Real World Management of Anaphylaxis Versus the National Institute for Health and Clinical Excellence (NICE) Guidelines.

Objectives  Anaphylaxis is an acute, life-threatening immediate allergic reaction caused by the sudden systemic release of mediators from mast cells. This study aims to assess the current practice of emergency management of children and adults diagnosed with anaphylaxis at the Royal Hospital, Muscat, Oman, in line with the National Institute for Health and Clinical Excellence (NICE) guidelines.  Methods This is an observational retrospective study of all anaphylaxis cases seen at the emergency department (ED) from January 2013 to January 2018 and compared with the management of anaphylaxis in the ED as per the NICE guidelines. Inclusion criteria were all patients, children (age 16 and below), and adults diagnosed with anaphylaxis based on the World Allergy Organization (WAO) criteria. Exclusion criteria are all cases labeled as anaphylaxis that did not match the WAO criteria for anaphylaxis. Results Of 100 patients with a preliminary diagnosis of anaphylaxis, 49 patients (49%) were true-anaphylaxis cases based on the WAO definition 16 were children (age 16 years and below), and 33 were adults ( age 16 years and above). The other 51 patients (51%) with misdiagnosed anaphylaxis were later diagnosed with spontaneous urticaria, septic shock, vocal cord dysfunction, severe asthma, and anxiety attack. All 49 patients with true-anaphylaxis appropriately received adrenaline intramuscularly at the ED. All 16 children were admitted, seen by an allergist, and received an adrenaline auto-injector when indicated. Only 5 of the 33 adults were admitted and seen by an allergist, and 4 of those required an adrenaline auto-injector upon discharge. The remaining 28 adults were discharged from the ED, and only 3 of these were referred to the allergist. None received an adrenaline auto-injector upon discharge from the ED, and no mention in the ED notes on patient education regarding allergen avoidance. Conclusion Third of the patients who presented to ED were children (<16 years), and two third were adults. Insect venom was the main reason for anaphylaxis in both age groups. There was an underutilization of adrenaline auto-injector prescriptions for adult patients. This could be very well improved by disseminating policies and guidelines to adult physicians.

Characteristics of Pyogenic Liver Abscess: Experience of a single centre in Oman.

Objectives: This study aimed to analyse the epidemiological, aetiological and clinical characteristics of pyogenic liver abscess (PLA) occurring in Oman. The intention was to obtain the information needed for the adequate liver abscess (LA) empirical treatment. LA can develop as a complication of hepatobiliary disease or other intraabdominal infections, but more recently, it is associated with primary and secondary liver malignancies and their treatment. Methods: This retrospective study took place in the Royal Hospital, Muscat, Oman. Consecutive patients treated for LA from January 2013 to December 2017 were enrolled. Their demographic and clinical data were used to study the characteristics of PLA occurring in Oman. Results: A total of 53 patients with PLA were enrolled in the study. They were predominantly male and younger than 60 years. Klebsiella pneumoniae was found to be the most common bacteria causing LA. Clinical presentation was non-specific, and abdominal pain and high fever were the most common symptoms. Conclusion: The majority of PLAs are caused by K. pneumoniae, so the empirical treatment should begin with antibiotic directed against it. Further studies are needed to establish the local role of anaerobic bacteria in PLA and monitor the presence of hypervirulent K. pneumoniae in Oman.

Amoebic Liver Abscess: A disease native to Oman?

Objectives: Amoebic liver abscess (ALA) is endemic to many areas of the world. This study sought to investigate the epidemiology, presentation, laboratory tests and imaging characteristics of ALA in Oman and ultimately determine whether it is native to Oman or originated abroad. Methods: This case series study was conducted at the Royal Hospital, Muscat, Oman, from January 2013 to December 2017 with patients older than 13 years and having a discharge diagnosis of ALA. Patient data were extracted from the Royal Hospital patient database. Results: 22 patients were included in the study-18 Omani patients and four expatriates. Only two Omanis had a history of traveling abroad. There were 15 male patients and seven were female with an average age of 45.2 years. The most common presentation was abdominal pain, which was seen in 17 patients. Fever was seen in 13 patients. Alanine transferase was found to be elevated in 13 patients. The majority of patients (90%) had no symptomatic infections prior to developing ALA. Conclusion: The data suggests that ALA is endemic to Oman, considering the high number of local patients and lack of travel abroad in this population. As the number of patients treated for ALA is rather small, it can be concluded that the occurrence of ALA is much lower in Oman than in other endemic areas. The majority of patients had no prior symptomatic infections; thus, a method of control involves screening to prevent amoebic spread.

Successful Desensitization to the Radiocontrast Material Iohexol (Omnipaque™).

Adverse reactions to radiocontrast media (RCM) are rare and occur predominantly in association with intravenous administration but may also occur with intra-arterial and nonvascular injections (e.g., retrograde pyelography, intra-articular injections) of RCM. This article reports the case of a 52-year-old lady who was known to have amyloidosis secondary to rheumatoid arthritis and was on regular renal replacement therapy. She was under follow-up for regular angioplasties to manage the central vein stenosis that was affecting her right brachiocephalic arteriovenous fistula (AVF) and was referred to our Immunology service when she developed an allergic reaction after her AVF angioplasty (central venoplasty). Despite being dialysed immediately post-angioplasty, she complained of skin rash and itching with hoarseness of voice that developed almost six to eight hours post-angioplasty. We decided to arrange the iodinated non-ionic iso-osmolar contrast agent iodixanol (Visipaque™) for her instead, as it is known to be better tolerated in patients with reactions to Omnipaque™ due to its lower osmolarity as compared to Omnipaque™. However, since it was the first time to request this contrast in our hospital, it was not possible due to logistical reasons. It was necessary that our patient continued to undergo angioplasty every three months, however, she was developing more severe and earlier symptoms with each subsequent exposure to the radiocontrast medium. After her latest reaction of generalized itching and angioedema with shortness of breath during the procedure despite premedication, it was decided for her to undergo desensitization to Omnipaque™. In the absence of a published protocol for this, we used a protocol used for desensitization to Visipaque™. She showed an excellent response and completed her remaining angioplasties until Visipaque™ became available. Hence, desensitization to Omnipaque™ using the published protocol to Visipaque™ is likely to help patients allergic to Omnipaque™ or where Visipaque™ is not available or non-affordable in low/middle-income countries.

Severe imported malaria in an intensive care unit: A case series.

INTRODUCTION: Complicated malaria is a medical emergency with a high mortality if untreated. AIM: To describe the clinical spectrum, treatment practices and outcome of severe malaria cases admitted to an intensive care unit. METHOD: Thirteen severe malaria cases admitted to the ICU over a 6 years period (2012 - October 2018) were included. The data was retrospectively extracted from the hospital patient data management system. RESULTS: Nine patients had P. falciparum malaria, three had P.Vivax, and one had both. Only one had received malarial chemoprophylaxis. The median time of attending to medical health facility after symptoms started was 7 days (range: 2-21 days). All cases responded to antimalarial therapy and supportive management. Complications included shock 54%, kidney failure 38%, respiratory failure 69%, cerebral malaria 61%, hypoglycemia 23%, coagulation derangement 8%, and acidosis 23%. There were no fatal outcomes but one case had permanent brain damage and the rest recovered completely. CONCLUSION: The median treatment delay of seven days explains why these patients ended in intensive care with multiple symptoms of severe malaria and often multiorgan failure. Pretravel advice and use of malaria chemoprophylaxis when visiting high risk areas would probably have prevented infection and timely attendance to healthcare once symptomatic would have reduced the morbidity associated with infection, reduced length of stay in hospital and hence resources.