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ABSTRACT: Evaluation of anaphylaxis is a common reason for emergency department referral to an allergist. Establishing unified diagnostic criteria has been an evolving process with the most recent definition proposed by the Second Symposium on the Definition and Management of Anaphylaxis convened by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network. Proper identification of these patients in the emergency department allows for the opportunity to dispense potentially life-saving epinephrine autoinjectors, provide education, and allergist referral. Future epidemiological studies are likely to be impacted as the definition of anaphylaxis becomes more unified.
Allergy and Asthma Proceedings 03/2013; 34(2):115-9. · 2.17 Impact Factor
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Sangil Lee,
Erik P Hess,
David M Nestler,
Venkatesh R Bellamkonda Athmaram,
M Fernanda Bellolio,
Wyatt W Decker, James T C Li,
John B Hagan,
Veena Manivannan,
Samuel C Vukov,
Ronna L Campbell
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ABSTRACT: BACKGROUND: Risk factors for increased anaphylaxis severity are poorly understood. Angiotensin-converting enzyme (ACE) inhibitors have been associated with severe anaphylactic reactions in patients with hymenoptera venom allergy. Studies evaluating the association between beta-blockers and severe anaphylaxis have been conflicting. OBJECTIVE: To evaluate the association between antihypertensive medication use and increased anaphylaxis severity. METHODS: We included emergency department anaphylaxis patients aged 18 years and older. Markers of severe anaphylaxis were defined as (1) syncope, hypotension, or hypoxia; (2) signs and symptoms involving 3 or more organ systems; and (3) hospitalization. Antihypertensive medications evaluated included beta-blockers, ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and diuretics. Simple and multiple logistic regression analyses were conducted to estimate the association between antihypertensive medication use and markers of increased anaphylaxis severity. RESULTS: Among 302 patients with anaphylaxis, 55 (18%) had syncope, hypoxia, or hypotension, 57 (19%) required hospitalization, and 139 (46%) had 3 or more organ system involvement. After adjusting for age, gender, suspected trigger, and preexisting lung disease, beta-blocker, ACE-inhibitor, diuretic, or antihypertensive medication use in aggregate remained associated with both 3 or more organ system involvement and need for hospital admission. The adjusted associations between antihypertensive medication use in aggregate and 3 or more organ system involvement yielded an odds ratio of 2.8 (95% CI, 1.5-5.2; P = .0008) and with hospitalization an odds ratio of 4.0 (95% CI, 1.9-8.4; P = .0001). CONCLUSIONS: In emergency department anaphylaxis patients, antihypertensive medication use is associated with increased organ system involvement and increased odds of hospital admission, independent of age, gender, suspected trigger, or preexisting lung disease.
The Journal of allergy and clinical immunology 02/2013; · 9.17 Impact Factor
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ABSTRACT: Diagnostic criteria were proposed at the Second Symposium on the Definition and Management of Anaphylaxis convened by the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN). Validation is needed before these criteria can be widely adapted into clinical practice.
Our aim was to retrospectively assess the diagnostic accuracy of the NIAID/FAAN criteria for the diagnosis of anaphylaxis in emergency department (ED) patients.
A retrospective cohort study of ED patients presenting from April to October 2008 was conducted. Patients given a diagnosis of an allergic reaction or anaphylaxis and a subset of patients with related diagnoses were included. Electronic medical records were reviewed and data were abstracted to determine whether the NIAID/FAAN criteria were met. Records were also independently reviewed in a blinded fashion by 2 experienced attending allergists. Final diagnosis by allergists was considered the reference standard.
Of 214 patients, 86 (40.2%) met the NIAID/FAAN criteria for anaphylaxis. Allergists gave 61 (28.5%) patients diagnoses of anaphylaxis, 59 (96.7%) of whom satisfied the NIAID/FAAN criteria. The interrater agreement between allergists was substantial (κ = 0.77). The test characteristics of the NIAID/FAAN criteria were as follows: sensitivity, 96.7% (95% CI, 88.8% to 99.1%); specificity, 82.4% (95% CI, 75.5% to 87.6%); positive predictive value, 68.6% (95% CI, 58.2% to 77.4%); negative predictive value, 98.4% (95% CI, 94.5% to 99.6%); positive likelihood ratio, 5.48; and negative likelihood ratio, 0.04.
These results suggest that the NIAID/FAAN criteria are highly sensitive but less specific and are likely to be useful in the ED for the diagnosis of anaphylaxis.
The Journal of allergy and clinical immunology 11/2011; 129(3):748-52. · 9.17 Impact Factor
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ABSTRACT: Anaphylaxis is a potentially life-threatening allergic reaction commonly managed in the emergency department (ED). Data describing patients 50 or 65 years or older with anaphylaxis are limited.
To describe the presentation and management of patients with anaphylaxis who were 50 or 65 years or older and to compare these findings with those of younger patients.
A consecutive cohort study of patients presenting to an ED with approximately 80,000 visits per year was conducted. Patients who met diagnostic criteria for anaphylaxis from April 2008 to June 2010 were included. Data were collected on suspected causes, signs and symptoms, management, ED disposition, and follow-up.
The study included 220 patients. Food was the most common suspected cause of anaphylaxis for patients younger than 50 (42.2%) or 65 years (38.5%) but was much less common in patients 50 (14.8%, P < .001) or 65 years or older (14.3%, P = .01). Cardiovascular symptoms were more likely to occur in older patients (≥50 years old, 55.6% vs 30.1%, P < .001; ≥65 years old, 64.3% vs 32.3%, P = .002). Patients 50 or 65 years or older were less likely to be dismissed home directly from the ED (≥50 years old, 35.2% vs 56.6%, P = .006; ≥65 years old, 32.1% vs 54.2%, P = .03) and were less likely to be prescribed self-injectable epinephrine (≥50 years old, 40.7% vs 63.3%, P = .004; ≥65 years old, 32.1% vs 61.5%, P = .003).
In ED patients presenting with anaphylaxis, age of 50 or 65 years or older is associated with a decreased likelihood of food-induced anaphylaxis, increased likelihood of experiencing cardiovascular symptoms, decreased dismissal to home directly from the ED, and decreased prescriptions for self-injectable epinephrine.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 05/2011; 106(5):401-6. · 2.83 Impact Factor
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Kaiser G Lim,
Matthew A Rank, James T C Li,
Ashok Patel,
Gerald W Volcheck,
Megan E Branda,
Rosa Cabanela,
James M Naessens,
Nilay D Shah,
Amy Wagie,
Timothy Beebe
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ABSTRACT: Self-report is the most commonly used method for collecting information regarding asthma medication possession and adherence in clinical practice.
To determine the agreement between self-report and pharmacy claims data for asthma medication possession.
This is a retrospective study that examined pharmacy claims data 12 months before and after participants completed a structured asthma survey. This study was performed in a sample of health care workers and dependents >17 years old in a large, self-insured Midwestern United States health care center. The main outcome measure was agreement (kappa calculation) between self-report and pharmacy claims data of asthma medication possession.
Self-report of asthma medication use agreed moderately with pharmacy claims data for short-acting albuterol (κ=0.47 ± 0.03), salmeterol (κ=0.79 ± 0.04), and montelukast (κ=0.69 ± 0.03) but only slightly for inhaled corticosteroids (κ=0.18 ± 0.03) and prednisone (κ=0.10 ± 0.03) (n=1050 respondents). Both under self-reporting and over self-reporting were common with inhaled corticosteroids (14.4% and 23.1%, respectively) and varied significantly by specific drug type.
Self-report moderately agrees with asthma medication possession for most adult asthma patients, though the agreement differs considerably between and within asthma medication classes.
Journal of Asthma 10/2010; 47(8):878-82. · 1.52 Impact Factor
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ABSTRACT: Studies looking at the use of repeated doses of epinephrine in patients experiencing anaphylaxis are limited.
To determine which patients are most likely to receive repeated doses of epinephrine during anaphylaxis management.
A population-based study with medical record review was conducted. All patients seen during the study period who met the criteria for the diagnosis of anaphylaxis were included.
The cohort included 208 patients (55.8% female). Anaphylaxis treatment included epinephrine in 104 patients (50.0%). Repeated doses were used in 27 patients (13.0%), 13 (48.1%) of them female. The median age of those who received repeated doses was 18.9 (interquartile range, 10-34) years vs 31.1 (interquartile range, 15-41) years for those who did not receive repeated doses (P = .06). The inciting agents were food (29.6%), insects (11.1%), medications (22.2%), others (7.4%), and unknown (29.6%). Patients who received repeated doses were more likely to have wheezing (P = .03), cyanosis (P = .001), hypotension and shock (P = .03), stridor and laryngeal edema (P = .007), nausea and emesis (P = .04), arrhythmias (P < .01), and cough (P = .04) and less likely to have urticaria (P = .049). They were more likely to be admitted to the hospital than patients who did not receive repeated doses (48.2% vs 15.6%; P < .001). There was no significant difference in the history of asthma between patients who received repeated doses and those who did not (P = .17).
Of the patients, 13.0% received repeated epinephrine doses. Patients were younger and were likely to present with wheezing, cyanosis, arrhythmias, hypotension and shock, stridor, laryngeal edema, cough, nausea, and emesis and less likely to have urticaria. A history of asthma did not predict use of repeated doses of epinephrine. Our results help identify high-risk patients who may benefit from carrying more than 1 dose of epinephrine.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 11/2009; 103(5):395-400. · 2.83 Impact Factor
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Mayo Clinic Proceedings 10/2009; 84(9):845-6. · 5.70 Impact Factor
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ABSTRACT: We present a user-friendly visual representation of The National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network criteria so as to enhance recognition of anaphylaxis and active teaching and learning.
International Journal of Emergency Medicine 05/2009; 2(1):3-5.
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The Journal of allergy and clinical immunology 05/2009; · 9.17 Impact Factor
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ABSTRACT: Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.
Mayo Clinic Proceedings 12/2008; 83(11):1263-70. · 5.70 Impact Factor
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ABSTRACT: Reported incidences of anaphylaxis range from 3.2 to 20 per 100,000 population. The incidence and trend over time has meaningful public health implications but has not been well characterized because of a lack of a standard definition and deficiencies in reporting of events.
We sought to determine the incidence and cause of anaphylaxis over a 10-year period.
We performed a population-based incidence study that was conducted in Rochester, Minnesota, from 1990 through 2000. Anaphylaxis episodes were identified on the basis of symptoms and signs of mast cell and basophil mediator release plus mucocutaneous, gastrointestinal tract, respiratory tract, or cardiovascular system involvement.
Two hundred eleven cases of anaphylaxis were identified (55.9% in female subjects). The mean age was 29.3 years (SD, 18.2 years; range, 0.8-78.2 years). The overall age- and sex-adjusted incidence rate was 49.8 (95% CI, 45.0-54.5) per 100,000 person-years. Age-specific rates were highest for ages 0 to 19 years (70 per 100,000 person-years). Ingested foods accounted for 33.2% (70 cases), insect stings accounted for 18.5% (39 cases), medication accounted for 13.7% (29 cases), radiologic contrast agent accounted for 0.5% (1 case), "other" causes accounted for 9% (19 cases), and "unknown" causes accounted for 25.1% (53 cases). The "other" group included cats, latex, cleaning agents, environmental allergens, and exercise. There was an increase in the annual incidence rate during the study period from 46.9 per 100,000 persons in 1990 to 58.9 per 100,000 persons in 2000 (P = .03).
The overall incidence rate is 49.8 per 100,000 person-years, which is higher than previously reported. The annual incidence rate is also increasing. Food and insect stings continue to be major inciting agents for anaphylaxis.
The Journal of allergy and clinical immunology 12/2008; 122(6):1161-5. · 9.17 Impact Factor
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ABSTRACT: The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.
Mayo Clinic Proceedings 08/2008; 83(7):814-20. · 5.70 Impact Factor
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ABSTRACT: Allergen immunotherapy involves exposing a patient to a gradually escalating dose of a specific allergen with the intention of decreasing allergic and inflammatory responses, ultimately leading to a sustained decrease in allergic symptoms. A build-up phase (once weekly injections) is followed by a maintenance phase (once monthly injections) that generally continues for 3 to 5 years. Allergen immunotherapy is indicated for select patients with allergic rhinoconjunctivitis, allergic asthma, and stinging insect hypersensitivity. The safety and efficacy of allergen immunotherapy have been confirmed by numerous well-designed studies. Recent research has helped uncover the mechanisms by which allergen immunotherapy exerts its therapeutic effect, paving the way for the development of safer, more effective therapy for a wider range of allergic diseases.
Mayo Clinic Proceedings 10/2007; 82(9):1119-23. · 5.70 Impact Factor
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ABSTRACT: Identification of risk factors is an integral part of a physician's evaluation of a patient.
To determine whether female sex is an independent risk factor for penicillin allergy.
Rates of positive penicillin skin test (PST) results, according to sex, were determined in patients with a history of penicillin allergy undergoing penicillin allergy evaluation with major and minor determinants of penicillin between June 1, 2002, and June 30, 2004. Univariate and multivariate logistic regression analyses were used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for sex differences in the rates of positive PST results.
Of the 1,921 patients, 1,759 underwent PST and 157 did not; 5 medical records were not available for review. The mean patient age was 60 years. Sixty-four patients (4%) had a positive PST reaction; of these, 53 (83%) were females and 11 (17%) were males (OR, 3.6; 95% CI, 1.9-7.2; P < .001). In a multivariate logistic regression analysis adjusted for age, history of multiple drug allergies, and elapsed time from the initial penicillin adverse drug reaction to PST, female sex again had a significant risk of a positive PST reaction (OR, 3.2; 95% CI, 1.6-6.7; P = .001).
A greater risk of penicillin allergy exists in association with female sex in patients with a history of penicillin allergy.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 08/2007; 99(1):54-8. · 2.83 Impact Factor
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ABSTRACT: To assess the frequency and types of visits related to modifications in the intensity of asthma medications.
We retrospectively reviewed the medical records of adults (aged 18-40 years) and children (aged 6-17 years) living in Olmsted County, Minnesota, to evaluate changes in asthma medications by dose and drug class and site and type of visit (routine vs unscheduled) at the time of changes. All records from all visits were reviewed for each patient to identify asthma-related visits at all sites of care from January 1, 2002, through December 31, 2003.
The study consisted of 397 adults and children. In 255 patients, 597 asthma medication changes occurred. Step-up changes usually occurred because of an exacerbation or loss of control of asthma and adhered to the medication hierarchy in the national asthma guidelines. Twenty step-up changes involved skipping inhaled corticosteroid (ICS) monotherapy and moving directly to combined ICSs plus a long-acting beta-agonist (LABA). Lack of documentation of asthma symptom frequency or interference with activities made it impossible to determine whether these 'skips' were appropriate. Only 78 physician-directed step-down changes were documented, usually to a lower dose of combined ICSs and LABAs or a move from combined ICSs and LABAs to anti-inflammatory monotherapy. Patients initiated additional step-down changes between encounters. Step-down changes occurred at routine or follow-up asthma visits, but the limited number of such visits provided few opportunities for step-down care.
The continuing episodic-style treatment of asthma aimed at exacerbation management facilitates step-up changes in asthma therapy. The dearth of asthma evaluation visits limited opportunities to step down use of asthma medications and to provide long-term asthma management.
Mayo Clinic Proceedings 05/2007; 82(4):414-21. · 5.70 Impact Factor
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ABSTRACT: We developed a clinical pathway to optimize the use of antimicrobials by decreasing vancomycin use in preoperative patients with a history of penicillin allergy.
To decrease the use of vancomycin in surgical patients with a self-reported penicillin allergy.
In June 2002, same-day allergy consultation and penicillin skin testing were made available for preoperative patients with self-reported penicillin allergy at the preoperative evaluation (POE) clinic. We reviewed the penicillin allergy skin test results, recommendations, and beta-lactam antibiotic administration outcomes from July 1, 2002, to September 16, 2003.
A total of 1,204 of 11,819 patients were evaluated for beta-lactam allergy at the POE clinic. Of these, 1,120 were approved by the institutional review board for inclusion in the study and 9 were excluded from the study. Of the remaining 1,111 patients, 1,030 (93%) underwent skin testing for penicillin allergy. Forty-three (4%) had a positive skin test result to penicillin. A total of 947 (85%) of the 1,111 patients with a history of beta-lactam allergy were advised to use a beta-lactam antibiotic, and 164 (15%) were advised to avoid beta-lactams. A total of 955 patients (86%) actually received preoperative antibiotics. Of these 955 patients, 716 (75%) received cefazolin, and only 149 (16%) received vancomycin compared with 30% historical controls (P < .01). Among the patients with a negative penicillin skin test result who received a cephalosporin, 5 (0.7%) of 675 experienced an adverse drug reaction to a cephalosporin.
Establishment of a clinical pathway in a preoperative clinic that includes allergy consultation and penicillin skin testing reduced vancomycin use to only 16% in surgical patients with a history of beta-lactam allergy.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 12/2006; 97(5):681-7. · 2.83 Impact Factor
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ABSTRACT: We sought to assess self-rated importance of the medical interview to clinical practice and competence in physician-patient communication among new internal medicine faculty at an academic medical center.
Since 2001, new internal medicine faculty at the Mayo Clinic College of Medicine (Rochester, Minnesota) have completed a survey on physician-patient communication. The survey asks the new faculty to rate their overall competence in medical interviewing, the importance of the medical interview to their practice, their confidence and adequacy of previous training in handling eight frequently encountered challenging communication scenarios, and whether they would benefit from additional communication training.
Between 2001 and 2004, 75 general internists and internal medicine subspecialists were appointed to the faculty, and of these, 58 (77%) completed the survey. The faculty rated (on a 10-point scale) the importance of the medical interview higher than their competence in interviewing; this difference was significant (average +/- SD, 9.4 +/- 1.0 vs 7.7 +/- 1.2, P < .001). Similar results were obtained by sex, age, specialty, years since residency or fellowship training, and perceived benefit of training. Experienced faculty rated their competence in medical interviewing and the importance of the medical interview higher than recent graduates (ie, less than one year since training). For each challenging communication scenario, the new faculty rated the adequacy of their previous training in handling the scenario relatively low. A majority (57%) said they would benefit from additional communication training.
Although new internal medicine faculty rate high the importance of the medical interview, they rate their competence and adequacy of previous training in medical interviewing relatively low, and many indicate that they would benefit from additional communication training. These results should encourage academic medical centers to make curricula in physician-patient communication available to their faculty members because many of them not only care for patients, but also teach clinical skills, including communication skills, to trainees.
BMC Medical Education 01/2006; 6:30. · 1.15 Impact Factor
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ABSTRACT: Among patients with a reported history of penicillin allergy, 80% to 90% have no evidence of IgE antibodies to penicillin on skin testing and thus avoid penicillin unnecessarily. Moreover, 97% to 99% of such patients with a penicillin skin test negative to the major and minor determinants can tolerate penicillin without risk of an immediate-type hypersensitivity reaction. A penicillin skin test is valuable for evaluating penicillin allergy in patients who need penicillin or cephalosporin. Assessment of sensitivities to penicillin is important to reduce the unnecessary use of antimicrobial agents such as vancomycin. We review the role of penicillin skin testing for evaluating penicillin allergy and the use of cephalosporin in patients with a history of penicillin allergy.
Mayo Clinic Proceedings 04/2005; 80(3):405-10. · 5.70 Impact Factor
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ABSTRACT: Allergic reactions to cephalosporins may occur because of sensitization to cephalosporin determinants shared with penicillin or to unique cephalosporin haptens. The exact nature of the haptenic determinants resulting from the degradation of currently available cephalosporins is incompletely understood. Cephalosporin skin testing or specific IgE immunoassays have limited clinical utility. Patients with a history of allergy to cephalosporins or penicillin may be at increased risk for a reaction to cephalosporins. Skin testing for an allergy to penicillin may be helpful in patients with a history of penicillin allergy who have a clinical indication for cephalosporin use. Most of these patients have negative tests and should not be at increased risk for a reaction to cephalosporins.
Immunology and Allergy Clinics of North America 09/2004; 24(3):463-76, vi-vii. · 2.56 Impact Factor
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ABSTRACT: The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) have identified six areas of general competency. This study surveyed graduates of allergy and immunology training programs about their perceived clinical competency and the adequacy of their subspecialty training.
In August 2000 and May 2001, a questionnaire was mailed to 373 physicians who had completed a fellowship in allergy and immunology in the United States between 1995 and 2001. Physicians were asked to rate the perceived importance and adequacy of their training in, and their level of competency for, 57 general competencies and subspecialty-specific competencies and procedures.
A total of 253 physicians responded (68%). All items in the six ACGME/ABMS general competencies had high ratings (>/= 90%) for perceived importance. One item in the practice-based learning area had low ratings for adequacy of training (57%) and intermediate for competency (75%). Two items in the system-based practice area had low ratings for training (65% and 67%) and intermediate for competency (86% and 88%). Generally, core specialty-specific items (allergic rhinitis, asthma, and urticaria) had high ratings (>/= 90%) for importance, training, and competency. Without exception, items with ratings of less than 70% for adequacy of training also had ratings of less than 90% for competency.
The general competencies were considered important, but training in system-based practice and practice-based learning may be deficient. Although self-perceived competency in core areas of allergy and immunology was high, weaknesses in training and self-perceived competency in selected areas were identified.
Academic Medicine 10/2003; 78(9):933-8. · 3.52 Impact Factor
