Health-related quality of life in children and adolescents after systemic sting reaction

INTRODUCTION AND OBJECTIVES

Insect stings are the second trigger of anaphylaxis in children and adolescents, causing a potentially life-threatening reactions. Hence health-related quality of life (HRQoL) is an important issue for Hymenoptera venom allergy (HVA) patients. The aim of this cross-sectional study was to evaluate the impact of HVA on young patients' HRQoL, including their socio-demographic characteristics.

MATERIAL AND METHODS

The study sample included 102 patients aged 8-17 (Mean 12.5 years, SD=3.0), who were under diagnosis or venom immunotherapy due to systemic reaction after an insect sting in one of the tertiary referential centers in Poland. They were mostly boys (70%), and mainly from rural areas (63%). HRQoL of studied patients was measured with the Children's Hymenoptera Venom Allergy Quality of Life Scale, a questionnaire covering 6 dimensions: anxiety, caution, limitations, discomfort, support received from parents and a feeling of safety, each measured from 1 to 5. Independent predictors of HRQoL were estimated using the Generalized Linear Model.

RESULTS

In the group of children being dermal reactors, girls reported a higher level of anxiety (B=1.17, 95%CI=(0.30;2.03), p=0.008). In the group of children with grade 2 it was the girls who reported lower anxiety (B=-1.33, 95%CI=(-2.38;-0.29), p=0.013). Boys treated longer than 3 years had their level of anxiety significantly lower than those studied at diagnosis (B=-0.65, 95%CI=(-1.23;-0.07), p=0.028). The feeling of safety was higher in children living in villages than in those living in towns (B=0.30, 95%CI=(0.03;0.56), p=0.031).

CONCLUSIONS

The gender, treatment duration and stage of anaphylactic reaction influenced level of anxiety. The level of feeling of safety was related to the place of living.

Anxiety and stress in mothers of food-allergic children

BACKGROUND

Previous reports suggest that parents especially mothers of food-allergic children may have increased anxiety. Studies with an appropriate control group have not been undertaken, and the determinants of such anxiety are not known. We compared measures of anxiety and stress in mothers of food-allergic children and atopic non-food-allergic children, with anxiety and stress in mothers of children with no chronic illness.

METHODS

Cross-sectional study of mothers attending a hospital appointment for their 8- to 16-year-old child. Mothers of children with food allergy, asthma but no food allergy or no chronic illness completed questionnaires including State-Trait Anxiety Inventory, Perceived Stress Scale and measures of anxiety and psychologic adjustment in their child.

RESULTS

Forty mothers of food-allergic children, 18 mothers of asthmatic children without food allergy and 38 mothers of children with no chronic illness (controls) were recruited. Mothers of food-allergic children showed increased state anxiety – median anxiety score 38.0 (IQR 30.0, 44.0) food allergy, 27.0 (22.0, 40.0) control p = 0.012; and increased stress – median stress score 18.5 (12.0, 22.0) food allergy, 14.0 (7.5, 19.5)control p = 0.035. No significant differences were seen between mothers in the asthmatic group and controls. In multivariate analysis, previous food anaphylaxis(p = 0.008) and poorly controlled asthma (p = 0.004) were associated with increased maternal anxiety. Child anxiety and adjustment did not differ between food-allergic and control groups.

CONCLUSIONS

Mothers of food-allergic children have increased anxiety and stress compared with mothers of children with no chronic illness. Anaphylaxis and poorly controlled asthma are associated with maternal anxiety.

Strategies for living with the risk of anaphylaxis in adolescence: qualitative study of young people and their parents

BACKGROUND

Adolescents with anaphylaxis are at increased risk of fatal outcomes. Gaps in their knowledge of day-to-day and emergency management have been identified. There are also gaps in services available to support adolescents at risk of anaphylaxis.

AIMS

To explore the experiences and healthcare needs of adolescents living with the risk of anaphylaxis; to understand the perspectives of their parents; and to look at how care might be improved.

METHODS

A qualitative study was undertaken using in-depth interviews with adolescents with a recent history of severe allergic reactions and with their parents.

RESULTS

Twenty-six adolescents at risk of anaphylaxis living in Scotland and their parents (n=28) were recruited. Most anaphylactic reactions reported by participants appeared to result from accidents, misinformation, or inexperience. For many, management involved finding a balance between taking their allergies seriously whilst not allowing these concerns to dominate their lives. Risks were often difficult to judge, with reactions sometimes taking place even after careful checking of meal ingredients. Most admitted taking some risks with trace-labelled foods. Appropriate healthcare support for adolescents in learning to manage the risk of anaphylaxis independently and advice and support for their parents was inconsistently provided.

CONCLUSIONS

Adolescents tend to see their risk management strategies as 'good enough', but these strategies were often inconsistent with clinical best practice and, in some cases, had not prevented reactions. Building on adolescents' existing skills and knowledge and the use of Internet and associated social media resources may help to support more effective self-management among adolescents.

The psychosocial impact of life-threatening childhood food allergies

The purpose of this integrated literature review was to bring understanding to medical professionals of the psychosocial impact of parenting a child with life-threatening food allergies. Prevalence of life-threatening food allergy among children is increasing, and families continue to navigate the effects it can have on all members of a family. A comprehensive literature review was performed related to chronic childhood illnesses and life-threatening food allergies. Commonalities among the conditions exist related to stress, coping, and adaptive responses when parental perceptions and experiences are considered. This information may provide a conceptual context for the adaptation process involved with parenting a young child with life-threatening food allergies, revealing areas where nursing can serve to intervene and support this process.

[Influence of venom immunotherapy on anxiety level of being re-stung]

Hymenoptera venom allergy is related to higher risk of potential life -threatening anaphylactic reactions, which leads to anxiety and decreased quality of life.

AIM

The aim of this paper was: 1) estimation of fear level of being re-stung among venom allergy adults treated with venom specific immunotherapy (VIT)--before and during treatment; 2) estimation of expectation of outcome of VIT as compared to level of anxiety of being re-strug, in the Visual Analogue Scale--VAS score; 3) identification of factors influencing changes in the fear level among patients during VIT.

MATERIAL AND METHODS

The study group comprised 42 patients (18 women, 24 men) in the mean age 42.6 years, with bee or vespid allergy, who had been qualified to the VIT treatment with Alutard SQ. Visual Analogue Scale--VAS and the Expectation of Outcome Questionnaire were used. The demographic data were collected.

RESULTS

The VAS score before VIT for insect venom allergic patients was 8.8 (SD = 0.9). It decreased after achieving maintenance dose to 3.1 (SD = 1.6) and was significantly lower in men (p < 0.05). Score achieved in the Expectation of Outcome Questionnaire was for each question 2.2 (SD = 1.5) and there was correlation with VAS score during VIT.

CONCLUSIONS

The patients with insect venom allergy, who undergo a serious allergic reaction (SR) as a result of being stung and who are qualified to VIT, have a high level of anxiety of being re-stung. Achieving the maintenance dose of VIT, results in a significant decrease of anxiety level in women and men, significantly so in men. There is a significant correlation between VAS score and the Expectation of Outcome Questionnaire results during VIT. Both VAS for anxiety level and the Expectation of Outcome Questionnaire can be simple, easily available and useful instruments helping to estimate quality of life. VIT significantly decreases the patients level of anxiety of being restung and improves their quality of life.

Justified concern or exaggerated fear: the risk of anaphylaxis in percutaneous treatment of cystic echinococcosis-a systematic literature review

Percutaneous treatment (PT) emerged in the mid-1980s as an alternative to surgery for selected cases of abdominal cystic echinococcosis (CE). Despite its efficacy and widespread use, the puncture of echinococcal cysts is still far from being universally accepted. One of the main reasons for this reluctance is the perceived risk of anaphylaxis linked to PTs. To quantify the risk of anaphylactic reactions and lethal anaphylaxis with PT, we systematically searched MEDLINE for publications on PT of CE and reviewed the PT-related complications. After including 124 publications published between 1980 and 2010, we collected a total number of 5943 PT procedures on 5517 hepatic and non-hepatic echinococcal cysts. Overall, two cases of lethal anaphylaxis and 99 reversible anaphylactic reactions were reported. Lethal anaphylaxis occurred in 0.03% of PT procedures, corresponding to 0.04% of treated cysts, while reversible allergic reactions complicated 1.7% of PTs, corresponding to 1.8% of treated echinococcal cysts. Analysis of the literature shows that lethal anaphylaxis related to percutaneous treatment of CE is an extremely rare event and is observed no more frequently than drug-related anaphylactic side effects.

The risk of anaphylactic shock is the objection most often raised by opponents of percutaneous treatments for cystic echinococcosis, but there are no updated figures on the actual occurrence of anaphylaxis as a complication of this treatment.

To assess the number of lethal and non-lethal anaphylactic reactions following percutaneous aspiration of echinococcal cysts, we systematically reviewed the literature published from 1980–2010.

The analysis of the available literature shows that the risk of severe anaphylactic reactions resulting from percutaneous treatment of echinococcal cysts has been widely exaggerated and the actual risk may be lower than that following administration of certain antibiotics.

Provided adequate stand-by resuscitation measures are available, each time an echinococcal cyst is punctured, fear of anaphylactic shock is no longer justified as an argument to avoid this therapeutic option.

Illustrating risk: anaphylaxis through the eyes of the food-allergic child

The risk perception research is widely focused on children as targets of risk. To date, very few studies have consulted with the impacted group to assess the perceptions of risk associated with the exposures of interest. Much less research has investigated the experiences of children at risk for anaphylaxis, their concerns, and the psychosocial stresses associated with risk. The present study explores the perceptions and experiences of Ontario students with anaphylaxis, and their parents regarding school as a safe place in order to inform school policy around risk management and coping. A "child-centered" analytical framework incorporating illustrative techniques within interpretative analysis is outlined. Five prominent themes: (a) social and environmental barriers to safety, (b) coping strategies, (c) emotional burden of responsibility, (d) balance of responsibility (transitions), and (e) redefining "normal" are discussed. Results found that "child-centered" techniques empowered children in a process that is meaningful and relevant to their lives. A preliminary framework for understanding what risk means to children highlighted the differences in how they cope in the public sphere of school.

The psychosocial impact of anaphylaxis on young people and their parents

BACKGROUND

Anaphylaxis is a potentially life-threatening disorder that can affect people of all ages. Young people are at a disproportionately increased risk of anaphylaxis deaths for reasons that include a failure to institute appropriate long-term management regimens. A pre-requisite for effective supported self-management of young people with anaphylaxis is a better understanding of the factors that contribute to risk-taking behaviour.

OBJECTIVE

To explore the psychosocial impact of living with anaphylaxis on adolescents and their parents; their management of the condition; and perceptions of health care provision.

METHODS

In-depth interviews were conducted with 15 participants, these comprising of seven adolescents aged between 13 and 16 years with a history of clinician-diagnosed anaphylaxis and eight of their parents, in this Scottish community-based exploratory qualitative study.

RESULTS

Adolescents in this study typically perceived anaphylaxis as 'no big deal', describing a relatively low impact on their day-to-day life when compared with their parents. This could largely be explained by the fact that most adolescents could not remember an anaphylactic reaction. Key obstacles to effective long-term self-management included inadequate knowledge to support detailed situation-specific risk assessment, this being compounded by a lack of confidence to make further enquiries about the ingredients of meals when with peers. Parents reported anxiety about 'handing over' the main responsibility for avoidance and emergency management to their children. Medical support for these families was very limited, with primary care teams in some cases actively hindering effective self-management.

CONCLUSION

Having a child with anaphylaxis can have a significant long-term psychological impact on parents and this anxiety may in some cases be transferred from parents onto their children. Parents and adolescents may benefit from tailored information to support the transition from parental- to self-management by adolescents. Access to appropriate national health service primary and specialist care was in some cases currently inadequate to support effective long-term management. Further, more in-depth research in a more heterogeneous group of adolescents is needed.

Significance and rationale of studies of health-related quality of life in anaphylactic disorders

PURPOSE OF REVIEW

Until recently, quality-of-life measures were only used in allergic diseases with ongoing symptoms, such as asthma and rhinoconjunctivitis. Anaphylaxis is a chronic disease without ongoing physical symptoms, but the problems concerning quality of life are related to the continuous vigilance required to prevent accidental exposure. This raises specific issues concerning the validation of quality-of-life instruments.

RECENT FINDINGS

The preferred independent measure for validation generally is an objective measurement of the severity of disease (e.g. spirometry in asthma). In patients suffering from anaphylaxis, the perceived expectation of what will happen following exposure can be used as the key independent measure. Recently, a specific instrument measuring this expectation (the 'Expectation of outcome' questionnaire) has been developed, and successfully used in insect-venom anaphylaxis.

SUMMARY

Also, in diseases without ongoing symptoms like anaphylaxis, quality of life can be measured and the disease-specific instrument validated. It is to be expected that many new instruments will be developed in the coming years to address important issues in anaphylaxis. They may provide a better understanding of the major problems of certain patient subgroups and may give direction to the kind of information that should be addressed and what kind of interventions could be important and whether they are useful or not.

Anaphylaxis: a review of 601 cases

BACKGROUND

The allergist usually sees patients with anaphylaxis after the event for the purposes of identifying the cause, establishing a prognosis, and preventing further episodes. Knowledge of the characteristics of such patients is essential to achieve these goals.

OBJECTIVE

To examine the natural history, clinical manifestations, and factors that affect the patients' adherence to suggested treatment and preventive strategies of anaphylaxis.

METHODS

A retrospective medical record review spanning 25 years (1978-2003) and follow-up questionnaires were used to obtain data on 601 patients who presented with anaphylaxis of unknown origin to a private university-affiliated allergy-immunology practice.

RESULTS

Patients ranged in age from 1 to 79 years, with a mean age of 37 years. Females comprised 62% of cases. Causes of anaphylaxis were elucidated in 41% of cases. Known causes included foods in 131 patients (22%), medications in 69 cases (11%), and exercise in 31 cases (5%). Two hundred twenty-three patients (37%) were found to be atopic by history confirmed with skin prick testing. The most common manifestation was urticaria and/or angioedema, reported in 87% of patients. Systemic mastocytosis was found in 3 patients. Episodes tended to decline in frequency with time. Adherence to instructions to carry epinephrine can be improved with more effective teaching.

CONCLUSIONS

In most cases, the cause of anaphylaxis is undetermined. Women are affected more commonly than men. Systemic mastocytosis should be considered in cases of idiopathic anaphylaxis, and patients with a history of atopy are at an increased risk of developing anaphylaxis. Patients are more reliably carrying epinephrine as a result of changes in physician instructions. Finally, anaphylactic episodes tend to decrease in frequency and severity with time.

Anaphylaxis: how do you live with it?

This article reports on a study of the needs of families coping with life-threatening allergies in a child. Due to the scarcity of publications on the psychosocial dimensions of anaphylaxis, the authors draw on selected literature on family coping with chronic illness, asthma, and allergy to provide a conceptual context for the research and discussion of findings. Using qualitative methodology, parents from 17 families were interviewed about their experiences adjusting to a diagnosis of anaphylaxis in a child. From participants' responses about the nature and sources of information and support, parenting dilemmas, family activities, anxieties, challenges, and coping strategies, the authors identify patterns in the adaptive processes related to predictable developmental and episodic events that increase anxiety and support needs. Social work clinicians and other family-serving professionals can help families maintain an optimal balance between protective and debilitating anxiety. Potential interventions in community and health settings are suggested.

Anaphylaxis--a patient perspective

In order to help us better understand our patients' experiences, Australian Family Physician is pleased to introduce the first in a series of articles written by people who are willing to share their stories. Ella was requested to write this article by AFP's Editor in Chief. Ella is now a year 11 student at Williamstown High School, Victoria.

Patient's perspective and public policy regarding anaphylaxis

It is estimated that dose to 7 million Americans have food allergy. The incidence of food allergy, particularly peanut allergy, is believed to be on the rise. Several studies have shown that in spite of a patient's best efforts to avoid ingesting the allergy-causing food, reactions will occur. These reactions occur from incorrect ingredient information in food service or restaurant settings, incorrect product labels, or mistakes in label reading. In the hospital setting, patients are sometimes treated for an anaphylactic reaction in the emergency room but are not given instructions to see a specialist to determine the cause of their reaction, nor are they given a prescription for epinephrine to arm them to treat future allergic emergencies. Two studies of fatal and near fatal allergic reactions concluded that a delay in administration of epinephrine could have been a factor in the fatal outcomes. However, schools often do not have written emergency action plans in place for children with documented food allergy, and patients and caregivers often report not knowing when to use the epinephrine kit or how to use it. Until there is a cure for food allergy and anaphylaxis, avoidance of the allergen is key. There is much work to be done in education and public policy regarding anaphylaxis.

Gastric surgery and restraint from food as triggering factors of eating disorders in morbid obesity

Obese patients may share some clinical features with anorexia nervosa patients because they risk developing an eating disorder when they diet. Methods and Results Some common etiological, psychological, and social factors have been proposed for both disorders. We present two cases of patients suffering from morbid obesity who, after weight loss, presented an intense fear of regaining weight and developed anorexic-like symptoms. In the first case, the symptoms appeared after gastric reduction surgery. In the second case, a strict diet was the triggering factor.

DISCUSSION

This paper stresses the need for psychiatric evaluation of all patients with morbid obesity who seek treatment in clinical settings, in order to identify the factors that may lead to psychiatric complications.

Pavlovian conditioning of lung anaphylactic response in rats

The present experiment was undertaken to verify if it is possible to impose Pavlovian conditioning on a lung anaphylactic response (LAR) in rats. Two experiments were done. In the 1st, egg albumin (OVA) aerosol inhalation, which induces signs and symptoms of LAR in OVA- sensitized rats, was paired with an audiovisual cue (conditional stimulus, CS). After reexposure to the CS, the signs and symptoms of LAR were quantitatively measured using a scoring system specially developed for this evaluation; the levels of stress response and anxiety were also quantified. Results showed that the rats reexposed to CS only, displayed LAR scores not significantly different from those reexposed to both CS and the antigen; animals of these groups showed significantly higher LAR scores than rats that received no OVA aerosol challenge. High levels of stress and anxiety were observed 30-40 min after the challenge with OVA aerosol. In the 2nd experiment, rats sensitized with OVA and submitted or not to Pavlovian conditioning were observed in the open-field and in the plus maze apparatus in the absence of OVA aerosol but in the presence of the CS; after behavioral observations the animals were sacrificed for serum corticosterone level determination. Both behavioral and biochemical data showed high levels of stress and anxiety in rats for which the antigen was previously paired with the CS; these changes were not observed in animals which received the antigen 24 h after the presentation of the CS (unpaired) or in those exposed to PBS aerosol (the OVA vehicle) only. The present data show not only that LAR can be submitted to Pavlovian conditioning, but also and importantly, that high levels of stress and anxiety are related to the course of LAR.

The "Peter Pan" syndrome and allergy practice: facilitating adherence through the use of social support

The complexity of care of some patients in an allergy-immunology practice may be increased by behavioral abnormalities of the patients. Facilitating adherence through the use of social support may be the most effective treatment strategy for some of the most difficult of these patients. We report three patients whose medical management problems were alleviated largely because of the participation of their support system. All three patients were stabilized because of the acceptance of responsibility and support of the physician by the designated member of the patient's support system. The range of social support used to manage nonadherent patients ranged from directly providing instructions to a family member to the consistent presence of a spouse or companion at multiple clinical visits. In all cases, the success in management was attributed largely to the presence of a support system.

Asiasari radix inhibits immunoglobulin E production on experimental models in vitro and in vivo

Immunoglobulin (Ig) E is the principal Ig involved in immediate hypersensitivities and chronic allergic diseases. The hallmark of these disorders is increased IgE production. The effect of an aqueous extract of the roots of Asiasari radix (ARAE) on an in vivo and in vitro IgE production was investigated. ARAE dose-dependently inhibited the active systemic anaphylaxis and serum IgE production induced by immunization with ovalbumin, Bordetella pertussis toxin and aluminum hydroxide gel. ARAE strongly inhibited IL-4-dependent IgE production by lipopolysaccharide- stimulated murine whole spleen cells. In the case of U266 human IgE-bearing B cells, ARAE also showed an inhibitory effect on the IgE production. These results suggest that ARAE has an anti-allergic activity by inhibition of IgE production from B cells.

The psychoimmunological association of panic disorder and allergic reaction

During treatment of out-patients suffering from DSM-III R panic disorder (PD) with and without agoraphobia, our attention was drawn to a high frequency of comorbid allergic reactions. In a controlled study, the prevalence of immediate type I reactions was determined in panic patients. Conversely, the prevalence of psychological disorders was recorded among allergic patients. Altogether, 79 out-patients with PD, 100 type I allergic out-patients and 66 controls underwent structured clinical interviews and tests for allergies. Of the patients suffering from PD, 70 per cent displayed type I immediate reactions (controls = 29 per cent). Vasodilatation (often approaching circulation collapse) is a frequently occurring allergic syndrome which is a very dramatic experience. Fifty per cent of the allergic patients showed mild to severe psychological disturbances (controls = 25 per cent); and 16 per cent had problems requiring treatment (controls = 9 per cent). Ten per cent of the allergic patients revealed PD (controls = 2 per cent). The association between PD and allergic (vasomotor) reactions was found to be highly significant. A functional relationship is hypothesized in terms of conditioning cognitive and vasomotor interactions during autonomic arousal.

Undifferentiated somatoform idiopathic anaphylaxis: nonorganic symptoms mimicking idiopathic anaphylaxis

BACKGROUND

Northwestern University's Division of Allergy and Immunology has had experience with the diagnosis and treatment of more than 350 patients with idiopathic anaphylaxis (IA). In 1992 we reported a group of patients with IA whose presentations mimicked IA, but IA and other organic causes were later excluded. Psychologic factors were suspected as the underlying problem. These patients were classified as IA-variant. Management of these cases was extremely difficult. There was significant morbidity and high and unnecessary costs.

OBJECTIVE

We aim to distinguish the nature of this disease and to highlight the evaluation and treatment of this group of patients.

METHODS

Their cases are reviewed and reported.

RESULTS

Common features included (1) presenting symptoms mimicking IA, (2) no objective findings that correlated with 1, (3) no response to the therapeutic regimen for IA, (4) meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for undifferentiated somatoform disorder, and (5) significant wasted health care expenditure.

CONCLUSIONS

This group of patients were better defined as having undifferentiated somatoform-IA. An algorithm was proposed to expedite the diagnosis of the disease so that with early recognition of the disease, unwarranted repetitive consultations, tests, and inappropriate therapy can be avoided.

Immediate hypersensitivity in the Flinders rat: further evidence for a possible link between susceptibility to allergies and depression

Rats of the Flinders sensitive line (FSL, selectively bred for their increased cholinergic activity and used as a genetic animal model of depression) were compared with their control counterparts, the Flinders resistant line, for their susceptibility to anaphylaxis and the response of small intestinal tissues to the muscarinic agonist, bethanechol. Following sensitization to ovalbumin (OA), rats of both lines were challenged in vivo either with 3 mg OA i.p. or with saline. In spite of the absence of line-related differences in IgE titers, FSL rats were more susceptible to the induction of anaphylactic shock as evidenced by (1) more pronounced mast cell degranulation; (2) a greater drop in rectal temperature; (3) higher hematocrit values; and (4) changes in gut function characterized by an elevation of basal short-circuit current and increased conductance (indicating increases in transport tone and permeability) of the tissues mounted in Ussing chambers. Thus, this study provides further evidence for a common cholinergic mechanisms in susceptibility to both allergies and depression.

Opiate antagonists reverse the hypoactivity associated with systemic anaphylaxis in mice

Systemic anaphylaxis in the mouse is associated with marked hypoactivity. This effect is reversed by treatment with the opiate antagonists, naloxone (5-10 mg/kg) or naltrexone (1 mg/kg). Administration of naltrexone methyl bromide (1 mg/kg), a selective peripherally acting opiate antagonist, is ineffective in reversing the hypoactivity induced by anaphylaxis. These results suggest a role for central nervous system opiate mechanisms in the hypoactivity induced by anaphylaxis. They support the hypothesis that endogenous opiates contribute to the pathophysiologic consequences of anaphylactic shock.