WHAT YOU SHOULD HAVE READ BUT….2012                 urticariaAttilio BonerUniversity ofVerona, Italy
Orticaria  valutazione
Utility of routine laboratory testing in management of               chronic urticaria/angioedema            Tarbox Ann Al...
Utility of routine laboratory testing in management of               chronic urticaria/angioedema            Tarbox Ann Al...
Orticaria  eziologia
Chronic palpable purpura mediated by Kiwi antigen      Act c 1-induced immune complex vasculitis                 Gutermuth...
Chronic palpable purpura mediated by Kiwi antigen     Act c 1-induced immune complex vasculitis                 Gutermuth,...
Response to a selective COX-2 inhibitor in patients with     urticaria/angioedema induced by nonsteroidal   anti-inflammat...
Response to a selective COX-2 inhibitor in patients with     urticaria/angioedema induced by nonsteroidal   anti-inflammat...
Orticaria  terapia
Factors that predict the success of cyclosporine            treatment for chronic urticaria       Hollander Ann Allergy As...
Factors that predict the success of cyclosporine            treatment for chronic urticaria       Hollander Ann Allergy As...
Factors that predict the success of cyclosporine            treatment for chronic urticaria       Hollander Ann Allergy As...
Factors that predict the success of cyclosporine            treatment for chronic urticaria       Hollander Ann Allergy As...
Factors that predict the success of cyclosporine            treatment for chronic urticaria       Hollander Ann Allergy As...
Treatment with propranolol of 6 patients            with idiopathic aquagenic pruritus                   Nosbaum, JACI 201...
Treatment with propranolol of 6 patients       with idiopathic aquagenic pruritus              Nosbaum, JACI 2011;128:1113...
Treatment with propranolol of 6 patients       with idiopathic aquagenic pruritus              Nosbaum, JACI 2011;128:1113...
Treatment with propranolol of 6 patients       with idiopathic aquagenic pruritus              Nosbaum, JACI 2011;128:1113...
angiedema
EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency:         conse...
EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency:         conse...
EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency:         conse...
EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency:        consens...
EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency:        consens...
EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency:        consens...
Take home
WHAT YOU SHOULD HAVE READ BUT….2012                 anaphylaxisAttilio BonerUniversity ofVerona, Italy
Classification of anaphylaxis and utility of the EAACI  Taskforce position paper on Anaphylaxis in Children          Vetan...
Classification of anaphylaxis and utility of the EAACI Taskforce position paper on Anaphylaxis in Children            Veta...
Anafilassiepidemiologia
Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the    diagno...
NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfil...
NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfil...
NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfil...
Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the     diagn...
Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the     diagn...
Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the    diagno...
Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the    diagno...
Potter Stewart and the definition of anaphylaxis                   Camargo, JACI 2012;129:753                            E...
Potter Stewart and the definition of anaphylaxis                        Camargo, JACI 2012;129:753                        ...
Potter Stewart and the definition of anaphylaxis                   Camargo, JACI 2012;129:753                            E...
Anaphylaxis and reactions to foods in children – a population-based case study of emergency department         visits. Vet...
Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department        visits. Vetan...
Anaphylaxis and reactions to foods in children – apopulation-based case study nuts,                          Tree of emerg...
Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department        visits. Vetan...
Anaphylaxis and reactions to foods in children – apopulation-based case study of children                    Pollen-allerg...
Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department        visits. Vetan...
Anafilassipatogenesi
Anafilassieziologia
Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis         registry ...
Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis         registry ...
Provoking allergens and treatment of anaphylaxis in  children and adolescents – data from the anaphylaxis          registr...
Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis         registry ...
Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis         registry ...
Risk factors for severe pediatric food anaphylaxis in Italy           Calvani Pediat Allergy Immunol 2011;22:813          ...
Risk factors for severe pediatric food anaphylaxis in Italy           Calvani Pediat Allergy Immunol 2011;22:813          ...
Risk factors for severe pediatric food anaphylaxis in Italy           Calvani Pediat Allergy Immunol 2011;22:813          ...
Anaphylaxis to diphtheria, tetanus, and pertussis   vaccines among children with cow’s milk allergy                   Katt...
Anaphylaxis to diphtheria, tetanus, and pertussis vaccines among children with cow’s milk allergy               Kattan JAC...
Anaphylaxis to diphtheria, tetanus, and pertussis vaccines among children with cow’s milk allergy                Kattan JA...
Anaphylactic reactions caused by oil body fraction         lipoproteins Pineda, Allergy 2011;66:7011) Allergies to olive f...
Anaphylactic reactions caused by oil body fraction        lipoproteins Pineda, Allergy 2011;66:7011) A 20-year-old man was...
Anaphylactic reactions caused by oil body fraction          lipoproteins Pineda, Allergy 2011;66:7011) The basophil activa...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids           Savvatianos, Siraga...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids           Savvatianos, Siraga...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids           Savvatianos, Siraga...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids           Savvatianos, Siraga...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids            Savvatianos, Sirag...
Cow’s milk allergy as a cause of anaphylaxis to systemic                     corticosteroids           Savvatianos, Siraga...
Hypersensitivity to total parenteral nutrition     fat-emulsion component in an egg-allergic child                  Lunn P...
Hypersensitivity to total parenteral nutrition     fat-emulsion component in an egg-allergic child                  Lunn P...
Hypersensitivity to total parenteral nutrition     fat-emulsion component in an egg-allergic child                  Lunn P...
Hypersensitivity to total parenteral nutrition     fat-emulsion component in an egg-allergic child                   Lunn ...
Hypersensitivity to total parenteral nutrition     fat-emulsion component in an egg-allergic child                  Lunn P...
Life-threatening anaphylactic reaction after the      administration of airway topical lidocaine             Soong Pediatr...
Life-threatening anaphylactic reaction after the    administration of airway topical lidocaine          Soong Pediatr Pulm...
Life-threatening anaphylactic reaction after the     administration of airway topical lidocaine               Soong Pediat...
Exercise Food Dependent Anaphylaxis
Anafilassicomorbidità
Mast cell activation syndrome: A newly recognized      disorder with systemic clinical manifestations                     ...
Mast cell activation syndrome: A newly recognized  disorder with systemic clinical manifestations                 Hamilton...
Mast cell activation syndrome: A newly recognized  disorder with systemic clinical manifestations              Hamilton JA...
Mast cell activation syndrome: A newly recognized     disorder with systemic clinical manifestations                      ...
diagnosidifferenziale
Total serum tryptase levels are higher in young infants           Belhocine Pediat Allergy Immunol 2011;22:600            ...
Anafilassi terapia
Training of trainers on epinephrine autoinjector use             Arga Pediat Allergy Immunol 2011;22:590                  ...
Training of trainers on epinephrine autoinjector use             Arga Pediat Allergy Immunol 2011;22:590 The majority of ...
Extremely low prevalence of epinephrine autoinjectors inhigh-risk food-allergic adolescents in Dutch high schools        F...
Extremely low prevalence of epinephrine autoinjectors inhigh-risk food-allergic adolescents in Dutch high schools       Fl...
Prescriptions for self-injectable epinephrine in    emergency department angioedema management     Manivannan Ann Allergy ...
Prescriptions for self-injectable epinephrine in    emergency department angioedema management     Manivannan Ann Allergy ...
Prescriptions for self-injectable epinephrine in    emergency department angioedema management     Manivannan Ann Allergy ...
The TEN study: time epinephrine needs to reach muscle           Baker Ann Allergy Asthma Immunol 2011;107:235             ...
The TEN study: time epinephrine needs to reach muscle           Baker Ann Allergy Asthma Immunol 2011;107:235             ...
Epinephrine auto-injector use in adolescents at risk  of anaphylaxis: a qualitative study in Scotland, UK                G...
Anaphylaxis in a New York City pediatric emergency  department: Triggers, treatments, and outcomes                    Huan...
Anaphylaxis in a New York City pediatric emergency  department: Triggers, treatments, and outcomes                    Huan...
Anaphylaxis in a New York City pediatric emergency  department: Triggers, treatments, and outcomes                 Huang J...
Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes                 Huang JA...
Development and Validation of Educational Materials     for Food allergy. Sicherer, J Pediatr 2012;160:651                ...
Development and Validation of Educational Materials     for Food allergy. Sicherer, J Pediatr 2012;160:651                ...
Development and Validation of Educational Materials     for Food allergy. Sicherer, J Pediatr 2012;160:651                ...
Comparing school environments with & without legislation   for the prevention & management of anaphylaxis.                ...
Comparing school environments with & without legislation   for the prevention & management of anaphylaxis.                ...
Comparing school environments with & without legislation   for the prevention & management of anaphylaxis.                ...
Comparing school environments with & without legislation   for the prevention & management of anaphylaxis.                ...
Comparing school environments with & without legislation   for the prevention & management of anaphylaxis.                ...
The use of adrenaline autoinjectors by children and       teenagers. Noimark, Clin Exp Allergy 2012;42:284                ...
The use of adrenaline autoinjectors by children and       teenagers. Noimark, Clin Exp Allergy 2012;42:284                ...
The use of adrenaline autoinjectors by children and       teenagers. Noimark, Clin Exp Allergy 2012;42:284                ...
Papaverina chloride as a topical vasodilator in accidental        injection of adrenaline into digital finger             ...
Papaverina chloride as a topical vasodilator in accidental        injection of adrenaline into digital finger             ...
Papaverina chloride as a topical vasodilator in accidental        injection of adrenaline into digital finger             ...
Papaverina chloride as a topical vasodilator in accidental        injection of adrenaline into digital finger             ...
Papaverina chloride as a topical vasodilator in accidental        injection of adrenaline into digital finger             ...
Comparison of cetirizine and diphenhydramine in the  treatment of acute food-induced allergic reactions                   ...
Comparison of cetirizine and diphenhydramine in the   treatment of acute food-induced allergic reactions                  ...
Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions                    ...
Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions                    ...
Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions                    ...
Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions                    ...
What 2012 urticaria anaphylaxis
What 2012 urticaria anaphylaxis
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What 2012 urticaria anaphylaxis

  1. 1. WHAT YOU SHOULD HAVE READ BUT….2012  urticariaAttilio BonerUniversity ofVerona, Italy
  2. 2. Orticaria valutazione
  3. 3. Utility of routine laboratory testing in management of chronic urticaria/angioedema Tarbox Ann Allergy Asthma Immunol 2011;107:239 Diagnostic studies Chronic urticaria/angioedema (CUA). Retrospective analysis of a random sample of 356 adult patients with CUA from 2001–2009. Abbreviations: CBC, cell blood count; CMP/BMP, complete/basic metabolic panel; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; TSH, thyroid- stimulating hormone; THG, thyroglobulin; M, microsomal; ANA, anti-nuclear antibody; IgE, immunoglobulin E; SPEP, serum protein electrophoresis; UA, urinalysis.
  4. 4. Utility of routine laboratory testing in management of chronic urticaria/angioedema Tarbox Ann Allergy Asthma Immunol 2011;107:239 Diagnostic studies Chronic Only 1 urticaria/angioedema patient benefited from a (CUA). subsequent change in management. Retrospectivetesting rarely Laboratory analysis of a random sample of lead to changes in 356 adult patients with management resulting CUA from 2001–2009. in improved outcomes of care. Abbreviations: CBC, cell blood count; CMP/BMP, complete/basic metabolic panel; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; TSH, thyroid- stimulating hormone; THG, thyroglobulin; M, microsomal; ANA, anti-nuclear antibody; IgE, immunoglobulin E; SPEP, serum protein electrophoresis; UA, urinalysis.
  5. 5. Orticaria eziologia
  6. 6. Chronic palpable purpura mediated by Kiwi antigen Act c 1-induced immune complex vasculitis Gutermuth, Allergy 2011;66:982 For 3 months, a 61 years old female developed recurrent palpable purpura with multiple erythematous and hyperpigmented papules and macules on the dorsum of the feet, lowerand upper legs. Multiple erythematous macules and papules on the lower extremities
  7. 7. Chronic palpable purpura mediated by Kiwi antigen Act c 1-induced immune complex vasculitis Gutermuth, Allergy 2011;66:982 Detailed history was taken concerning the circumstances under which new purpuric lesions occurred and the patient reported the ingestion of fruit salads preceding the active rashes; To verify or rule out foodstuff as elicitor of vasculitis, the patient was put on elimination diet and then orally challenged to 40 g of fresh fruits that she consumes regularly, including apple, banana, kiwi and pineapple; Six to ten hours after consumption of kiwi she reproducibly developed an itchy rash consisting of confluent 3–5 mm purpuric macules and papules on the legs, lower trunk and forearms with consecutive bleeding in the central part of the lesions.
  8. 8. Response to a selective COX-2 inhibitor in patients with urticaria/angioedema induced by nonsteroidal anti-inflammatory drugs. Doña, Allergy 2011;66:1428 % patients intolerant to etoricoxib 252 patients with urticaria 30 – and/or angioedema caused by hypersensitivity owing to cross-intolerance to 25% 20 – NSAIDs; (A) patients with intolerance to paracetamol; 10 – (B) patients with tolerance to paracetamol. 6% 0 GROUP A GROUP B
  9. 9. Response to a selective COX-2 inhibitor in patients with urticaria/angioedema induced by nonsteroidal anti-inflammatory drugs. Doña, Allergy 2011;66:1428 % patients intolerant to etoricoxib 252 Selective with urticaria patients COX-2 30 – and/or angioedemabe inhibitors may caused by hypersensitivity owing unsafe in subjects to with urticaria and/or cross-intolerance to 25% 20 – angioedema caused by NSAIDs; hypersensitivity (A) patientsto NSAIDs reactions with intolerance to paracetamol; 10 – with cross-intolerance to paracetamol. (B) patients with tolerance to paracetamol. 6% 0 GROUP A GROUP B
  10. 10. Orticaria terapia
  11. 11. Factors that predict the success of cyclosporine treatment for chronic urticaria Hollander Ann Allergy Asthma Immunol 2011;107:523 % pts with complete remission defined as ≤1 day of hives per month 80 – 68 adults with 70 – Chronic urticaria (CU). 60 – 50 – 78% Cyclosporine at an average dose of 1.8 ± 1.1 mg/kg. 40 – 30 – Follow-up = 6 weeks 20 – 10 – 00
  12. 12. Factors that predict the success of cyclosporine treatment for chronic urticaria Hollander Ann Allergy Asthma Immunol 2011;107:523 % pts with complete remission defined as ≤1 day of hives per month Recurrence 80 – 68 adults with in only occurred 70 – Chronic urticaria (CU). 7 patients; all achieved 60 – 50 – 78% Cyclosporine at an average doseremission mg/kg. of 1.8 ± 1.1 with 40 – resumption of 30 – cyclosporine. Follow-up = 6 weeks 20 – 10 – 00
  13. 13. Factors that predict the success of cyclosporine treatment for chronic urticaria Hollander Ann Allergy Asthma Immunol 2011;107:523 •A history of hives (P =0.01), 68 adults with •shorter duration of urticaria Chronic urticaria (CU). (mean: 55.2 wks vs 259.63 weeks; P = 0.03), and Cyclosporine at an average dose of 1.8 ± 1.1 mg/kg. •positive CU Index (P = 0.05) predicted a Follow-up = 6 weeks favorable response to cyclosporine.
  14. 14. Factors that predict the success of cyclosporine treatment for chronic urticaria Hollander Ann Allergy Asthma Immunol 2011;107:523 Chronic urticaria indexes (CU Index) is a nonspecific, histamine release assay in 68 adults with which donor blood cells are Chronic urticaria (CU). mixed with the patients serum as well as positive and Cyclosporine at an average negative control serum. dose of 1.8 ± 1.1 mg/kg. The amount of histamine released from each of these assays is measured, and an Follow-up = 6 weeks index is reported, with a normal result being less than 10.
  15. 15. Factors that predict the success of cyclosporine treatment for chronic urticaria Hollander Ann Allergy Asthma Immunol 2011;107:523 Chronic urticaria indexes (CU Index) is a nonspecific, Notably, autologous histamine release assay in 68 serum skin testing, adults with which donor blood cells are prior response to Chronic urticaria (CU). mixed with the patients serum steroids, atopic as well as positive and Cyclosporine at an average status, or presence negative control serum. dose of 1.8 ± 1.1 mg/kg. of antithyroid The amount of histamine antibodies was released from each of these assays is measured, and an Follow-up predictive. not = 6 weeks index is reported, with a normal result being less than 10.
  16. 16. Treatment with propranolol of 6 patients with idiopathic aquagenic pruritus Nosbaum, JACI 2011;128:1113• Idiopathic aquagenic pruritus (IAP) occurs after contact with water, involving intense itching without visible skin changes and without an underlying pathology (polycythemia vera, Hodgkin disease and blood disorders) or drugs that could induce this symptom.• Conventional treatments are the addition of sodium bicarbonate to bath water, antihistamines or phototherapy, which relieve symptoms in 24%, 47% and 50% of patients, respectively.
  17. 17. Treatment with propranolol of 6 patients with idiopathic aquagenic pruritus Nosbaum, JACI 2011;128:11136 patients received 10 to 40 mg/d propranolol for 3 months.
  18. 18. Treatment with propranolol of 6 patients with idiopathic aquagenic pruritus Nosbaum, JACI 2011;128:11136 patients received 10 to 40 mg/d propranolol for 3 months. According to our results (improvement of >90% in 5/6 patients with minimal side effects), the β-blocker appears more effective and better accepted than conventional treatments.
  19. 19. Treatment with propranolol of 6 patients with idiopathic aquagenic pruritus Nosbaum, JACI 2011;128:1113 The therapeutic effect of propranolol,6 patients received 10 to 40 mg/d propranolol for 3 months. a β-receptor antagonist of adrenaline, suggests involvement of the sympathetic system in the occurrence of IAP.
  20. 20. angiedema
  21. 21. EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Long-term prophylaxis (LTP) of attacks.1. Attenuated androgens Dosage recommended doses with acceptable long-term adverse effects are danazol ≤200mg/day & stanozol ≤2mg/day. Contraindications owing to residual androgenic hormonal activity, androgen derivatives are not recommended for women in pregnancy/lactation or children until after growth is complete. Monitoring Regular follow-up visit every 6 mo is recommended. Liver enzymes, lipid profile, complete blood cell count, alpha-feto-protein, and urinanalysis should be performed. Abdominal ultrasound yearly is advisable for early diagnosis of liver tumors.
  22. 22. EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Long-term prophylaxis (LTP) of attacks.2. Plasma-derived C1-INH concentrates Dosage In USA, C1-INH (Cinryze®) is FDA and Europe-approved for LTP in adolescents and adults at a dose of 1000 units every 3 or 4 days. Adverse effects The side-effects reported in published controlled trials are minimal. There are concerns about infection at injection site and intrinsic infectivity risk of human blood products; however, as for any chronic user of blood products, hepatitis B vaccination is advisable.
  23. 23. EB recommendations for the therapeutic management of angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Acute treatment (AT) for attacks.1. Acute treatment aims to resolve angioedema symptoms as quickly as possible.2. Evidence suggests that: - C1-INH concentrates plasma-derived (Berinert®, Cinryze®, Cetor®); - C1-INH concentrates plasma-recombinant (Rhucin®/Ruconest®); - kallikrein inhibitor ecallantide (Kalbitor®); - bradykinin B2 receptor antagonist icatibant (Firazyr®) are suitable for AT of HAE.
  24. 24. EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Acute treatment (AT) for attacks.• Plasma-derived (Berinert®, Cinryze®, Cetor®) efficacy is consistent at all sites, including laryngeal swellings. Training of patients to self-administer C1-INH is safe and improves symptom control. Reports on the use in pregnancy, lactation, very young children and babies provide unique evidence for the safety and efficacy of this treatment in these critical subgroups of HAE patients. Allergic/pseudoallergic systemic reactions in a few patients represent the only absolute contraindication to C1-INH.
  25. 25. EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Acute treatment (AT) for attacks.• Plasma-recombinant (Rhucin®/Ruconest®) are unsuitable for patients with proven rabbit allergy. Skin prick testing or serum-specific IgE to rabbit epithelium prior to prescribing. Long-term data on larger populations are required to confirm the safety of the product. There are no data in pregnancy or in breastfeeding.• Kallikrein inhibitor ecallantide (Kalbitor®) should be administered only by a healthcare professional who has medical support to manage anaphylaxis and HAE.
  26. 26. EB recommendations for the therapeutic managementof angioedema owing to hereditary C1 inhibitor deficiency: consensus report of an Int’l Working Group Cicardi, Allergy 2012;67:147Acute treatment (AT) for attacks.1. All patients with HAE owing to C1-INH deficiency, even still if asymptomatic , should have access to at least one of the specific medicines, which obtained high grade of evidence for their efficacy in treating acute attacks ’on demand’.2. Whenever allowed by drug-specific characteristics, patients should be trained to self-administer these medicines at home.3. All attacks are eligible for treatment, ideally before visible or disabling symptoms develop.4. Patients should report to the hospital if laryngeal symptoms persist.Long-term prophylaxis (LTP) of attacks.1. The goal is to reduce the likelihood of swelling in a patient undergoing a stressor or a procedure likely to precipitate an attack or to decrease the number and severity of angioedema attacks (LTP).
  27. 27. Take home
  28. 28. WHAT YOU SHOULD HAVE READ BUT….2012  anaphylaxisAttilio BonerUniversity ofVerona, Italy
  29. 29. Classification of anaphylaxis and utility of the EAACI Taskforce position paper on Anaphylaxis in Children Vetander Pediat Allergy Immunol 2011;22:369 371 children with 381 reactions to foods. Symptoms/signs of reactions to foods recorded for classification of anaphylaxis were related to those presented in the EAACI Taskforce position paper on Anaphylaxis in Children (Allergy 2007;62:857). 46 different symptoms/signs of reactions to foods were retrieved. Several severe signs or symptoms from the respiratory tract and signs indicating reduced brain perfusion were not described in detail in the EAACI paper, hampering correct classification of anaphylaxis including grading of severity in our material.
  30. 30. Classification of anaphylaxis and utility of the EAACI Taskforce position paper on Anaphylaxis in Children Vetander Pediat Allergy Immunol 2011;22:369Suggested modification of the EAACI Taskforce position paper on Anaphylaxis in Children table The symptoms added by us are marked in bold.
  31. 31. Anafilassiepidemiologia
  32. 32. Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients Campbell, JACI 2012;129:748Background: Diagnostic criteria were proposed at the SecondSymposium on the Definition and Management of Anaphylaxisconvened by the National Institute of Allergy and InfectiousDiseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN).Validation is needed before these criteria can be widely adaptedinto clinical practice.Objective: Our aim was to retrospectively assess the diagnosticaccuracy of the NIAID/FAAN criteria for the diagnosis ofanaphylaxis in emergency department (ED) patients.
  33. 33. NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfilled:1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongueuvula)AND AT LEAST ONE OF THE FOLLOWINGa. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence)Sampson HA, J Allergy Clin Immunol 2006;117:391-7.
  34. 34. NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfilled:1. A2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lipstongue-uvula)b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) Sampson HA, J Allergy Clin Immunol 2006;117:391-7.
  35. 35. NIAID/FAAD clinical criteria for anaphylaxisAnaphylaxis is highly likely when any one of the following 3criteria is fulfilled:1. A2. A3. Reduced BP after exposure to known allergen for that patient (minutes to several hours):a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s baselinePEF, Peak expiratory flow; BP, blood pressure.*Low systolic blood pressure for children is defined as less than 70 mm Hg from1 month to 1 year, less than (70 mm Hg + [2 x age]) from 1 to 10 years, and lessthan 90 mm Hg from 11 to 17 years. Sampson HA, J Allergy Clin Immunol 2006;117:391-7.
  36. 36. Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients Campbell, JACI 2012;129:748 50 – b A retrospective cohort study of % patients who ED patients 40 – 40.2% 214 patients with a diagnosis of 86/214 an allergic reaction or anaphylaxis 30 – and a subset of patients with 28.5% 20 – 61/214 related diagnosis Medical records reviewed to 10 – determine whether the NIAID/FAAN criteria were met aaa 0 Met the Had the Final diagnosis by allergists NIAID/FAAD allergists’ considered the reference criteria for diagnosis standard anaphylaxis
  37. 37. Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients Campbell, JACI 2012;129:748 50 – b A retrospective cohort study of 59 (96.7%) of whom % patients who ED patients 40 – satisfied the 40.2% 214 patients with a diagnosis of NIAID/FAAN criteria 86/214 an allergic reaction or anaphylaxis 30 – and a subset of patients with 28.5% 20 – 61/214 related diagnosis Medical records reviewed to 10 – determine whether the NIAID/FAAN criteria were met aaa 0 Met the Had the Final diagnosis by allergists NIAID/FAAD allergists’ considered the reference criteria for diagnosis standard anaphylaxis
  38. 38. Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients Campbell, JACI 2012;129:748 The test characteristics of the NIAID/FAAN criteria were as follows:  Sensitivity: 96.7%  Specificity: 82.4%  Positive predictive value: 68.6%  Negative predictive value: 98.4%  Positive likelihood ratio: 5.48  Negative likelihood ratio: 0.04
  39. 39. Evaluation of National Institute of Allergy and InfectiousDiseases/Food and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients Campbell, JACI 2012;129:748 The test characteristics of the NIAID/FAAN criteria were as follows:  Sensitivity: 96.7% The NIAID/FAAN criteria are highly  Specificity: 82.4% sensitive but  Positive predictive value: 68.6% less specific and  Negative predictive value: 98.4% are likely to be useful in the ED for the  Positive likelihood ratio: 5.48 diagnosis of  Negative likelihood ratio: 0.04 anaphylaxis
  40. 40. Potter Stewart and the definition of anaphylaxis Camargo, JACI 2012;129:753 Editorial• Potter Stewart was an Associate Justice of the US Supreme Courtwho might be best known for a snippet from his opinion in theobscenity case of Jacobellis v Ohio (1964). In that case heacknowledged that ‘‘hard-core pornography’’ was difficult to definebut then added that ‘‘I know it when I see it.’’• Even though most allergists/immunologists knew anaphylaxis whenthey saw it, clinicians in other fields, such as emergency medicine,might not.
  41. 41. Potter Stewart and the definition of anaphylaxis Camargo, JACI 2012;129:753 Editorial• The original goals of the NIAID/FAAN criteria, which were notmeant to make an actual diagnosis of anaphylaxis but rather toidentify patients who were ‘‘highly likely’’ to have anaphylaxis.• The intention was not to replace expert opinion but to encourageconsideration of the diagnosis and, on further reflection, theappropriate use of epinephrine.• The negative predictive value of 98% sounds impressive, but thiswill not be useful to most ED clinicians because overdiagnosis ofanaphylaxis is not a problem. On the contrary, ED studiesconsistently suggest underdiagnosis.FAAD: Food Allergy and Anaphylaxis NetworkNIAID: National Institute of Allergy and Infectious Disease
  42. 42. Potter Stewart and the definition of anaphylaxis Camargo, JACI 2012;129:753 Editorial• In the context of ED care today, a more valuable combination oftest characteristics would be high sensitivity and very high positivepredictive value.• The investigators report a sensitivity of 98% but a positivepredictive value of only 69%. In other words, if the NIAID/FAANcriteria identified 100 patients as being ‘‘highly likely’’ to haveanaphylaxis, only 69 would have anaphylaxis, and 31 would not.• Although I agree that use of the NIAID/FAAN criteria is likely toimprove ED anaphylaxis care, which remains suboptimal, theinvestigators also have demonstrated that clinicians should not followthe NIAID/FAAN criteria blindly.
  43. 43. Anaphylaxis and reactions to foods in children – a population-based case study of emergency department visits. Vetander, Clin Exp Allergy 2012;42:568 Age distribution in relation to severity of reactions to foods. 371 children with ED visits at any of 3 paediatric hospitals in Stockholm during 2007.
  44. 44. Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department visits. Vetander, Clin Exp Allergy 2012;42:568 Eliciting foods in relation to age
  45. 45. Anaphylaxis and reactions to foods in children – apopulation-based case study nuts, Tree of emergency department particular cashew, and peanut were the most visits. Vetander, Clin Exp Allergy 2012;42:568 common eliciting foods, and in children under 3 yrs, reactions to these 2 foods allergens were as Eliciting foods in relation to age common as reactions to milk and egg.
  46. 46. Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department visits. Vetander, Clin Exp Allergy 2012;42:568
  47. 47. Anaphylaxis and reactions to foods in children – apopulation-based case study of children Pollen-allergic emergency department visits. Vetander, Clin Expdue to food-induced seemed to be admitted Allergy 2012;42:568 anaphylaxis, more often during the deciduous tree pollen season compared with the rest of the yr. (p=0.015).
  48. 48. Anaphylaxis and reactions to foods in children – apopulation-based case study of emergency department visits. Vetander, Clin Exp Allergy 2012;42:568 % of children with symptoms of the lower airways during the reactions100 –90 –80 –70 –60 – 72% p<0.0150 –40 –30 – 49%20 –10 – 0 Yes No Asthma
  49. 49. Anafilassipatogenesi
  50. 50. Anafilassieziologia
  51. 51. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German-speaking countries Hompes Pediat Allergy Immunol 2011;22:568 % affected organs during reaction Severe systemic allergic reactions 90 – with concomitant 80 – 89% 87% pulmonary and/or 70 – cardiovascular 60 – symptoms. 50 – 40 – 47% 43% 197 reported 30 – anaphylactic reactions 20 – from children and 10 – adolescents. 0 Skin Respiratory Cardiovasc. G-I
  52. 52. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German-speaking countries Hompes Pediat Allergy Immunol 2011;22:568 Etiology % Severe systemic 60 – allergic reactions 50 – 58% with concomitant pulmonary and/or 40 – cardiovascular 30 – symptoms. 20 – 24% 197 reported anaphylactic reactions 10 – from children and 0 8% adolescents. Food Insect Drugs Allergens venom
  53. 53. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German-speaking countries Hompes Pediat Allergy Immunol 2011;22:568 The most frequent Etiology % Severe systemic food allergens were 60 – allergic reactions peanuts followed by 50 – 58% with concomitant tree nuts and animal pulmonary and/or 40 – related food cardiovascular products. 30 – symptoms. In 18% aggravating 20 – 24% 197 reported as factors such physical exercise anaphylactic reactions 10 – from childrenby the were noted and 8% clinicians. adolescents. 0 Food Insect Drugs Allergens venom
  54. 54. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German-speaking countries Hompes Pediat Allergy Immunol 2011;22:568 % drug used 90 – Severe systemic allergic reactions 80 – 87% 85% 70 – with concomitant 60 – pulmonary and/or cardiovascular 50 – symptoms. 40 – 30 – 197 reported 20 – anaphylactic reactions 22% 10 – from children and 0 adolescents. Antihistamines Corticosteroids Adrenaline
  55. 55. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German-speaking countries Hompes Pediat Allergy Immunol 2011;22:568 % drug used 90 – Severe systemic 26% of the allergic reactions 80 – 87% 85% analysed with concomitant 70 – patients had pulmonary and/or 60 – cardiovascular experienced 50 – symptoms. 40 – more than one 30 – reaction. 197 reported 20 – 22% anaphylactic reactions 10 – from children and 0 adolescents. Antihistamines Corticosteroids Adrenaline
  56. 56. Risk factors for severe pediatric food anaphylaxis in Italy Calvani Pediat Allergy Immunol 2011;22:813 In children with a clinical 10 – history of asthma OR for 163 children with 09 – 08 – anaphylaxis consecutively 07 – attending 29 outpatient 6.9 06 – allergy clinics throughout 05 – Italy. 04 – 03 – Food sensitization was 02 – evaluated by SPTs. 01 – 00 2.2 Wheezing Respiratory arrest During the episode
  57. 57. Risk factors for severe pediatric food anaphylaxis in Italy Calvani Pediat Allergy Immunol 2011;22:813 In children with a clinical of chronic gastrointestinal 10 – symptoms OR for 163 children with 09 – anaphylaxis consecutively 08 – 9.2 attending 29 outpatient 07 – 06 – 7.9 allergy clinics throughout 05 – Italy. 04 – 03 – Food sensitization was 02 – evaluated by SPTs. 01 – 00 2.2 Vomiting Hypotension Bradycardia/ cardiac arrest
  58. 58. Risk factors for severe pediatric food anaphylaxis in Italy Calvani Pediat Allergy Immunol 2011;22:813 In children with a clinical of chronic gastrointestinal 10 – symptoms OR for 163 children with 09 – Peanut and egg anaphylaxis consecutively 08 – 9.2 were the most attending 29 outpatient 07 – 06 – 7.9 frequent causes allergy clinics throughout 05 – Italy. of severe 04 – 03 – anaphylaxis. Food sensitization was 02 – evaluated by skin-prick 01 – 2.2 test. 00 Vomiting Hypotension Bradycardia/ cardiac arrest
  59. 59. Anaphylaxis to diphtheria, tetanus, and pertussis vaccines among children with cow’s milk allergy Kattan JACI 2011;128:215 The US national Vaccine Adverse Events Reporting System lists 39 anaphylactic reactions to DTaP, DTP, or Tdap vaccines for patients aged 0 to 17 years from 2007-2010. We noted that these vaccines are labeled as being processed in medium containing casamino acids (derived from cow’s milk), raising the concern that residual casein in the vaccines might have triggered these reactions. To investigate this possibility, we tested 8 lots of the vaccines for residual casein.
  60. 60. Anaphylaxis to diphtheria, tetanus, and pertussis vaccines among children with cow’s milk allergy Kattan JACI 2011;128:215 Mean casein concentrations in vaccine samples examined
  61. 61. Anaphylaxis to diphtheria, tetanus, and pertussis vaccines among children with cow’s milk allergy Kattan JACI 2011;128:215 8 children were obtained by means of chart review. These patients were selected based on reports of anaphylactic reactions to the vaccines and not because of a history of milk allergy. Six of the patients had prior acute allergic reactions to cow’s milk, including severe reactions in 5 patients and reactions to trace exposures in 4 patients. In conclusion, our novel observation raises a concern regarding booster vaccination of children with high levels of milk allergy with Tdap and DTaP.
  62. 62. Anaphylactic reactions caused by oil body fraction lipoproteins Pineda, Allergy 2011;66:7011) Allergies to olive fruit and derivative product have seldom been reported;2) Few cases of contact dermatitis and contact urticaria caused by olive oil or olives have been documented, and only three cases of allergy caused by olive ingestion have been described;3) Thaumatin-like protein and other proteins with a 10–15 kDa molecular mass are those described as allergenic in the patients with olive allergy.
  63. 63. Anaphylactic reactions caused by oil body fraction lipoproteins Pineda, Allergy 2011;66:7011) A 20-year-old man was admitted to our allergy unit for investigation into recurrent food-induced anaphylaxis;2) Skin prick test was positive for Platanus and Parietaria pollen and only positive for hazelnut, walnut, peach peel, sunflower seed, and mustard food extracts when testing the panel of plant food allergens;3) Further, SPTs were performed using home-made extract of liposoluble proteins from olives and prick to prick with olive. A wheal diameter of 13.9 and 10 mm was obtained from olive and liposoluble proteins from olive fruit respectively.
  64. 64. Anaphylactic reactions caused by oil body fraction lipoproteins Pineda, Allergy 2011;66:7011) The basophil activation test (BAT) was performed;2) The stimuli used were lipoproteins from olive;3) The test was positive for olive fruit (30,5%);4) The BAT was performed in parallel with two nonallergic individuals obtaining a negative result with the Basophil activation test (BAT) to oil body fraction proteins from hazelnut, stimuli tested. olive and sesame.
  65. 65. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk  Immediate IgE-mediated allergic reactions to corticosteroids are rather uncommon, whereas causative agents usually involve the native steroid molecule or a pharmaceutical excipient, in most cases as succinate ester bound to methyl-prednisolone or hydrocortisone;  We here report two cases of immediate reaction to methyl-prednisolone, attributed to milk allergen contamination.
  66. 66. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk 1) A 9 yrs old boy with severe persistent cow’s milk allergy (CMA) was seen for asthma exacerbation; 2) The boy was administered 40 mg of methyl-prednisolone by intravenous injection; 3) Paradoxically, wheezing deteriorated; 4) The boy was given another course of the same medication on assumption of clinical under-responsiveness; 5) Within a few minutes the patient acutely collapsed.
  67. 67. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk a) Another patient, a 7-year-old boy with severe CMA was similarly treated with intravenous administration of 40 mg methyl-prednisolone; b) The therapeutic intervention resulted in a full-blown anaphylactic reaction; c) Both children were evaluated within the next 6 months for assumed IgE-mediated reactivity to methyl-prednisolone.
  68. 68. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk Skin testing results in both patients with acute reaction to lactose-containing succinylated methyl-prednisolone
  69. 69. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk Sensitization to theresultssteroid molecule andwith acute Skin testing native in both patients to the succinate reaction to lactose-containing succinylated ester was ruled out by negative skin tests, while both patients exhibited positive skin response exclusively to lactose-containing preparations. methyl-prednisolone
  70. 70. Cow’s milk allergy as a cause of anaphylaxis to systemic corticosteroids Savvatianos, Siragakis, Allergy 2011;66:983 milk Subsequent drug provocation tests were negative in both patients Skin a full therapeuticboth patients with acute reaction for testing results in dose (125 mg) of non-lactose to lactose-containing succinylated methyl-prednisolone containing, otherwise identical to the one that elicited the reaction, succinylated methyl-prednisolone preparation (Solu-Medrol 125 mg, Pfizer)
  71. 71. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child Lunn Pediatrics 2011;128:e1025 Intravenous fat emulsions (IFEs) are a vital component of total parental nutrition, because they provide essential fatty acids. IFE is a sterile fat emulsion that contains egg-yolk phospholipids. Although egg allergy is listed as a contraindication, adverse reactions are uncommon.
  72. 72. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child Lunn Pediatrics 2011;128:e1025 2-year-old patient with previously undocumented egg allergy. Placed on total parental nutrition and a 20% IFE postoperatively and developed diffuse pruritus 14 days after initiation of therapy.
  73. 73. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child Lunn Pediatrics 2011;128:e1025 2-year-old patient with previously undocumented egg allergy. Placed on total parental nutrition and a 20% IFE postoperatively and developed diffuse pruritus 14 days after initiation of therapy. She showed transient improvement with intravenous antihistamine, but her symptoms did not resolve until the IFE was stopped.
  74. 74. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child Lunn Pediatrics 2011;128:e1025 2-year-old patient with previously undocumented egg allergy. Placed on total parental nutrition and a 20% IFE postoperatively and developed diffuse pruritus 14 days after initiation of therapy. She showed transient improvement with intravenous antihistamine, but her symptoms did not resolve until the IFE was stopped. On the basis of clinical history, including aversion to egg, we performed skin-prick testing, the results of which were positive for egg white allergy.
  75. 75. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child Lunn Pediatrics 2011;128:e1025 2-year-old patient with previously undocumented egg allergy. Placed on total parental nutrition and a 20% IFE postoperatively Although ingestion of egg lecithin and developed diffuse pruritus 14 days after initiation of in cooked food therapy. is generally tolerated by egg-allergic people, She showed transient improvement with intravenous administration of antihistamine, but her symptoms did not resolve until the IFE intravenous egg-containing lipid was stopped. On the basis of clinical may cause significant egg, emulsions history, including aversion to adverse reactions. we performed skin-prick testing, the results of which were positive for egg white allergy.
  76. 76. Life-threatening anaphylactic reaction after the administration of airway topical lidocaine Soong Pediatr Pulmonol 2011;46:505A 9-year-old boy who developed a life-threateninganaphylaxis reaction of the airway and subsequentdyspnea and circulation collapse because ofinstilled the topical lidocaine into the airway within 2 minbefore performing flexible bronchoscopy (FB).FB revealed swollen airway mucosa and extensive foamysecretion that severely compromised the ventilation lumen.Rapid detection with FB and immediate resuscitation, includingprompt administration of epinephrine, volume expander, andpositive pressure ventilation with pure oxygen via anendotracheal tube, were successfully save the patients life.
  77. 77. Life-threatening anaphylactic reaction after the administration of airway topical lidocaine Soong Pediatr Pulmonol 2011;46:505 Summary of patients clinical course with time and data
  78. 78. Life-threatening anaphylactic reaction after the administration of airway topical lidocaine Soong Pediatr Pulmonol 2011;46:505An endoscopic view showing Four hours after resuscitation of the extensive foamy secretion anaphylactic reaction, the chest film with edematous mucosa in shows edematous infiltrations overthe tracheobronchial lumen. the bilateral lung fields.
  79. 79. Exercise Food Dependent Anaphylaxis
  80. 80. Anafilassicomorbidità
  81. 81. Mast cell activation syndrome: A newly recognized disorder with systemic clinical manifestations Hamilton JACI 2011;128:147 18 patients with MC % patients with 100 – activation syndrome. 90 – 94% Patients enrolled had 80 – 89% 89% at least. 70 – 72% 4 of the signs and 60 – symptoms of abdominal 50 – pain, diarrhea, flushing, 40 – dermatographism, 30 – memory and 20 – concentration 10 – difficulties, or 0 headache. Abdominal Dermato- Flushing Constellation pain graphism of all 3 symptoms
  82. 82. Mast cell activation syndrome: A newly recognized disorder with systemic clinical manifestations Hamilton JACI 2011;128:147 Patients with suspected MCAS were treated by means of stepwise application of mediator-targeting drugs, as Type I and II histamine blockers (ie, diphenhydramine), cetirizine, loratidine and ranitidine. Depending on the response to treatment, additional medications were sequentially added, including cromolyn sodium (Gastrocrom) as montelukast.
  83. 83. Mast cell activation syndrome: A newly recognized disorder with systemic clinical manifestations Hamilton JACI 2011;128:147 Signs and symptoms of patients with MCAS Sign or symptom Total (%), n = 18 Abdominal pain 17 (94) Dermatographism 16 (89) Flushing 16 (89) Headache 15 (83) Poor concentration and memory 12 (67) Diarrhea 12 (67) Naso-ocular 7 (39) Asthma 7 (39) Anaphylaxis 3 (17)
  84. 84. Mast cell activation syndrome: A newly recognized disorder with systemic clinical manifestations Hamilton JACI 2011;128:147•Complete regression(CR) was resolution of Assessment of treatment responseall symptoms,•major regression(MR) was improvementin symptoms bygreater than 50%,•partial regression(PR) was improvementin symptoms by 10%to 50%, and•no regression (NR)was less than 10%improvement insymptoms.
  85. 85. diagnosidifferenziale
  86. 86. Total serum tryptase levels are higher in young infants Belhocine Pediat Allergy Immunol 2011;22:600 Serum tryptase levels as a function of 3-month age groups from birth to 12 months Total serum tryptase levels (ImmunoCAP; Phadia). 372 sera from infants < 1 yr.
  87. 87. Anafilassi terapia
  88. 88. Training of trainers on epinephrine autoinjector use Arga Pediat Allergy Immunol 2011;22:590 % doctors using correctly The majority of physicians epinephrine autoinjector do not know how to use 80 – epinephrine autoinjectors. 74% 70 – 151 residents, specialists, 60 – and consultants from 50 – General Pediatrics 40 – excluding allergists and 30 – allergy fellows. 20 – 23% 10 – An 8-item questionnaire 0 followed by a practical Before After session. Training
  89. 89. Training of trainers on epinephrine autoinjector use Arga Pediat Allergy Immunol 2011;22:590 The majority of physicians Mean time to administer do not know how to use on autoinjector (seconds) epinephrine autoinjectors. 30 – 28 sec. 151 residents, specialists, p<0.001 and consultants from 20 – General Pediatrics excluding allergists and 10 – allergy fellows. 5 sec An 8-item questionnaire 0 followed by a practical Before After session. Training
  90. 90. Extremely low prevalence of epinephrine autoinjectors inhigh-risk food-allergic adolescents in Dutch high schools Flokstra-de Blok Pediat Allergy Immunol 2011;22:374 To assess the need for an EAI, we asked whether the adolescent ever had an life- threatening anaphylactic reaction to a food The aim of the study was to requiring emergency treatment or estimate the prevalence of hospitalization as a result, whether there was probable food allergy in coexistent asthma, and whether there had been clear systemic reactions to traces of adolescents aged 11–20. food (i.e., itchy palms, food soles and/or generalized itch, urticaria, swelling of face Examine the frequency of and/or body, asthmatic symptoms, dizziness, epinephrine autoinjector gastrointestinal, or cardiovascular symptoms). (EAI) ownership among high-risk individuals. Screening questionnaire. 23 adolescents were considered candidates for an EAI, whereas only 2 of them had been prescribed this medication.
  91. 91. Extremely low prevalence of epinephrine autoinjectors inhigh-risk food-allergic adolescents in Dutch high schools Flokstra-de Blok Pediat Allergy Immunol 2011;22:374 A number of studies suggest that the prevalence of food allergy is increasing. The only proven forms of treatment for food allergy are strict avoidance of the food(s) involved and medication for emergency treatment. When a severe allergic reaction occurs, prompt administration of epinephrine is essential. Therefore, all food-allergic patients at risk for severe allergic reactions should carry an epinephrine autoinjector (EAI). However, there is no definite international consensus on whom should be prescribed an EAI. Simons KJ, Curr Opin Allergy Clin Immunol 2010: 10: 354–61.
  92. 92. Prescriptions for self-injectable epinephrine in emergency department angioedema management Manivannan Ann Allergy Asthma Immunol 2011;106:489 % patients receiving 90 – 80 – 87.3% 70 – 81.0% A retrospective 60 – cohort study of 50 – 63 ED patients 40 – with angioedema. 30 – 20 – 27.0% 10 – .0 Epinephrine Antihistamines Steroids
  93. 93. Prescriptions for self-injectable epinephrine in emergency department angioedema management Manivannan Ann Allergy Asthma Immunol 2011;106:489 RR of being treated with epinephrine 5.5 – 5.0 – 5.28 4.5 – 4.0 – A retrospective 3.5 – 3.0 – cohort study of 3.31 2.5 – 3.04 63 ED patients 2.0 – with angioedema. 1.5 – 1.0 – 0.5 – 0 0 Edema of Tightness/fullness Dyspnea the tongue of throat wheeze
  94. 94. Prescriptions for self-injectable epinephrine in emergency department angioedema management Manivannan Ann Allergy Asthma Immunol 2011;106:489 RR of being treated with epinephrine 5.5 – 5.0 – 5.28 4.5 – 4.0 – 13 patients A retrospective 3.5 – (22.0%) were cohort study of 3.0 – 3.31 discharged with 2.5 – 3.04 63 ED patients self-injectable with angioedema. 2.0 – epinephrine. 1.5 – 1.0 – 0.5 – 0 0 Edema of Tightness/fullness Dyspnea the tongue of throat wheeze
  95. 95. The TEN study: time epinephrine needs to reach muscle Baker Ann Allergy Asthma Immunol 2011;107:235 Relationship between the duration of injection and amount of epinephrine injected An epinephrine autoinjector (circle) and the percentage of epinephrine (EAI) is designed to deliver absorbed by the marbleized beef (square). epinephrine into the vastus lateralis muscle. Several studies have demonstrated both patient and physician difficulties in correctly using EAIs, specifically premature removal of the device from the thigh.
  96. 96. The TEN study: time epinephrine needs to reach muscle Baker Ann Allergy Asthma Immunol 2011;107:235 Relationship between the duration of injection and amount of epinephrine injected An epinephrine autoinjector (circle) and the percentage of epinephrine (EAI) is designed to deliver absorbed by the marbleized beef (square). Holding the epinephrine into the vastus lateralis muscle. device in place Several studies have is for 1 second demonstrated both patient as effective as and physician difficulties in 10 seconds. correctly using EAIs, specifically premature removal of the device from the thigh.
  97. 97. Epinephrine auto-injector use in adolescents at risk of anaphylaxis: a qualitative study in Scotland, UK Gallagher Demoly CEA 2011;41:869 1) Most adolescents had not used the auto-injector in an anaphylactic emergency. 26 adolescents 2) Barriers to use, including: with a history of -failure to recognize anaphylaxis; anaphylaxis and -uncertainty about auto-injector 28 parents. technique and when to administer it; -fear of using the auto-injector. 3) Most adolescents reported carrying auto-injectors some of the time, though several found this inconvenient due to the size.
  98. 98. Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes Huang JACI 2012;129:162Review of pediatric 80 – % reactions due to emergency 70 – department (PED) records for 60 – 71% anaphylactic 50 – reactions over 5 years. 40 – 30 –213 anaphylactic reactions in 20 – 192 children 9% (20 had multiple 10 – 15% 5% 00 reactions). Foods Unknown Drugs Others
  99. 99. Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes Huang JACI 2012;129:162 % reactions treatedReview of pediatric 80 – 79% emergency 70 – department (PED) records for 60 – anaphylactic 50 – reactions over 5 years. 40 – 30 –213 anaphylactic reactions in 20 – 192 children 10 – (20 had multiple 00 reactions). with epinephrine
  100. 100. Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes Huang JACI 2012;129:162 % reactions treatedReview of27% of In pediatric 80 – 79% emergency reactions 70 – department (PED) epinephrine was records for 60 – administered anaphylactic 50 – reactions arrival before over 5 years.PED. in the 40 – For 6% of 30 –213 anaphylactic the reactions, 20 – reactions in 2 doses of 192 children 10 – epinephrine (20 had multiple were administered. reactions). 00 with epinephrine
  101. 101. Anaphylaxis in a New York City pediatric emergency department: Triggers, treatments, and outcomes Huang JACI 2012;129:162 % reactions treated 80 – Administration of both epinephrine doses before arrival 70 – 60 – 79% to the PED 50 – was associated with alower rate of hospitalization 40 – compared with 30 – epinephrine administration 20 – in the PED (p<0.05). 10 – 00 with epinephrine
  102. 102. Development and Validation of Educational Materials for Food allergy. Sicherer, J Pediatr 2012;160:651 Autoinjector competency score. Materials developed through focus groups and parental and expert review. Submitted to 60 parents of newly referred children with a prior food allergy diagnosis and an epinephrine autoinjector. The main outcome was correct demonstration of an autoinjector.
  103. 103. Development and Validation of Educational Materials for Food allergy. Sicherer, J Pediatr 2012;160:651 Autoinjector competency score. Materials developed through focus groups and parental and expert review. score was Overall statistically Submitted to 60 parentssignificantly increased of newly referred from baseline children with a prior and mantained food allergy diagnosis and an12 months. at epinephrine autoinjector. The main outcome was correct demonstration of an autoinjector.
  104. 104. Development and Validation of Educational Materials for Food allergy. Sicherer, J Pediatr 2012;160:651 Autoinjector competency score. Materials developed through focus groups and parental and expert This food allergy review. educational curriculum for parents, Submitted to 60 parents now available online of newly referred children withcost at no a prior (http://www.cofargroup.org/), food allergy diagnosis showed high levels and an epinephrine of satisfaction autoinjector. and efficacy. The main outcome was correct demonstration of an autoinjector.
  105. 105. Comparing school environments with & without legislation for the prevention & management of anaphylaxis. Cicutto, Allergy 2012;67:1311. Anaphylaxis is a severe, potentially fatal, systemic allergic reaction that can occur suddenly after contact with an allergy-causing substance.2. Prevention is achieved only through allergen avoidance.3. Allergen exposure is common in school settings with approximately 18% of food allergic reactions occurring at school.4. Schools in Ontario have a legal obligation to protect the welfare of students while at school; therefore, they are obliged to support students at risk for anaphylaxis through allergen avoidance and management of reactions.5. However, school personnel often lack the knowledge and skills necessary to recognize and treat anaphylactic reactions.
  106. 106. Comparing school environments with & without legislation for the prevention & management of anaphylaxis. Cicutto, Allergy 2012;67:131Background: School personnel in contact with students withlife-threatening allergies often lack necessary supports, creatinga potentially dangerous situation.Sabrina’s Law, the first legislation in the world designed to protectsuch children, requires all Ontario public schools to have a planto protect children at risk.Although it has captured international attention, the differences alegislative approach makes have not been identified.Our study compared the approaches to anaphylaxis prevention andmanagement in schools with and without legislation.
  107. 107. Comparing school environments with & without legislation for the prevention & management of anaphylaxis. Cicutto, Allergy 2012;67:131 School board policy consistency with Canadian guidelines for preventing & managing Legislated (Ontario) anaphylaxis at schools. and nonlegislated (Alberta, British Columbia, Newfoundland&Labrador, and Quebec) environments. School board anaphylaxis policies were assessed for consistency with Canadian anaphylaxis guidelines.
  108. 108. Comparing school environments with & without legislation for the prevention & management of anaphylaxis. Cicutto, Allergy 2012;67:131 Parental reports of student food allergy.
  109. 109. Comparing school environments with & without legislation for the prevention & management of anaphylaxis. Cicutto, Allergy 2012;67:131 Parental reports of their children’s school environments regarding prevention and management of anaphylaxis.
  110. 110. The use of adrenaline autoinjectors by children and teenagers. Noimark, Clin Exp Allergy 2012;42:284 % of patients using adrenaline autoinjector 40 – 14 paediatric allergy clinics throughout UK. 30 – Questionnaire of allergic 20 – reactions in the previous yr. 969 patients. 10 – 16.7% 00 of patients experiencing anaphylaxis
  111. 111. The use of adrenaline autoinjectors by children and teenagers. Noimark, Clin Exp Allergy 2012;42:284 % of patients prescribed adrenaline and receiving >1 dose 14 paediatric allergy clinics throughout UK. 40 – Questionnaire of allergic 30 – 31.7% reactions in the previous yr. 969 patients. 20 – 10 – 00
  112. 112. The use of adrenaline autoinjectors by children and teenagers. Noimark, Clin Exp Allergy 2012;42:284 Commonest reasons for using >1 dose 40 – 14 paediatric allergy clinics 40% throughout UK. 30 – Questionnaire of allergic 20 – reactions in the previous yr. 20% 10 – 13.3% 969 patients. 00 Severe Lack of Miss-firing breathing improvment with difficulties 1stdose
  113. 113. Papaverina chloride as a topical vasodilator in accidental injection of adrenaline into digital finger Baris, Allergy 2011;66:1495 1) Restoration of blood flow by immersion in warm water was attempted unsuccessfully; 2) Papaverine chloride (Papaverin HCl 20 mg/ml) was diluted (20 mg in 10 ml of saline) and embedded into a sponge; 3) The sponge was placed around the right thumb, and it was wrapped with bandage for 3 h; 4) The finger turned to normal appearance and was warm and pain-free with normal capillary refill time.
  114. 114. Papaverina chloride as a topical vasodilator in accidental injection of adrenaline into digital finger Baris, Allergy 2011;66:1495 Right thumb after injection of adrenaline auto-injection An increasing trend in accidental injection cases into digits has been observed with the frequent use of adrenaline auto-injectors; This is an annoying situation with pain and possesses a potential risk of tissue necrosis in the victims.
  115. 115. Papaverina chloride as a topical vasodilator in accidental injection of adrenaline into digital finger Baris, Allergy 2011;66:1495 Right thumb after injection of adrenaline auto-injection An increasing trend in accidental injection cases intoHer finger digits has been was cold and observed with the frequent use of adrenaline auto-injectors; she pale, and suffered situation This is an annoying from pain. with pain and possesses a potential risk of tissue necrosis in the victims.
  116. 116. Papaverina chloride as a topical vasodilator in accidental injection of adrenaline into digital finger Baris, Allergy 2011;66:1495• Immersion into warm water, digital massage, and application of topical nitroglycerin are announced to be conservative applications with a wide acceptance;• Because adrenaline induces a vasoconstriction through an α-adrenergic effect, the use of topical phentolamine, which is a nonselective α-adrenergic antagonist, is very effective in patients unresponsive to the conservative treatment mentioned earlier.• Local injection of phentolamine to the area can reverse ischemia quickly and efficiently.
  117. 117. Papaverina chloride as a topical vasodilator in accidental injection of adrenaline into digital finger Baris, Allergy 2011;66:1495 •However, because of limited space in the accidental injection area, additional volumes of phentolamine may cause a possible compartment syndrome, which may worsen ischemia by extra induced pressure. •Papaverine is an opiate, act as smooth muscle relaxant, which inhibits phosphodiesterase enzyme, and it is widely used during or after vascular surgeries to reverse vasospasm.
  118. 118. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127• Diphenhydramine has been commonly used as the antihistamine of choice for acute food-induced allergic reactions given its prompt onset of action (15-60 minutes) and ready availability, although epinephrine is still the first-line therapy for anaphylaxis.• However, sedation is a common side effect of diphenhydramine, which can complicate the assessment of a patient being treated for an acute food-induced allergic reaction.• Cetirizine is a second-generation antihistamine with a similar onset (15-30 minutes) but longer duration of action (≥ 24 hours) compared with diphenhydramine.• Furthermore, central nervous system effects are less commonly reported.
  119. 119. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127 70 allergic reactions % patients experienced during oral food sedation challenge 30 – involving 64 patients aged 3-19 yrs. ns 28.6% 20 – 35 reactions included in each treatment arm. 17.1% 10 – Either liquid diphenhydramine (1mg/kg) or liquid 0 CETIRIZINE DIPHENHYDRAMINE cetirizine (0.25 mg/kg)
  120. 120. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127 Mean time of resolution of Mean time of resolution of urticaria (minutes) pruritus (minutes)50 – 50 –40 – 40 – 40.8 42.330 – min min 30 – 31.3 min 28.620 – 20 – min10 – 10 –00 00 CETIRIZINE DIPHENHYDRAMINE CETIRIZINE DIPHENHYDRAMINE
  121. 121. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127 9 patients in each group required administration of Mean time of resolution of steroid or epinephrine for symptomsresolution of Mean time of of urticaria (minutes) pruritus (minutes)50 – abdominal pain, nausea,50 – cough, wheezing, and angioedema.40 – 40 – 40.8 42.330 – min min 30 – 31.3 min 28.620 – 20 – min10 – 10 –00 00 CETIRIZINE DIPHENHYDRAMINE CETIRIZINE DIPHENHYDRAMINE
  122. 122. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127 Cetirizine has similar efficacy and onset of action compared with diphenhydramine in treating Mean time of resolution of Mean time of resolution of urticaria (minutes) acute food-induced allergic reactions but(minutes) pruritus has also50 – 50 – longer duration of action compared with diphenhydramine…40 – 40 – 40.8 42.330 – min min 30 – 31.3 min 28.620 – 20 – min10 – 10 –00 00 CETIRIZINE DIPHENHYDRAMINE CETIRIZINE DIPHENHYDRAMINE
  123. 123. Comparison of cetirizine and diphenhydramine in the treatment of acute food-induced allergic reactions Park, JACI 2011;128:1127 Mean time of resolution of Mean time of resolution of … Cetirizine is a good treatment option urticaria (minutes) pruritus (minutes)50 – for acute food induced allergic reactions. 50 –40 – 40 – 40.8 42.330 – min min 30 – 31.3 min 28.620 – 20 – min10 – 10 –00 00 CETIRIZINE DIPHENHYDRAMINE CETIRIZINE DIPHENHYDRAMINE

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