Management of Refractory Anaphylaxis: An Overview of Current Guidelines

Adrenaline; Anaphylaxis; VasopressorsAdrenalina; Anafilaxi; VasopressorsAdrenalina; Anafilaxia; VasopresoresIn this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.This work has no funding. P.J.T. is supported by the UK Medical Research Council (Grant Ref: MR/W018616/1), and through the NHR Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising. T.E.D. is supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health, under Award Number UL1TR001425. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH

Analyse descriptive des cas de gale en pédiatrie au centre hospitalier de Roubaix

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Interprétations du cliché de thorax et gravité des infections à virus respiratoire syncytial du nourrisson

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Pourquoi et comment améliorer l'évaluation du contrôle de l'asthme chez l'enfant en médecine libérale?

L asthme de l enfant est un problème de santé publique dans les pays industrialisés et sa prévalence augmente. L évaluation de l asthme repose sur la notion de contrôle des manifestations cliniques et fonctionnelles, selon des recommandations récentes et largement diffusées. Pourtant, le contrôle de l asthme chez l enfant reste insuffisant. Les facteurs liés à l enfant et sa famille pouvant expliquer un contrôle insuffisant ont été explorés mais peu d études se sont attachées à préciser les facteurs en lien avec le médecin. Nous avons analysé la manière dont les médecins généralistes évaluent le contrôle de l asthme chez l enfant en médecine libérale et recherché, dans leurs connaissances et leurs pratiques, les facteurs pouvant expliquer un faible contrôle de l asthme. Méthode et population. Nous avons interrogé 207 médecins généralistes du Nord-Pas-de-Calais et 80 internes de médecine générale de la faculté de Lille 2 sur leurs connaissances et pratiques dans l asthme de l enfant. Pour les médecins, un questionnaire était adressé par voie postale avec une relance pour 50 médecins et douze médecins étaient questionnés lors d un entretien individuel au cabinet. Pour les internes, le questionnaire était rempli lors d une séance de cours.Résultats. Quatre-vingt-trois médecins (42%) et 48 internes (60%) ont répondu au questionnaire. Les items à évaluer pour le contrôle de l asthme étaient globalement connus mais l absentéisme scolaire et la mesure du débit de pointe/VEMS étaient évalués lors des consultations dans seulement 32% et 39% des cas, respectivement. Seuls 10% des médecins avaient l habitude d évaluer l ensemble des items nécessaires selon les recommandations. La plupart des médecins (78%) déclaraient revoir en consultation leurs patients tous les trois mois. Pour affirmer le contrôle optimal, les médecins oubliaient de prendre en compte l absentéisme scolaire dans 75% des cas, les données fonctionnelles dans 63% des cas et le nombre d exacerbations dans 49% des cas. Seuls 7% des médecins définissaient correctement la notion de contrôle optimal en prenant en compte l ensemble des items nécessaires. Les réponses des médecins à deux cas cliniques ont confirmé le sous-diagnostic de la gravité de l asthme des patients. Les auto-questionnaires de l asthme destinés au patient n étaient que rarement utilisés (19%) et n étaient connus que pour 65% des praticiens et 37% des internes. Un quart des médecins ne prescrivaient des épreuves fonctionnelles respiratoires (EFR) que très rarement mais deux tiers des patients étaient adressés à un pneumologue, la moitié à un pneumopédiatre, un quart à un allergologue. Conclusion. Notre étude confirme la nécessité d améliorer les connaissances et les pratiques médicales sur l évaluation du contrôle de l asthme de l enfant. Une formation optimisée des internes, l utilisation des auto-questionnaires de l asthme destiné au patient, une plus grande disponibilité des spécialistes et des plateaux techniques pour les EFR voire le développement d outils numériques simples, utilisables au cabinet, pourraient permettre d améliorer l évaluation du contrôle de l asthme.LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Supplémentation en vitamine D et en fluor chez le nourrisson (enquête auprès des parents et des médecins)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Therapeutic approach of anaphylaxis

International audiencePurpose of review: Anaphylaxis is a recognized cause of death in all ages, which requires prompt recognition and treatment. We here propose to review the current and new pharmacological treatment of anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals with new tools that can be used to treat symptoms and prevent anaphylaxis.Recent findings: The recent description of phenotypes provides new insight and understanding into the mechanisms and causes of anaphylaxis through a better understanding of endotypes and application of precision medicine. Several biologic therapies and new devices are emerging as potential preventive treatment for anaphylaxis.Summary: Adrenaline (epinephrine) is still the first-line treatment for any type of anaphylaxis and is recognized as the only medication documented to prevent hospitalizations, hypoxic sequelae and fatalities. β2-adrenergic agonists and glucagon remains as the second-line treatment of anaphylaxis, meanwhile glucocorticoids and antihistamines should be used only as third-line treatment. Their administration should never delay adrenaline injection in anaphylaxis. More intuitive adrenaline autoinjectors design and features are required as well as a worldwide availability of adrenaline autoinjectors. Biological drugs, such as omalizumab, have been used as therapeutic adjuvants as a preventive treatment of anaphylaxis, but cost-effectiveness should be considered individually. Understanding the specifications of underlying mechanisms can potentially support improvements in the patients' allergological work-up and open the opportunity of developments of potential new drugs, such as biological agents. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among healthcare providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality

Anaphylaxis admissions in pediatric intensive care units: follow up and risk of recurrence

Abstract Background Data about the risk of anaphylaxis recurrence in children are lacking. We assessed anaphylaxis recurrence and medical follow-up in a cohort of children previously hospitalized in a French pediatric intensive care unit (PICU) for anaphylaxis. Methods We conducted a telephone survey of 166 children (?18y) hospitalized from 2003 to 2013. Results In all, 106 (64%) completed the survey [boys, 59%; mean age (SD):15.3y (5.5)]. The main index triggers were drugs (45%) and foods (37%). The mean duration follow-up was of 7.7y (SD: 2.4). Thirty-eight (36%) children experienced 399 new allergic reactions during a follow-up period of 282 patient-years (incidence rate: 1.4/100 patients/year; 95% CI: 0.64?2.04). Twelve children experienced 19 anaphylaxis reactions including five requiring PICU admission (anaphylaxis recurrence rate: 0.20/100 patients/year; 95%CI non-calculable). Food was the trigger for 79% of recurrent reactions, drugs for 8%. The food trigger was previously known in 83%, the same as the index trigger in 69%. Overall, 1.5% of the recurrent reactions were treated with adrenaline injection and 8% an emergency hospital admission. Patients with recurrence had more likely a history of food allergy (

Adrenaline auto injectors pharmacokinetic/pharmacodynamic studies and potential consequences for clinical practice

Abstract Background Anaphylaxis is a sudden multisystem allergic reaction which may result in a fatal outcome if not treated promptly. Guidelines worldwide suggest intramuscular adrenaline as the first‐line treatment for anaphylaxis outside a perioperative reaction. Adrenaline autoinjectors (AAIs) are widely used self‐administrable devices, especially in community settings. Different commercial AAIs have been authorized to be marketed in Europe. For an AAI to be efficacious, a rapid adrenaline delivery in patients, including those who are overweight or obese, resulting in an optimal cardiovascular (CV) response, is a key feature. AAIs are designed to achieve this requirement, which is reflected in their differing functional properties such as primary container selection, drug delivery mechanism (cartridge‐or syringe‐based), needle length, needle gauge, and adrenaline dose (150 μg, 300 μg, or 500 μg). However, the differences in functional properties across these devices may play a critical role in achieving these requirements as well as the differences in ergonomics in the handling of these devices. The purpose of this review Considering the dynamic pharmacokinetic/pharmacodynamic (PK/PD) profiles of different AAIs marketed in Europe and their effect on adrenaline delivery, the expert panel, also serving as author for this paper have carried out a detailed analysis of the PK/PD profiles of four AAIs, namely, Anapen, Emerade, EpiPen, and Jext, to delineate the adrenaline delivery and their subsequent physiological effects on the backdrop of device characteristics, dose strength, and the skin‐to‐muscle distances of the participants

Food-related anaphylaxis fatalities: Analysis of the Allergy Vigilance Network ® database

International audienc