Globalization and anaphylaxis.

PURPOSE OF REVIEW: To understand the impact of globalization in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. RECENT FINDINGS: Developments in the field of anaphylaxis have been consistently following these globalization trends offering possibilities of collaborations of the allergy community and integrated international initiatives to reach quality care of allergic patients worldwide. SUMMARY: Globalization is the process of interaction and integration between people, companies, and governments worldwide. Developments in the field of anaphylaxis have been following these globalization trends offering possibilities of collaborations and integrated international initiatives to reach quality care of allergic patients worldwide. Complex disorders, such as anaphylaxis, have called for complex integrative strategies, leading to a new acceptance of outside traditions. Allergy is encouraging us to accept holistic and integrative medical practices as viable options. With the dissolution of multinational boundaries and the universal free access to information, the notion of holistic and global-based care is emerging as the new reality of the medicine. We strongly believe that the integrated action plan to the management and prevention of anaphylaxis, just possible through the globalization, is a key health, political and economical move that advocates for the best practice of allergology.

Immunotherapy safety: what have we learned from surveillance surveys?

Subcutaneous allergen immunotherapy (SCIT) is beneficial for the treatment of allergic rhinitis, asthma, and in preventing stinging insect anaphylaxis, but is not without risks. Four retrospective surveillance surveys and one on-going national prospective study have attempted to characterize the incidence and risk factors for fatal and non-fatal SCIT reactions. These studies have contributed significantly to currently recommended SCIT safety guidelines. Recent surveillance studies indicate stable SR rates, and a possible decline in the incidence of fatal reactions since the implementation of evidence-based safety guidelines. This review will provide a detailed summary of the evidence from surveillance studies for risk factors associated with SCIT reactions, including: uncontrolled asthma, prior systemic reactions, dosing during peak pollen seasons, epinephrine being delayed or not given, dosing or administration errors, inadequate waiting times, reactions occurring more than 30 min after injections, injections given in medically unsupervised settings, concomitant beta-blocker and angiotensin-converting enzyme inhibitor (ACEi) use, and accelerated build-up regimens.

Anaphylactic shock and lethal anaphylaxis caused by compound amino acid solution, a nutritional treatment widely used in China.

Compound amino acid solution (CAAS) is a large class of solution of amino acids' mixture and was widely used in China. Its extensive nutritional treatment was accompanied by a substantial incidence of adverse reactions, especially life-threatening anaphylaxis. However, the adverse reactions were reported in isolated case reports only, and the reasons behind this needed further investigation. The Chinese language papers were searched from China National Knowledge Infrastructure and Wanfang database published in China from 1985 to 2010. The search terms "anaphylactic", "anaphylaxis", "allergic", "allergy", "shock", and "adverse reaction" combined with the term "amino acid" were used. Totally 71 episodes of anaphylactic shock and seven deaths in 38 articles were analyzed. Chest distress and cool extremities were the most common clinical manifestations. Almost all patients suffered from significant hypotension. The vast majority of patients were not found to be allergic to certain substances. CAAS was inappropriately administrated in more than one-third of patients. The life-threatening anaphylaxis was prominently prevalent in pregnant women, the elderly and patients with hypersensitivity such as asthma, and patients without medicinal indication. Innovation of processing technique and establishment of more strict supervision system are an urgent need for CAAS to control its production quality and thus improve its safety in China.

Comments on serious anaphylaxis caused by nine Chinese herbal injections used to treat common colds and upper respiratory tract infections.

Reports describing severe allergic shock and fatality following treatment of a common cold or upper respiratory tract infection (URTI) with a Chinese herbal injection were collected. Our analysis of the risks associated with this treatment suggested that the potential risk of serious, or even lethal, anaphylaxis should preclude its use in treating common colds and URTIs. In light of our findings herein, we propose the following five suggestions for improving the clinical safety of delivering Chinese herbal injections as medical treatments. First, Chinese herbal injections should not be delivered in the clinic to treat patients in accordance with Bian zheng lun zhi (broad-spectrum application based on holistic Traditional Chinese Medicine (TCM) theory and methodology), but rather they should be administered to target specific indicated disease processes. Second, Chinese herbal injection indications should be based on the results of double-blind randomized controlled clinical trials. Third, Chinese herbal injections should be used only in cases involving severe disease or to rescue patients in critical condition; they should not be used to treat mild, relatively innocuous diseases, such as common colds and upper respiratory tract infections, given the risk of doing harm. Fourth, Chinese herbal injection formulas should include materials from only a single or a small number of plant sources in known quantities. Fifth, more studies examining the toxicology and allergenic potential of Chinese herbal injections are needed.

Epidemiology of life-threatening and lethal anaphylaxis: a review.

Severe anaphylaxis is a systemic reaction affecting two or more organs or systems and is due to the release of active mediators from mast cells and basophils. A four-grade classification routinely places 'severe' anaphylaxis in grades 3 and 4 (death could be graded as grade 5). Studies are underway to determine the prevalence of severe and lethal anaphylaxis in different populations and the relative frequencies of food, drug, latex and Hymenoptera anaphylaxis. These studies will also analyse the risk arising from the lack of preventive measures applied in schools (personalized management protocols) and from the insufficient use of self-injected adrenalin. Allergy-related conditions may account for 0.2-1% of emergency consultations. Severe anaphylaxis affects 1-3 per 10 000 people, but for the United States and Australia figures are even higher. It is estimated to cause death in 0.65-2% of patients, i.e. 1-3 per million people. An increased prevalence has been revealed by monitoring hospitalized populations by reference to the international classification of disease (ICD) codes. The relative frequency of aetiological factors of allergy (food, drugs, insects and latex) varies in different studies. Food, drug and Hymenoptera allergies are potentially lethal. The risk of food-mediated anaphylaxis can be assessed from the number of personalized management protocols in French schools: 0.065%. Another means of assessment may be the rate of adrenalin prescriptions. However, an overestimation of the anaphylaxis risk may result from this method (0.95% of Canadian children). Data from the literature leads to several possibilities. First, a definition of severe anaphylaxis should be agreed. Secondly, prospective, multicentre enquiries, using ICD codes, should be implemented. Moreover, the high number of anaphylaxis cases for which the aetiology is not identified, and the variation in aetiology in the published series, indicate that a closer cooperation between emergency specialists and allergists is essential.

Inactivation of C5a anaphylatoxin by a peptide that is complementary to a region of C5a.

PL37 (RAARISLGPRCIKAFTE) is an antisense homology box peptide composed of aa 37-53 of C5a-anaphylatoxin and is considered to be the region essential for C5a function. Using a computer program, we designed the complementary peptides ASGAPAPGPAGPLRPMF (Pep-A) and ASTAPARAGLPRLPKFF (Pep-B). Pep-A bound to PL37 and to C5a with very slow dissociation as determined by analysis using surface plasmon resonance, whereas Pep-B failed to bind at all. C5a was inactivated by concentrations of 7 nM or more of Pep-A, and this concentration of Pep-A inhibited induction of intracellular Ca(2+) influx in neutrophils. Patch clamp electrophysiology experiments also showed the effectiveness of Pep-A in C5aR-expressing neuroblastoma cells. Furthermore, Pep-A administration prevented rats from C5a-mediated rapid lethal shock induced by an Ab to a membrane inhibitor of complement after LPS sensitization.

Psyllium-associated anaphylaxis and death: a case report and review of the literature.

BACKGROUND: Psyllium use has increased significantly in the United States in part due to its lipid-lowering property. The increased prevalence of consumption has led to its recognition as an emerging food allergen. OBJECTIVES: To report the case of a 42-year-old woman who experienced fatal anaphylaxis after ingesting a psyllium-based product and to review the literature. METHODS: The MEDLINE database was searched for articles from 1966 to 2002 using the keywords psyllium or ispaghula and each of the following: allergy, hypersensitivity, anaphylaxis, and asthma. Both English and non-English articles were included. RESULTS: Psyllium hypersensitivity has been well described in health care workers and pharmaceutical plant employees. Clinical manifestations of allergy range from upper respiratory tract symptoms on inhalation to anaphylaxis on ingestion. The prevalence of sensitization varies between these 2 groups. The allergenic epitope is not known. CONCLUSIONS: We present a case of psyllium hypersensitivity that resulted in death. There is a clear association between atopy and psyllium allergy. The case underscores the fact that even nonprescription "natural" products can be harmful to people with allergies.

Clinical update on peanut allergy.

BACKGROUND: Peanut allergy is common, potentially severe, and there has been a recent surge in clinical investigation of this important food allergen. OBJECTIVE: To provide the reader with a clinically oriented update on peanut allergy. DATA SOURCES: English language articles were selected from PubMed searches (search terms: peanut allergy, food allergy, anaphylaxis) and selected abstracts with a bias toward recent (3 years) studies judged to have immediate, practical clinical implications. RESULTS: Peanut allergy is an increasing problem in western diets that include this food. Both genetic and environmental factors influences the expression of this allergy. The at-risk subject is an atopic individual, with heightened risk for those with atopic dermatitis and/or other food allergies. The allergy is long-lived for most, may increase slightly in severity over time, but approximately 20% of young children will develop tolerance. Parameters that may identify the subset likely to achieve tolerance have been identified. Several large studies have determined laboratory parameters (skin tests, peanut-specific serum immunoglobulin E concentrations) with excellent predictive value (>95%) to diagnose current clinical reactivity or tolerance, although oral food challenges are necessary for a definitive diagnosis. Numerous practical lessons concerning management (avoidance, treatment, and prevention) have been identified. CONCLUSIONS: Recent studies provide the clinician with an armament of improved diagnostic and treatment modalities for peanut allergy. Studies are underway that are likely to provide more definitive therapies in the near future.

[The modification of the effect of microwave radiation on the biochemical processes in anaphylactic shock by using exposure to a weak and perturbed geomagnetic field]. / Modifikatsiia vliianiia mikrovolnovogo izlucheniia na biokhimicheskie protsessy pri anafilakticheskom shoke s pomoshch'iu vozdeistviia oslablennogo i iskazhennogo geomagnitnogo polia.

Repeated exposure of guinea pigs to microwave radiation (1 mW/cm2) caused in some animals inhibition of anaphylactic response accompanied by increasing the content of histamine, epinephrine and norepinephrine in the blood. This increase was more pronounced in irradiated guinea pigs died from anaphylactic shock than in nonirradiated animals. The long-term stay in the perturbed and weak geometric field reduced the effect induced by microwave radiation.

[Effect of naloxone on blood microcirculatory changes in anaphylactic shock]. / Vliianie naloksona na izmeneniia gemomikrotsirkuliatsii pri anafilakticheskom shoke.

During the experiment conducted upon 85 guinea-pigs it has been found that the injection of naloxone at the dose of 0.5 g/kg half an hour before the reproduction of anaphylactic shock (AS) by the use of horse serum increases the number of cases of the retarded development of pathological reaction and survival of the animals. Except for the quantitative differences mentioned any peculiarities characterizing the effect of naloxone were not found. As to the morphological differences of variants in the course of AS they are distinctly defined only at the analysis of film preparations of the intestinal mesentery. The typical AS becomes apparent by haemorrhages, by dilatation of all the vessels of blood circulation and by forming of erythrocytic aggregates in them. At the retarded development of AS a spasm of precapillaries is observed. After convalescence of the animals the aggregates of erythrocytes can be revealed only in venules. Studying the animals recovered after AS one can find that for a long time these animals had the erythrocytic aggregates in the clearances of venules, as well as the signs of new formation of the capillaries.

Effects of different levels of vitamin C intake on the vitamin C concentration in guinea pigs plasma and the effect of vitamin C intake on anaphylaxis.

The plasma ascorbate level after a single intraperitoneal dose of 25, 100 or 250 mg Na-ascorbate was followed up in vivo over a period of 24 hours. Intraperitoneal administration of Na-ascorbate caused a rapid increase of ascorbic acid plasma concentration. Maximum ascorbic acid plasma level was obtained 30 minutes after parenteral administration of the test dose. No great difference was found between the 12- and 24-hour ascorbic acid plasma values. The effect of Na-ascorbate on fatal anaphylaxis was also investigated in 18 guinea pigs. The animals treated with 281 mg/day Na-ascorbate rarely developed anaphylactic shock or the shock was of weaker intensity. Mortality was reduced from 40% (control group) to 11% when Vitamin C was given for four days before and one day after passive transfer of rabbit anti-HGG (human gamma globulin) antibody. A possible protective role of ascorbic acid by preventing anaphylaxis is discussed. Passive administration of ascorbic acid was found to protect guinea pigs from fatal anaphylaxis.

Decreased incidence and mortality of anaphylaxis to chymopapain.

A recognized side effect of chemonucleolysis is life-threatening anaphylaxis to chymopapain. In the clinical trials of chymopapain, 13 cases of anaphylaxis were reported in 1585 administrations (0.82%). Two patients died. Data from a postmarketing survey (48,239 questionnaires) were reviewed to identify factors influencing the incidence and severity of anaphylaxis. The results indicate the incidence of anaphylaxis decreased to 0.44% in the 1983-1984 period (126/23,736), a level significantly (P less than or equal to 0.001) below the incidence of 0.82% observed in initial clinical trials. Only three deaths from complications related to anaphylaxis occurred in approximately 75,000 administrations (producing 252 anaphylactic episodes) reported since December 1982. The prophylactic use of antihistamines and pretreatment with intravenous fluids coincide with the dramatic reduction in mortality due to anaphylaxis. However, overdiagnosis of anaphylaxis in the clinical trials and avoidance of chemonucleolysis in patients with IgE antibodies to chymopapain may account, in part, for the reduction in incidence.

Bee-sting diseases: Who is at risk? What is the treatment?

Many of the large number of people who are stung each year by bees experience frightening systemic reactions, but the vast majority of such reactions are not life-threatening. There is no evidence that the very few who die as a result of a bee sting come from the pool of those who once before sustained a systemic reaction. On the contrary, no reaction at all may be a more ominous predictor of a lethal outcome on a subsequent sting. Death comes about through multiple mechanisms, and not through anaphylaxis alone. Like most cases of sudden death, underlying coronary atherosclerosis appears to be the principal mechanism. External factors that affect mortality include environmental temperature and site of sting. In general, however, because the numbers of deaths are so small, death comes unpredictably, and those at risk have not been identified. Immunotherapy, whether with venom or whole-body extract, has not been proven to prevent death from a bee sting.