Peri-Operative Anaphylaxis—An Investigational Challenge

Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia

Is there a role for telemedicine in adult allergy services?

Telemedicine refers to the application of telecommunication and information technology (IT) in the delivery of health and clinical care at a distance or remotely and can be broadly considered in two modalities: store-and-forward and real-time interactive services. Preliminary studies have shown promising results in radiology, dermatology, intensive care, diabetes, rheumatology and primary care. However, the evidence is limited and hampered by small sample sizes, paucity of randomised controlled studies and lack of data relating to cost-effectiveness, health related quality of life and patient and clinician satisfaction. This review appraises the evidence from studies that have employed telemedicine tools in other disciplines and makes suggestions for its potential applications in specific clinical scenarios in adult allergy services. Possible examples include: triaging patients to determine the need for allergy tests; pre-assessment for specialised treatments such as allergen immunotherapy; follow up to assess treatment response and side effects; and education in self-management plan including training updates for self-injectable adrenaline and nasal spray use. This approach might improve access for those with limited mobility or living far away from regional centres, as well as bringing convenience and cost savings for the patient and service provider. These potential benefits need to be carefully weighed against evidence of service safety and quality. Keys to success include delineation of appropriate clinical scenarios, patient selection, training, IT support and robust information governance framework. Well-designed prospective studies are needed to evaluate its role. This article is protected by copyright. All rights reserved

CLINICAL AND MICROBIOLOGICAL PROFILE OF CANDIDA ISOLATES FROM ORAL CANDIDIASIS IN PATIENTS UNDERGOING RADIOTHERAPY FOR HEAD AND NECK MALIGNANCY

ABSTRACTObjective: To study the clinico-microbiological profile of oral candidiasis in head and neck squamous cell cancer (HNSCC) patients undergoingcurative radiotherapy (cRT).Methods: Patients undergoing cRT and developing oral candidiasis were enrolled. Clinical features such as pain and xerostomia were recorded.Candida isolates from lesions were speciated using CHROMagar (Himedia Inc.), and antifungal susceptibility was determined using microbrothdilution (MBD). Patients were followed up to study the clinical course of infection.Results: Of the 100 patients undergoing cRT, 79 developed oral candidiasis. Median duration to development of infection was 4 weeks (range:1-6.5 weeks). Mucositis was observed in 76 (96.2%) and xerostomia in 53 (67.1%) patients; 61 patients (77.2%) had symptoms attributable tocandidiasis. However, there was no correlation between severity of infection and mucositis (p=0.84) or xerostomia (p=0.51). Candida albicans was themost frequent (47 patients, 59.4%) isolate, followed by Candida tropicalis (23 patients; 29.1%). All isolates were sensitive to nystatin, but fluconazoleresistance/dose-dependent susceptibility was noted in 26 (32.9%) isolates. Both Candida krusei and two of four Candida glabrata isolate exhibitedfluconazole resistance. All patients received treatment for Candidiasis. On follow-up, 1 month after cRT, oral candidiasis resolved with gradualrecovery of mucositis in all patients.Conclusion: Candida albicans was the most common cause of oral Candidiasis in HNSCC cRT, and all isolates were susceptible to nystatin in-vitro.All lesions resolved with recovery from mucositis. In addition, as no patient developed systemic candidiasis, it appears that oral candidiasis thoughtroublesome is curable with treatment.Keywords: Radiation mucositis, CHROMagar, Microbroth dilution, Antifungal susceptibility

Exploring facilitators and barriers in asthma management in rural, semi-urban and urban populations in Vellore, India:an interview study of patients and primary care physicians

Summary box In India, there are deficits in asthma self-management and asthma training for primary care physicians. We advocate culturally tailored interventions for patients and clinically oriented training for primary care physicians.<br/

The role of the RACK1 ortholog Cpc2p in modulating pheromone-induced cell cycle arrest in fission yeast

The detection and amplification of extracellular signals requires the involvement of multiple protein components. In mammalian cells the receptor of activated C kinase (RACK1) is an important scaffolding protein for signal transduction networks. Further, it also performs a critical function in regulating the cell cycle by modulating the G1/S transition. Many eukaryotic cells express RACK1 orthologs, with one example being Cpc2p in the fission yeast Schizosaccharomyces pombe. In contrast to RACK1, Cpc2p has been described to positively regulate, at the ribosomal level, cells entry into M phase. In addition, Cpc2p controls the stress response pathways through an interaction with Msa2p, and sexual development by modulating Ran1p/Pat1p. Here we describe investigations into the role, which Cpc2p performs in controlling the G protein-mediated mating response pathway. Despite structural similarity to Gβ-like subunits, Cpc2p appears not to function at the G protein level. However, upon pheromone stimulation, cells overexpressing Cpc2p display substantial cell morphology defects, disorientation of septum formation and a significantly protracted G1 arrest. Cpc2p has the potential to function at multiple positions within the pheromone response pathway. We provide a mechanistic interpretation of this novel data by linking Cpc2p function, during the mating response, with its previous described interactions with Ran1p/Pat1p. We suggest that overexpressing Cpc2p prolongs the stimulated state of pheromone-induced cells by increasing ste11 gene expression. These data indicate that Cpc2p regulates the pheromone-induced cell cycle arrest in fission yeast by delaying cells entry into S phase