Frequencies and predictors of subcutaneous and intraosseous injection with four epinephrine autoinjector devices.

BACKGROUND: To prevent anaphylaxis-associated illness, intramuscular-epinephrine injection is recommended. Subcutaneous injection may reduce efficacy and intraosseous injection promotes morbidity. A few studies suggest that commercially-available thigh-epinephrine autoinjectors (EAIs) may induce subcutaneous/intraosseous injection in some adults. OBJECTIVE: This cross-sectional study estimated the subcutaneous/intraosseous-injection rates of four EAIs by comparing their needle lengths to the ultrasound-measured skin-to-muscle-depth (STMD) and skin-to-bone-depth (STBD) of the mid-thigh of allergic adults. Patient factors that predict subcutaneous-EAI injection were also determined. METHODS: Thigh-ultrasound was conducted in a convenience-recruited cohort with minimal and maximal compression to estimate the effect of EAI-induced compression. Subcutaneous/intraosseous-injection rates were estimated for Anapen, EpiPen, Jext, and Emerade. Multivariate analyses for subcutaneous-injection risk were conducted with age, sex, abdominal and thigh circumferences, and upper-arm skinfold thickness. RESULTS: 68 patients were recruited. Compression respectively thinned the subcutaneous tissue and muscle by 1 and 9 mm on average. Projected subcutaneous-injection rates with/without compression were high for Anapen (65-66%), moderate for EpiPen and Jext (29-38%), and lowest for Emerade (13-21%). Compression introduced a small intraosseous-injection risk with Emerade (4%). Female sex predicted subcutaneous injection (Odds-ratios 1.3-2.0, all p<0.001). Depending on the EAI, 29-97% of women and 0-41% of men would be injected subcutaneously. Older men were at risk of intraosseous Emerade injection. Obesity-related variables predicted subcutaneous injection poorly. CONCLUSION: Anapen associated with high subcutaneous-injection rates. EpiPen and Jext were projected to provide intramuscular injection in all men without risk of intraosseous injection. Emerade yielded the lowest subcutaneous-injection rates in women. Compression largely affected the muscle.

A European survey of management approaches in chronic urticaria in children: EAACI pediatric urticaria taskforce.

BACKGROUND: Although well described in adults, there are scarce and heterogeneous data on the diagnosis and management of chronic urticaria (CU) in children (0-18 years) throughout Europe. Our aim was to explore country differences and identify the extent to which the EAACI/GA²LEN/EDF/WAO guideline recommendations for pediatric urticaria are implemented. METHODS: The EAACI Task Force for pediatric CU disseminated an online clinical survey among EAACI pediatric section members. Members were asked to answer 35 multiple choice questions on current practices in their respective centers. RESULTS: The survey was sent to 2,773 physicians of whom 358 (13.8%) responded, mainly pediatric allergists (80%) and pediatricians (49.7%), working in 69 countries. For diagnosis, Southern European countries used significantly more routine tests (eg, autoimmune testing, allergological tests, and parasitic investigation) than Northern European countries. Most respondents (60.3%) used a 2nd -generation antihistamine as first-line treatment of whom 64.8% updosed as a second line. Omalizumab was used as a second-line treatment by 1.7% and third line by 20.7% of respondents. Most clinicians (65%) follow EAACI/WAO/GA2LEN/EDF guidelines when diagnosing CU, and only 7.3% follow no specific guidelines. Some clinicians prefer to follow national guidelines (18.4%, mainly Northern European) or the AAAAI practice parameter (1.7%). CONCLUSIONS: Even though most members of the Pediatric Section of EAACI are familiar with the EAACI/WAO/GA2LEN/EDF guidelines, a significant number do not follow them. Also, the large variation in diagnosis and treatment strengthens the need to re-evaluate, update, and standardize guidelines on the diagnosis and management of CU in children.

Physician's experience on managing asthma in adolescents: results of the International AMADO (Asthma Management in ADOlescents) survey.

BACKGROUND: Worldwide prevalence of asthma seems to be increasing in adolescents, but limited data is available regarding the management of asthma in this age group. OBJECTIVE: Therefore, we conducted an international survey focused on physicians who manage asthma in order to understand how Asthma Management in ADOlescents (AMADO) is currently performed. METHODS: The AMADO survey is a web-based global survey of physician's attitudes towards the management of asthma in adolescents, circulated for 17 weeks. The survey had an anonymous and voluntary standard. The questionnaire consisted in 27 questions covering the training background of respondents, difficulties in diagnosis, and in management of asthma in adolescents. RESULTS: Two hundred forty-four responses were received from 46 countries, from all continents. Most (65%) of participants indicated allergy as being their main specialty. The majority of participants (62%) had more than 5 years of clinical practice, but 62% have no formal training in management of adolescents with asthma. Most of participants (96%) indicated having at least one case of asthma in adolescents per month. 60% of respondents mentioned that the asthmatic adolescents only had the consultation due to the family imposition. All respondents mentioned having difficulties in the management of asthma in adolescents due to patient poor adherence. Overall, 44% of participants have no specific health care resources for adolescents in their departments. Main suggestions from the participants were: optimization of time and personalized communication to these cohort, and standardization of multidisciplinary actions to improve adherence to asthma control treatment. CONCLUSION: Management of asthma in adolescents is still a challenge in clinical practice. The results from this survey helped us to identify the key issues to improve clinical outcomes in the future. This survey is the first step of the international AMADO initiative, which intends to optimize diagnosis and control of asthma and prevent avoidable deaths.

Anaphylaxis to Beluga caviar.

Fish roe is an extremely rare cause of anaphylaxis and although its consumption has increased in recent years. We described the case of a 59-year-old man, who experienced an anaphylactic reaction after consuming caviar. Skin prick-test were performed with Beluga caviar, salmon caviar, cod, salmon, hen egg yolk and egg white, ovalbumin, ovomucoid, shrimp and mold. Only SPT to Beluga caviar was positive. The absence of sensitization to fish and hen egg was confirmed by undetectable specific IgEs to cod, parvalbumin (Gad c 1 and Cyp c 1), egg yolk and egg white, ovalbumin and ovomucoid. An immunoblot was also performed and showed an IgE-reactive band indicated that the patient was sensitized to a 26 kDa protein in Beluga caviar. In the present case, immunoblotting of the patient's serum revealed a single IgE-reactive band at 26 kDa band, which does not appear to correspond to the previous cases.

Comparative study with new accuracy metrics for target volume contouring in PET image guided radiation therapy.

The impact of PET on radiation therapy is held back by poor methods of defining functional volumes of interest. Many new software tools are being proposed for contouring target volumes but the different approaches are not adequately compared and their accuracy is poorly evaluated due to the illdefinition of ground truth. This paper compares the largest cohort to date of established, emerging and proposed PET contouring methods, in terms of accuracy and variability. We emphasise spatial accuracy and present a new metric that addresses the lack of unique ground truth. 30 methods are used at 13 different institutions to contour functional VOIs in clinical PET/CT and a custom-built PET phantom representing typical problems in image guided radiotherapy. Contouring methods are grouped according to algorithmic type, level of interactivity and how they exploit structural information in hybrid images. Experiments reveal benefits of high levels of user interaction, as well as simultaneous visualisation of CT images and PET gradients to guide interactive procedures. Method-wise evaluation identifies the danger of over-automation and the value of prior knowledge built into an algorithm.

Hyperconnections and hierarchical representations for grayscale and multiband image processing.

Connections in image processing are an important notion that describes how pixels can be grouped together according to their spatial relationships and/or their gray-level values. In recent years, several works were devoted to the development of new theories of connections among which hyperconnection (h-connection) is a very promising notion. This paper addresses two major issues of this theory. First, we propose a new axiomatic that ensures that every h-connection generates decompositions that are consistent for image processing and, more precisely, for the design of h-connected filters. Second, we develop a general framework to represent the decomposition of an image into h-connections as a tree that corresponds to the generalization of the connected component tree. Such trees are indeed an efficient and intuitive way to design attribute filters or to perform detection tasks based on qualitative or quantitative attributes. These theoretical developments are applied to a particular fuzzy h-connection, and we test this new framework on several classical applications in image processing, i.e., segmentation, connected filtering, and document image binarization. The experiments confirm the suitability of the proposed approach: It is robust to noise, and it provides an efficient framework to design selective filters.

Thermodynamic and kinetic study of phenol degradation by a non-catalytic wet air oxidation process.

This work is dedicated to an accurate evaluation of thermodynamic and kinetics aspects of phenol degradation using wet air oxidation process. Phenol is a well known polluting molecule and therefore it is important having data of its behaviour during this process. A view cell is used for the experimental study, with an internal volume of 150 mL, able to reach pressures up to 30 MPa and temperatures up to 350°C. Concerning the thermodynamic phase equilibria, experimental and modelling results are obtained for different binary systems (water/nitrogen, water/air) and ternary system (water/nitrogen/phenol). The best model is the Predictive Soave Redlich Kwong one. This information is necessary to predict the composition of the gas phase during the process. It is also important for an implementation in a process simulation. The second part is dedicated to kinetics evaluation of the degradation of phenol. Different compounds have been detected using GC coupled with a MS. A kinetic scheme is deduced, taking into account the evolution of phenol, hydroquinones, catechol, resorcinol and acetic acid. The kinetic parameters are calculated for this scheme. These data are important to evaluate the evolution of the concentration of the different polluting molecules during the process. A simplified kinetic scheme, which can be easily implemented in a process simulation, is also determined for the direct degradation of phenol into H(2)O and CO(2). The Arrhenius law data obtained for the phenol disappearance are the following: k=1.8×10(6)±3.9×10(5)M(-1)s(-1) (pre-exponential factor) and E(a)=77±8 kJ mol(-1) (activation energy).

Morphological description of color images for content-based image retrieval.

Placed within the context of content-based image retrieval, we study in this paper the potential of morphological operators as far as color description is concerned, a booming field to which the morphological framework, however, has only recently started to be applied. More precisely, we present three morphology-based approaches, one making use of granulometries independently computed for each subquantized color and two employing the principle of multiresolution histograms for describing color, using respectively morphological levelings and watersheds. These new morphological color descriptors are subsequently compared against known alternatives in a series of experiments, the results of which assert the practical interest of the proposed methods.