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1.
Emerg Med Clin North Am ; 40(1): 1-17, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34782082

RESUMO

Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.


Assuntos
Anafilaxia/fisiopatologia , Hipersensibilidade/fisiopatologia , Anafilaxia/diagnóstico , Epinefrina/uso terapêutico , Humanos , Hipersensibilidade/diagnóstico , Fatores de Risco
2.
Immunol Allergy Clin North Am ; 42(1): 187-200, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34823747

RESUMO

There are significant anaphylaxis data and knowledge gaps that result in suboptimal patient care and outcomes. To address these gaps there is need for collaborative, multidisciplinary research networks to strategically design practice changing research specific to the following anaphylaxis themes: Population Science, Basic and Translational Sciences, Acute Management, and Long-Term Management. Top priorities are to refine anaphylaxis diagnostic criteria, identify accurate diagnostic and predictive anaphylaxis biomarkers, standardize postanaphylaxis care (observation periods, hospitalization criteria), and determine immunotherapy best practices. Addressing these gaps will result in improved, optimal care and clinical outcomes for patients with or at risk of anaphylaxis.


Assuntos
Anafilaxia , Anafilaxia/diagnóstico , Anafilaxia/epidemiologia , Anafilaxia/terapia , Epinefrina , Hospitalização , Humanos
3.
Artigo em Inglês | MEDLINE | ID: mdl-34390722

RESUMO

BACKGROUND: Despite a better understanding of the epidemiology, pathogenesis, and management of patients with anaphylaxis, there remain knowledge gaps. Enumerating and prioritizing these gaps would allow limited scientific resources to be directed more effectively. OBJECTIVE: We sought to systematically describe and appraise anaphylaxis knowledge gaps and future research priorities based on their potential impact and feasibility. METHODS: We convened a 25-member multidisciplinary panel of anaphylaxis experts. Panelists formulated knowledge gaps/research priority statements in an anonymous electronic survey. Four anaphylaxis themed writing groups were formed to refine statements: (1) Population Science, (2) Basic and Translational Sciences, (3) Emergency Department Care/Acute Management, and (4) Long-Term Management Strategies and Prevention. Revised statements were incorporated into an anonymous electronic survey, and panelists were asked to rate the impact and feasibility of addressing statements on a continuous 0 to 100 scale. RESULTS: The panel generated 98 statements across the 4 anaphylaxis themes: Population Science (29), Basic and Translational Sciences (27), Emergency Department Care/Acute Management (24), and Long-Term Management Strategies and Prevention (18). Median scores for impact and feasibility ranged from 50.0 to 95.0 and from 40.0 to 90.0, respectively. Key statements based on median rating for impact/feasibility included the need to refine anaphylaxis diagnostic criteria, identify reliable diagnostic, predictive, and prognostic anaphylaxis bioassays, develop clinical prediction models to standardize postanaphylaxis observation periods and hospitalization criteria, and determine immunotherapy best practices. CONCLUSIONS: We identified and systematically appraised anaphylaxis knowledge gaps and future research priorities. This study reinforces the need to harmonize scientific pursuits to optimize the outcomes of patients with and at risk of anaphylaxis.

4.
J Allergy Clin Immunol Pract ; 9(10): 3546-3567, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34153517

RESUMO

Concerns for anaphylaxis may hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunization efforts. We convened a multidisciplinary group of international experts in anaphylaxis composed of allergy, infectious disease, emergency medicine, and front-line clinicians to systematically develop recommendations regarding SARS-CoV-2 vaccine immediate allergic reactions. Medline, EMBASE, Web of Science, the World Health Organizstion (WHO) global coronavirus database, and the gray literature (inception, March 19, 2021) were systematically searched. Paired reviewers independently selected studies addressing anaphylaxis after SARS-CoV-2 vaccination, polyethylene glycol (PEG) and polysorbate allergy, and accuracy of allergy testing for SARS-CoV-2 vaccine allergy. Random effects models synthesized the data to inform recommendations based on the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, agreed upon using a modified Delphi panel. The incidence of SARS-CoV-2 vaccine anaphylaxis is 7.91 cases per million (n = 41,000,000 vaccinations; 95% confidence interval [95% CI] 4.02-15.59; 26 studies, moderate certainty), the incidence of 0.15 cases per million patient-years (95% CI 0.11-0.2), and the sensitivity for PEG skin testing is poor, although specificity is high (15 studies, very low certainty). We recommend vaccination over either no vaccination or performing SARS-CoV-2 vaccine/excipient screening allergy testing for individuals without history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient, and a shared decision-making paradigm in consultation with an allergy specialist for individuals with a history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient. We recommend further research to clarify SARS-CoV-2 vaccine/vaccine excipient testing utility in individuals potentially allergic to SARS-CoV2 vaccines or their excipients.


Assuntos
Anafilaxia , COVID-19 , Anafilaxia/diagnóstico , Anafilaxia/epidemiologia , Vacinas contra COVID-19 , Consenso , Abordagem GRADE , Humanos , RNA Viral , SARS-CoV-2
5.
J Allergy Clin Immunol ; 148(1): 173-181, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33476673

RESUMO

BACKGROUND: There is no widely adopted severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, thus limiting the ability to optimize and standardize management practices and advance research. OBJECTIVE: The aim of this study was to develop a severity grading system for acute allergic reactions for use in clinical care and research. METHODS: From May to September 2020, we convened a 21-member multidisciplinary panel of allergy and emergency care experts; 9 members formed a writing group to critically appraise and assess the strengths and limitations of prior severity grading systems and develop the structure and content for an optimal severity grading system. The entire study panel then revised the grading system and sought consensus by utilizing Delphi methodology. RESULTS: The writing group recommended that an optimal grading system encompass the severity of acute allergic reactions on a continuum from mild allergic reactions to anaphylactic shock. Additionally, the severity grading system must be able to discriminate between clinically important differences in reaction severity to be relevant in research while also being intuitive and straightforward to apply in clinical care. Consensus was reached for all elements of the proposed severity grading system. CONCLUSION: We developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions. Successful international validation, refinement, dissemination, and application of the grading system will improve communication among providers and patients about the severity of allergic reactions and will help advance future research.


Assuntos
Anafilaxia/patologia , Hipersensibilidade/patologia , Doença Aguda , Consenso , Técnica Delfos , Serviços Médicos de Emergência/métodos , Humanos , Índice de Gravidade de Doença
6.
BMJ Open ; 11(1): e037341, 2021 01 05.
Artigo em Inglês | MEDLINE | ID: mdl-33402402

RESUMO

INTRODUCTION: There remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity. METHODS AND ANALYSIS: The study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity. ETHICS AND DISSEMINATION: All sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.


Assuntos
Anafilaxia , Medicina de Emergência Pediátrica , Anafilaxia/tratamento farmacológico , Anafilaxia/epidemiologia , Criança , Estudos de Coortes , Serviço Hospitalar de Emergência , Epinefrina/uso terapêutico , Humanos , Estudos Multicêntricos como Assunto
7.
J Allergy Clin Immunol ; 146(5): 1089-1096, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32853640

RESUMO

BACKGROUND: The use of inconsistent definitions for anaphylaxis outcomes limits our understanding of the natural history and epidemiology of anaphylaxis, hindering clinical practice and research efforts. OBJECTIVE: Our aim was to develop consensus definitions for clinically relevant anaphylaxis outcomes by utilizing a multidisciplinary group of clinical and research experts in anaphylaxis. METHODS: Using Delphi methodology, we developed agenda topics and drafted questions to review during monthly conference calls. Through online surveys, a 19-member panel consisting of experts in allergy and/or immunology and emergency medicine rated their level of agreement with the appropriateness of statements on a scale of 1 to 9. A median value of 1.0 to 3.4 was considered inappropriate, a median value of 3.5 to 6.9 was considered uncertain, and a median value of 7.0 to 9.0 was considered appropriate. A disagreement index was then calculated, with values less than 1.0 categorized as "consensus reached." If consensus was not reached after the initial survey, subsequent surveys incorporating the aggregate de-identified responses from prior surveys were sent to panel members. This process was repeated until consensus was reached or 4 survey rounds had been completed, after which the question was categorized as "no consensus reached." RESULTS: The panel developed outcome definitions for persistent, refractory, and biphasic anaphylaxis, as well as for persistent and biphasic nonanaphylactic reactions. There was also consensus among panel members regarding the need to develop an anaphylaxis severity grading system. CONCLUSION: Dissemination and application of these definitions in clinical care and research will help standardize the terminology used to describe anaphylaxis outcomes and serve as the foundation for future research, including research aimed at development of an anaphylaxis severity grading system.


Assuntos
Anafilaxia/diagnóstico , Anafilaxia/classificação , Anafilaxia/epidemiologia , Consenso , Técnica Delfos , Progressão da Doença , Humanos , Comunicação Interdisciplinar , Recidiva , Inquéritos e Questionários , Terminologia como Assunto , Estados Unidos/epidemiologia
8.
J Pediatr ; 224: 187-188, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32464223
10.
J Pediatr ; 220: 159-164.e2, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31987654

RESUMO

OBJECTIVE: To assess whether a history of asthma was associated with anaphylaxis severity in children hospitalized for anaphylaxis. STUDY DESIGN: Retrospective cohort study of children ≤21 years old hospitalized for anaphylaxis from 2009 to 2016. The primary outcome was severe anaphylactic reactions defined by examination findings (stridor, respiratory distress, or hypotension) or administered therapies (≥2 dose of intramuscular epinephrine, continuous albuterol, vasopressors, or positive pressure ventilation). Multivariable analyses were used to assess whether a history of asthma was associated with severe anaphylactic reactions, adjusting for patient age, allergen, and history of atopic dermatitis or anaphylaxis. RESULTS: Among 603 children hospitalized for anaphylaxis, 231 (38.3%) had a history of asthma. Children with a history of asthma were older (median age, 6.6 years [IQR, 3.6-12.1] vs 4.0 years [IQR, 1.6-9.3]), more likely to have a history of anaphylaxis (38.1% vs 18.0%), and have food as the inciting allergen (68.0% vs 52.2%). Children with a history of asthma were not more likely to have severe anaphylactic reactions (OR, 0.97; 95% CI, 0.67-1.39). CONCLUSIONS: Children hospitalized for anaphylaxis with a history of asthma were not more likely to have severe anaphylactic reactions compared with children without asthma. This study supports managing children with anaphylaxis based on the severity of symptomatology, and, if validated, clinicians should not consider asthma comorbidity as a stand-alone criterion for hospitalization.


Assuntos
Anafilaxia/epidemiologia , Anafilaxia/etiologia , Asma/complicações , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença
13.
PLoS One ; 14(2): e0211949, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30730977

RESUMO

OBJECTIVE: Opportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization. METHODS: We conducted a single-center retrospective cohort study of children 1-21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies. RESULTS: During the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6-98.8%) and a negative predictive value of 98.3% (CI 94.1-99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7-96.0%) and a negative predictive value of 92.4% (CI 85.6-96.7%). CONCLUSIONS: We derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization.


Assuntos
Manuseio das Vias Aéreas/métodos , Anafilaxia/terapia , Broncodilatadores/administração & dosagem , Epinefrina/administração & dosagem , Vasoconstritores/administração & dosagem , Adolescente , Broncodilatadores/uso terapêutico , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Epinefrina/uso terapêutico , Feminino , Hospitalização , Humanos , Lactente , Injeções Intramusculares , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Vasoconstritores/uso terapêutico , Adulto Jovem
14.
Pediatrics ; 139(6)2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28562277

RESUMO

BACKGROUND AND OBJECTIVES: Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis. METHODS: We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children's hospitals over the same time period were analyzed. RESULTS: Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period. CONCLUSIONS: We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.


Assuntos
Anafilaxia , Hospitalização/tendências , Administração dos Cuidados ao Paciente/normas , Melhoria de Qualidade , Adolescente , Anafilaxia/tratamento farmacológico , Boston , Criança , Pré-Escolar , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Guias de Prática Clínica como Assunto
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