of the patients suffered traumatic injuries. The most common diagnoses of the traumatic eye injuries were foreign bodies at the cornea and conjunctiva and minor trauma to the conjunctiva. The most common mechanisms were foreign bodies in the eyes, cuts, or pierces. The most common causes of the injuries were from metals and housewares. The most common nontraumatic eye diagnoses were conjunctivitis and corneal ulcer. The most common noneye diagnoses were exposure of healthcare providers to secretions from patients, angioedema, and hypertensive crisis.

Conclusions

Most of the patients who came to the ER with chief complaints of the eyes could be treated by doctors in the emergency room without consulting ophthalmologists. Chief complaints of the eyes could be the leading symptoms of many organ systems. Emergency physicians should be differentially diagnosed to cover neurologic, cardiovascular, and immunologic problems.

Managing food allergy and anaphylaxis: A new model for an integrated approach

There is an increasing public concern on food allergy and related anaphylactic reactions that occur mainly at the community level. The perception of the disease is huge among parents who believe that 1 out of 20 children suffers from severe food allergy. The discrepancy between this self-reported prevalence and the real one when a food challenge is performed, points out the gap in the implementation of guidelines for clinical practice. Health professionals as well show scarce adherence to the guidelines both at the Emergency Departments and at the primary care level. Anaphylactic reaction are not recognized, adrenaline is under-used and self-injectable devices are not prescribed. Although education and training are limited to local, spontaneous initiatives from patient's organization and few allergists, the data so far available demonstrate that improvement in knowledge and attitudes can be achieved further to a structured program. There is the need to establish good evidence -based practices for educational intervention that should be adopted in the context of public health policies for food allergy. This would imply a change in legislation in many countries to prevent prosecution for liability of lay people administering adrenaline when properly trained. In parallel an integrated clinical care pathway should be developed by multidisciplinary and multi-professional teams in the context of national Centres of Excellence -CoE. These CoE could drive the progression to digital health create, creating networks of CoE for best practices of care and for clinical trials.