OBJECTIVE: To identify bicyclist and environmental factors associated with fatal bicycle-related trauma in Ontario. DESIGN: Retrospective study. SETTING: Ontario. PARTICIPANTS: Information was extracted from the provincial coroner's reports on 212 people who had died of bicycle-related injuries in Ontario between 1986 and 1991. OUTCOME MEASURES: Age, sex and helmet use of the bicyclist, time and place of the event, type of bicyclist or motorist error(s) and use of alcohol by bicyclist or motorist. RESULTS: Only 32% of the deaths involved bicyclists under 15 years of age. The male-female ratio was 3.5. Over 75% of the cases involved head injury; however, only 8 (4%) of the bicyclists had been wearing a helmet. In 91% of the cases death occurred as the result of a bicycle-motor vehicle collision. Most (65%) of the deaths for which the time was known occurred between 4 pm and 8 am. Bicyclist error was the main cause of crash for 26 (79%) of the children less than 10 years old; it was also the main cause of crash among the bicyclists aged 10 to 19 years (43 [55%]) and those aged 45 years or more (15 [44%]). However, motorist error was the most common cause of collision in the group of cyclists 20 to 44 years of age (42 [63%]). Alcohol was detected in the blood of 7% of the bicyclists killed; alcohol had been consumed by 30% of the motorists who claimed not to have seen the cyclist. CONCLUSIONS: Bicycle-related deaths result from factors that are generally avoidable. Identifiable risk factors other than lack of helmet use suggest that additional research is required to determine the benefits of preventive interventions aimed at reducing the number of such deaths. Age-specific strategies appear warranted.
The completeness of AIDS (acquired immune deficiency syndrome) case reporting in Ontario was assessed by reviewing all AIDS death certificates compiled by the Registrar General between Jan. 1, 1985, and Dec. 31, 1987. Several demographic variables were used to match death certificates with cases reported to the provincial AIDS registry. The completeness of case reporting was then estimated by examining the ratio of reported deaths of patients with AIDS to the total number of deaths reviewed. The estimated completeness of case reporting was 81.1% in 1985, 71.5% in 1986 and 75.4% in 1987; the overall rate for 1985-87 was 75.2%. The difference in the completeness of case reporting from year to year was not statistically significant. There was a significant increase from 1985 to 1986 in the proportion of unreported cases in people who had never been married (p less than 0.02). Reporting was not associated with the patient's age, sex, occupation or place of residence. The deficiency in AIDS case reporting could adversely affect the long-term planning of health care resources and the development of programs to prevent and control the spread of AIDS.
Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death. Since it is unpredictable and potentially fatal, prompt recognition and treatment are vital to maximize a positive outcome. The occurrence of anaphylaxis is increasing across all ages in the United States, with increased risk of worse outcome in teenagers/young adults and in those with comorbid conditions such as asthma. Gaps in the assessment of patient-specific risk factors, identification and prevention of triggers, recognition of signs/symptoms, and pharmacologic treatment of anaphylaxis have been identified at the physician and caregiver/patient level. A PubMed literature search (January 2000–December 2011) was conducted to identify publications on childhood anaphylaxis using the following terms: food allergy, food allergens, food hypersensitivity, epinephrine, epinephrine auto-injectors, anaphylactic triggers, and anaphylaxis. This review will critically appraise these key issues and highlight strategies that might result in improved management of anaphylaxis in children.
Epinephrine; Food allergy; Food hypersensitivity; Pediatric; Children; Anaphylaxis; Diagnosis; Treatment
Anaphylaxis guidelines recommend that patients with a history of anaphylactic reaction should carry self-injectable epinephrine and should be referred to an allergist.
To evaluate how frequently patients dismissed from the emergency department after treatment for anaphylaxis received a prescription for self-injectable epinephrine or allergist referral.
A retrospective medical record review identified patients with anaphylaxis in a community-based study from 1990 through 2000. Records of patients with Hospital Adaptation of the International Classification of Diseases, Second Edition or International Classification of Diseases, Ninth Revision codes representing anaphylaxis were reviewed, and a random sample of patients with associated diagnoses was also reviewed. Patients who met the criteria for diagnosis of anaphylaxis were included in the study.
Among 208 patients identified with anaphylaxis, 134 (64.4%) were seen in the emergency department and discharged home. On dismissal, 49 patients (36.6%; 95% confidence interval [CI], 28.4%–44.7%) were prescribed self-injectable epinephrine, and 42 patients (31.3%; 95% CI, 23.5%–39.2%) were referred to an allergist. Treatment with epinephrine in the emergency department (odds ratio, 3.6; 95% CI, 1.6 –7.9; P = .001) and insect sting as the inciting allergen (odds ratio, 4.0; 95% CI, 1.6 –10.5; P = .004) were significantly associated with receiving a prescription for self-injectable epinephrine. Patient age younger than 18 years was the only factor associated with referral to an allergist (P = .007).
Most patients dismissed after treatment for anaphylaxis did not receive a self-injectable epinephrine prescription or allergist referral. Emergency physicians may be missing an important opportunity to ensure prompt treatment of future anaphylactic reactions and specialized follow-up care.
Traumatic injury from sledding and tobogganing can be reduced. The objective of this study was to determine the incidence of sledding and tobogganing deaths in Ontario. Operator, vehicle (sled), and environmental factors associated with these events were also examined. A retrospective series of cases from the Provincial Chief Coroner's Office identified all patients fatally injured while sledding or tobogganing in Ontario between 1986 and 1991. Communities should pay careful attention to injury prevention when planning organized sledding areas.
OBJECTIVE: To determine the number of Southeast Asians in Ontario who died of the sudden unexplained death syndrome in Asian immigrants. DESIGN: Retrospective review. SETTING: Ontario. CASES: All deaths reported to the Office of the Chief Coroner for Ontario from 1992 to 1995. OUTCOME MEASURES: Age, residence and country of origin of people who died of sudden unexplained death syndrome in Asian immigrants, as defined by standard criteria, autopsy findings and social history of cases. RESULTS: Eight cases of sudden unexplained death in Asian immigrants were reported during the study period. All involved men, and the mean age at death was 34 (standard error of the mean 7) years (range 23 to 44 years). All of the people were residents of metropolitan Toronto. Four were from Vietnam, three from China and one from the Philippines. Seven people lived with family members; the eighth was unemployed and lived alone. Death occurred during sleep or in the waking hours of the morning in six cases; in two of these cases the person's spouse was awakened by loud, laboured breathing. Two men experienced chest pain, and one of them also had sudden-onset dyspnea. There was no prodromal illness in any case. The only consistent autopsy finding was acute nonspecific pulmonary edema and congestion. Analysis of heart weights failed to reveal signs of significant cardiomegaly. CONCLUSION: Men from Southeast Asia aged 20 to 45 years are at risk of sudden unexplained death, which usually occurs during sleep. No specific factors have been found that could be used to identify people at risk.
Anaphylaxis after the ingestion of foods contaminated with mites has recently been reported. It is an immediate and potentially life-threatening reaction in patients with previous allergic rhinitis and/or asthma following the ingestion of mite-contaminated foods. Case series and case reports thus far have shown that mite-contaminated wheat flour is the major cause of oral mite anaphylaxis. However, we have encountered 8 cases of oral mite anaphylaxis in our hospital not caused by mite-contaminated wheat flour but by mite-contaminated okonomiyaki mix.
To review the current literature, in addition to our patients, we performed a MEDLINE search of articles on oral mite anaphylaxis in Japan up to June 2011 and collected patient characteristics, interview contents, results on specific IgE against mites, wheat, and pollen and other antigens, results of skin prick tests including those using extracts from mites and/or culprit flours, and microscopic examination results.
We found thirty oral mite anaphylaxis patients in Japan twenty-eight (93.3%) of whom ingested okonomiyaki or takoyaki, prepared at home using okonomiyaki mix (24 patients) or takoyaki mix (4 patients), respectively, which was previously opened and stored for months at ambient temperature. Takoyaki mix is similar to okonomiyaki mix, which is composed of flour, dried scallop, bonito, and mackerel. The other 2 patients ingested pancake mix. Microscopic examination of thirteen patients’ mixes revealed contaminating mites. Thyreophagus putrescentiae, Dermatophagoides pteronyssinus, Dermatophagoides farinae were found in mix samples of 4, 3, and 3 patients, respectively. The specific IgE against each mite is generally upregulated, which might be affected by cross-reactivities to other mites. Especially, the specific IgEs to Dermatophagoides pteronyssinus and Dermatophagoides farina were more than class 2 in all cases. It is suggested that mites are attracted to the flavors of okonomiyaki and takoyaki mixes and invade from a crack in a flour sack, and proliferate under favorable conditions.
Mite-contaminated flavored mix is a major cause of oral mite anaphylaxis in Japan.
Food-induced anaphylactic reactions are common and increasing in frequency. Despite the existence of a consensus definition of anaphylaxis, many cases are missed, recommended treatments are not given and follow-up is inadequate. New aspects of its pathophysiology and causes, including atypical food-induced causes., are still being uncovered. Epinephrine remains the cornerstone for successfully treating anaphylaxis; H1 and H2 antihistamines, glucocorticoids and β-agonists are ancillary medications that may be used in some cases in addition to epinephrine. However, the added utility of these secondary medications in anaphylaxis has not been conclusively demonstrated. Early recognition of anaphylaxis, appropriate emergency treatment and follow-up, including prescription of self-injectable epinephrine, are essential to prevent death and significant morbidity from anaphylaxis.
anaphylaxis; food allergy; epinephrine
Anaphylaxis incidence rates and time trends in the United States have been reported using different data sources and selection methods. Larger studies using diagnostic coding have inherent limitations in sensitivity and specificity. In contrast, smaller studies using chart reviews, including reports from single institutions, have better case characterization but suffer from reduced external validity due to their restricted nature. Increasing anaphylaxis hospitalization rates since the 1990s have been reported abroad. However, we report no significant overall increase in the United States. There have been several reports of increasing anaphylaxis rates in northern populations in the United States, especially in younger people, lending support to the suggestion that higher anaphylaxis rates occur at higher latitudes. We analyzed anaphylaxis hospitalization rates in comparably sized northern (New York) and southern (Florida) states and found significant time trend differences based on age. This suggests that the relationship of latitude to anaphylaxis incidence is complex.
Anaphylaxis; Epidemiology; Population based; Latitude; Time trend; ICD-9-CM code; Children; Incidence
To identify the predictors of residential fire deaths in the Ontario pediatric population using systematically collected data from the Office of the Chief Coroner.
Retrospective cohort study.
Children younger than 16 years of age who died in accidental residential fires in Ontario between January 1, 2001, and December 31, 2006.
Main outcome measures
The study retrospectively reviewed the coroner’s case files for 60 subjects who qualified according to the selection criteria. Reviewed documents included the coroner’s investigation statements, autopsy reports, toxicology reports, fire marshal’s reports, police reports, and Children’s Aid Society (CAS) reports. Information on a range of demographic, behavioural, social, and environmental factors was collected. Statistical tests, including relative risk, relative risk confidence intervals, and χ2 tests were performed to determine the correlation between factors of interest and to establish their significance.
Thirty-nine fire events resulting in 60 deaths occurred between 2001 and 2006. Fire play and electrical failures were the top 2 causes of residential fires. More fires occurred during the night (midnight to 9 am) than during the day (9 am to midnight). Nighttime fires were most commonly due to electrical failures or unattended candles, whereas daytime fires were primarily caused by unsupervised fire play and stove fires. Smoke alarms were present at 32 of 39 fire events (82%), but overall alarm functionality was only 54%. Children from families with a history of CAS involvement were approximately 32 times more likely to die in fires.
Risk factors for pediatric fire death in Ontario include smoke alarm functionality, fire play, fire escape behaviour, and CAS involvement. Efforts to prevent residential fire deaths should target these populations and risk factors, and primary care physicians should consider education around these issues as a primary preventive strategy for families with young children.
In 2007, Australia implemented the National human papillomavirus (HPV) Vaccination Program, which provides quadrivalent HPV vaccine free to all women aged 12–26 years. Following notification of 7 presumptive cases of anaphylaxis in the state of New South Wales, Australia, we verified cases and compared the incidence of anaphylaxis following HPV vaccination to other vaccines in comparable settings.
We contacted all patients with suspected anaphylaxis and obtained detailed histories from telephone interviews and a review of medical records. A multidisciplinary team determined whether each suspected case met the standardized Brighton definition. Some participants also received skin-prick allergy testing for common antigens and components of the HPV vaccine.
Of 12 suspected cases, 8 were classified as anaphylaxis. Of these, 4 participants had negative skin-prick test results for intradermal Gardasil. From the 269 680 HPV vaccine doses administered in schools, 7 cases of anaphylaxis were identified, which represents an incidence rate of 2.6 per 100 000 doses (95% CI 1.0–5.3 per 100 000). In comparison, the rate of identified anaphylaxis was 0.1 per 100 000 doses (95% CI 0.003–0.7) for conjugated meningococcal C vaccination in a 2003 school-based program.
Based on the number of confirmed cases, the estimated rate of anaphylaxis following quadrivalent HPV vaccine was significantly higher than identified in comparable school-based delivery of other vaccines. However, overall rates were very low and managed appropriately with no serious sequelae.
Percutaneous treatment (PT) emerged in the mid-1980s as an alternative to surgery for selected cases of abdominal cystic echinococcosis (CE). Despite its efficacy and widespread use, the puncture of echinococcal cysts is still far from being universally accepted. One of the main reasons for this reluctance is the perceived risk of anaphylaxis linked to PTs. To quantify the risk of anaphylactic reactions and lethal anaphylaxis with PT, we systematically searched MEDLINE for publications on PT of CE and reviewed the PT-related complications. After including 124 publications published between 1980 and 2010, we collected a total number of 5943 PT procedures on 5517 hepatic and non-hepatic echinococcal cysts. Overall, two cases of lethal anaphylaxis and 99 reversible anaphylactic reactions were reported. Lethal anaphylaxis occurred in 0.03% of PT procedures, corresponding to 0.04% of treated cysts, while reversible allergic reactions complicated 1.7% of PTs, corresponding to 1.8% of treated echinococcal cysts. Analysis of the literature shows that lethal anaphylaxis related to percutaneous treatment of CE is an extremely rare event and is observed no more frequently than drug-related anaphylactic side effects.
The risk of anaphylactic shock is the objection most often raised by opponents of percutaneous treatments for cystic echinococcosis, but there are no updated figures on the actual occurrence of anaphylaxis as a complication of this treatment.
To assess the number of lethal and non-lethal anaphylactic reactions following percutaneous aspiration of echinococcal cysts, we systematically reviewed the literature published from 1980–2010.
The analysis of the available literature shows that the risk of severe anaphylactic reactions resulting from percutaneous treatment of echinococcal cysts has been widely exaggerated and the actual risk may be lower than that following administration of certain antibiotics.
Provided adequate stand-by resuscitation measures are available, each time an echinococcal cyst is punctured, fear of anaphylactic shock is no longer justified as an argument to avoid this therapeutic option.
Aims—To determine the frequency at which classic manifestations of anaphylaxis are present at necropsy after fatal anaphylactic reactions.
Methods—A register has been established of fatal anaphylactic reactions in the UK since 1992, traced from the certified cause of death and other sources. Details of the previous medical history and the reaction suggest anaphylaxis as the cause of death for 130 cases; a postmortem report was available for 56.
Results—The 56 deaths studied included 19 reactions to bee or wasp venom, 16 to foods, and 21 to drugs or contrast media. Death occurred within one hour of anaphylaxis in 39 cases. Macroscopic findings included signs of asthma (mucous plugging and/or hyperinflated lungs) (15 of 56), petechial haemorrhages (10 of 56), pharyngeal/laryngeal oedema (23 of 56), but for 23 of 56 there was nothing indicative of an allergic death. Mast cell tryptase was raised in 14 of 16 cases tested; three of three tested had detectable IgE specific for the suspected allergen.
Conclusions—In many cases of fatal anaphylaxis no specific macroscopic findings are present at postmortem examination. This reflects the rapidity and mode of death, which is often the result of shock rather than asphyxia. Investigations that might help determine whether anaphylaxis was the cause of death had rarely been performed. In the presence of a typical clinical history, absence of postmortem findings does not exclude the diagnosis of anaphylaxis.
Key Words: necropsy • anaphylaxis • asthma
In late December 1986, 1224 institutional veterinarians and small and mixed animal clinics across Canada were sent a questionnaire in order to assess the status of Dirofilaria immitis in Canada in 1986; 46% of them responded. Veterinarians reported that 150,989 dogs were blood-tested for microfilariae and 869 dogs were found with heartworm. Another 65 dogs were amicrofilaremic but diagnosed with heartworm disease and one was found with heartworm at necropsy to give the total number diagnosed in 1986 as 935 (0.62%).
Heartworm was reported from Manitoba, New Brunswick, Ontario and Quebec, but most (810) of the cases were from Ontario. South-western Ontario continued to be the primary focus of the infection in Canada. There were 103 cases reported from Quebec, mostly from and around Montreal, and 21 cases from Manitoba, from Winnipeg and surrounding areas. Heartworm was found most frequently in companion dogs over three years of age maintained mainly outdoors in rural areas. About 33% of the cases were observed with clinical signs of heartworm disease and 81% had a history of not having left Canada.
Dirofilaria immitis; heartworm; dogs; prevalence; Canada
Adverse drug reactions (ADRs) are common in clinical practice, most of them presented only with mucocutaneous symptoms. Drug induced anaphylaxis is rare, but it is responsible for most deaths due to ADRs. The aim of this study was to evaluate drug induced anaphylaxis treated in an Allergy Outpatient Clinic of a University Hospital.
Retrospective analysis of medical records from patients who seek assistance because of ADR. We looked for clinical criteria for diagnosing anaphylaxis, as recommended in WAO Guidelines. Criteria were classified in numbers 1 to 3:1) Acute onset of an illness (minutes to several hours) with involvement of the skin-mucosal tissue and respiratory and/or cardiovascular compromise; 2) Two or more of the following that occur rapidly after exposure to a likely allergen: involvement of skin-mucosal tissue, respiratory, cardiovascular and/or gastrointestinal compromise; 3) Reduced blood pressure after exposure to known allergen for that patient. We analyzed patients gender and age, drugs involved in reactions and administration of epinephrin.
We studied 806 patients with history of ADR, of whom 123 (15.3%) presented clinical criteria of anaphylaxis (mean age 39.0 year old, female 101). The first clinical criteria was found in 60.2% and the second one in 38.2%. Epinephrin was injected in only 42 patients (34.1%). Non-steroidal anti-inflammatory drugs (NSAIDs) were most commonly suspected culprit drugs involved in anaphylactic reactions, with 59 patients (47.9%), followed by 40 patients with perioperative anaphylaxis (32.5%), 6 cases due to local anesthetics (4.9%) and 4 to antibiotics (3.2%). Between perioperative anaphylaxis, latex was involved in 10 reactions and neuromuscular blocking agents in 3.
We found a high prevalence of anaphylaxis, probably because patients with severe ADRs tend to be followed in university hospitals. Nevertheless, anaphylaxis is underdiagnosed in emergency departments, as we observed less than 35% of patients with drug induced anaphylaxis were treated with epinephrin. NSAIDs are still the most common drugs involved in ADRs in Brazil, including severe reactions, as anaphylaxis. In our country, latex still is an important agent incriminated in perioperative anaphylaxis, but anaphylaxis due to antibiotics are less common than in other countries.
The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.
anaphylaxis; risk factors; clinical diagnosis; epinephrine (adrenaline); antihistamines; glucocorticoids
To provide evidence-based practice guideline recommendations concerning the role of endolaryngeal surgery (with or without laser) compared with radiation therapy for patients with early (T1) glottic cancer, assessing survival, locoregional control, laryngeal preservation rates, and voice outcomes.
The medline, embase, and Cochrane Library databases were searched to identify relevant studies from 1996 to 2011. Recommendations were formulated based on that evidence and on the expert opinion of Cancer Care Ontario’s Head and Neck Cancer disease site group. The systematic review and practice guideline were externally reviewed by practitioners in Ontario, Canada.
The available evidence was of a level insufficient to demonstrate a clear difference between treatment options when considering the likelihood of local control or overall survival. Although the evidence was mainly retrospective, there was a suggestion that, compared with surgery, radiotherapy might be associated with less measureable perturbation of voice without a significant difference in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.
For patients with early (T1) glottic cancer, the evidence is insufficient to demonstrate a difference between endolaryngeal surgery (with or without laser) and external-beam radiation therapy. The choice between treatment modalities has been based on patient and clinician preferences and general medical condition.
Endolaryngeal; glottic; radiotherapy; surgery; T1
We have noticed changes in paediatric anaphylaxis triggers locally in Singapore.
We aimed to describe the demographic characteristics, clinical features, causative agents and management of children presenting with anaphylaxis.
This is a retrospective study of Singaporean children presenting with anaphylaxis between January 2005 and December 2009 to a tertiary paediatric hospital.
One hundred and eight cases of anaphylaxis in 98 children were included. Food was the commonest trigger (63%), followed by drugs (30%), whilst 7% were idiopathic. Peanut was the top food trigger (19%), followed by egg (12%), shellfish (10%) and bird's nest (10%). Ibuprofen was the commonest cause of drug induced anaphylaxis (50%), followed by paracetamol (15%) and other nonsteroidal anti-inflammatory drugs (NSAIDs, 12%). The median age of presentation for all anaphylaxis cases was 7.9 years old (interquartile range 3.6 to 10.8 years), but food triggers occurred significantly earlier compared to drugs (median 4.9 years vs. 10.5 years, p < 0.05). Mucocutaneous (91%) and respiratory features (88%) were the principal presenting symptoms. Drug anaphylaxis was more likely to result in hypotension compared to food anaphylaxis (21.9% vs. 2.7%, Fisher's exact probability < 0.01). There were 4 reported cases (3.6%) of biphasic reaction occurring within 24 h of anaphylaxis.
Food anaphylaxis patterns have changed over time in our study cohort of Singaporean children. Peanuts allergy, almost absent a decade ago, is currently the top food trigger, whilst seafood and bird's nest continue to be an important cause of food anaphylaxis locally. NSAIDs and paracetamol hypersensitivity are unique causes of drug induced anaphylaxis locally.
Anaphylaxis; Drug allergy; Food allergy; Paediatrics
This article reviews reports of 61 deaths associated with non-steroidal anti-inflammatory drugs (NSAIDs). These fatalities occurred in Ontario, between February 1, 1981 and January 1, 1986. The average age of these patients at death was 78.6 years, and 59% were female. One or more gastro-intestinal hemorrhages preceded death in 48 patients (79%), and perforation of ulcers with peritonitis and shock were reported in five cases. Other reports indicated that edema and renal failure had occurred in three patients, and bone-marrow depression in another three. The NSAIDs most frequently implicated in these deaths were piroxicam and naproxen, but without data on the numbers of patients taking the various NSAIDs, no conclusions can be drawn about the relative frequencies of severe reactions.
NSAID treatment; reported deaths
This systematic review of the Brazilian and worldwide literature aimed to evaluate the incidence and causes of perioperative and anesthesia-related mortality in pediatric patients. Studies were identified by searching EMBASE (1951-2011), PubMed (1966-2011), LILACS (1986-2011), and SciElo (1995-2011). Each paper was revised to identify the author(s), the data source, the time period, the number of patients, the time of death, and the perioperative and anesthesia-related mortality rates. Twenty trials were assessed. Studies from Brazil and developed countries worldwide documented similar total anesthesia-related mortality rates (<1 death per 10,000 anesthetics) and declines in anesthesia-related mortality rates in the past decade. Higher anesthesia-related mortality rates (2.4-3.3 per 10,000 anesthetics) were found in studies from developing countries over the same time period. Interestingly, pediatric perioperative mortality rates have increased over the past decade, and the rates are higher in Brazil (9.8 per 10,000 anesthetics) and other developing countries (10.7-15.9 per 10,000 anesthetics) compared with developed countries (0.41-6.8 per 10,000 anesthetics), with the exception of Australia (13.4 per 10,000 anesthetics). The major risk factors are being newborn or less than 1 year old, ASA III or worse physical status, and undergoing emergency surgery, general anesthesia, or cardiac surgery. The main causes of mortality were problems with airway management and cardiocirculatory events. Our systematic review of the literature shows that the pediatric anesthesia-related mortality rates in Brazil and in developed countries are similar, whereas the pediatric perioperative mortality rates are higher in Brazil compared with developed countries. Most cases of anesthesia-related mortality are associated with airway and cardiocirculatory events. The data regarding anesthesia-related and perioperative mortality rates may be useful in developing prevention strategies.
Anesthesia; Cardiac Arrest; Mortality; Perioperative; Pediatric; Review
The European Academy of Allergy and Clinical Immunology is in the process of developing its Guideline for Food Allergy and Anaphylaxis, and this systematic review is one of seven inter-linked evidence syntheses that are being undertaken in order to provide a state-of-the-art synopsis of the current evidence base in relation to epidemiology, prevention, diagnosis and clinical management and impact on quality of life, which will be used to inform clinical recommendations.
The aims of this systematic review will be to understand and describe the epidemiology of anaphylaxis, i.e. frequency, risk factors and outcomes of anaphylaxis, and describe how these characteristics vary by person, place and time.
A highly sensitive search strategy has been designed to retrieve all articles combining the concepts of anaphylaxis and epidemiology from electronic bibliographic databases.
This review will aim to provide some estimates of the incidence and prevalence of anaphylaxis in Europe. The occurrence of anaphylaxis can have a profound effect on the quality of life of the sufferer and their family. Estimates of disease frequency will help us to ascertain the burden of anaphylaxis and provide useful comparators for management strategies.
Anaphylaxis; Allergy; Epidemiology; Prevalence; Incidence
The risk of anaphylaxis ranges from 0.2 to 0.7%. The objective of this study was to describe the causes, clinical features and complications of patients with anaphylaxis treated in the emergency department of our hospital.
Materials and Methods
A prospective, observational and descriptive survey was conducted for assessing adult patients with a diagnosis of anaphylaxis from March 2005 to 2010. Information was obtained from the medical records and from a questionnaire was that completed for the patients and a relative. The information included, triggers, demographics, allergy history and clinical characteristics of the current episode. All the cases were followed to their outcome.
We documented 45 cases of anaphylaxis. 26 patients (58%) were male. The most common causes of anaphylaxis were: drug (49%) food (20%) and poison hymenoptera venom (16%). The most common clinical signs ando symptoms included: dyspnea (69%), nausea (58%) and hypotension (56%). 44% of patients came to emergency departments in the course of 30 minutes after onset of symptoms while the 29% took 30 minutes to 1 hour and 27% more than 1 hour. Among the associated diseases, hypertension was 13% and rhinitis (11%). In 85% of the cases, patients remained under observation for 3 to 12 hours were the most frequent discharged. 7 patients were hospitalized and 4 sent to intensive care later were discharged without complications.
Anaphylaxis is not uncommon in our environment. Drugs are the most common cause as reported in the literature. The most frequent clinical manifestations are respiratory and gastrointestinal.
To determine the population-based incidence of splenic injuries in the Province of Ontario, the proportion of splenic injuries treated by observation, splenectomy and splenorrhaphy, changes in management over time and the variation in management of splenic injuries among Ontario hospitals.
A retrospective cohort study.
All adults (older than 16 years) admitted with a diagnosis of splenic injury (clinical modification of the International Classification of Diseases, 9th revision) to acute care hospitals in Ontario between 1991 and 1994, identified from the Ontario Trauma Registry.
The incidence of splenic injury was 1.7 cases per 1000 trauma admissions per year. Patients with splenic injury were young (median age 32 years) and male (71%), and the death rate was 8%. Observation was the commonest method of treatment (69%), followed by splenectomy (28%) and splenorrhaphy (4%). The use of observation increased over the study period from 59% to 75% (p < 0.001). There was significant variation in the use of observation among hospitals (range 11% to 100%, p < 0.0001).
The majority of splenic injuries are managed by observation with an acceptable hospital death rate. The use of observation has increased over time, confirming the growing adoption of this management approach by most hospitals in the province when feasible. Splenorrhaphy was infrequently performed despite reports to the contrary from many centres in the United States. There was significant variation in splenic injury management, suggesting the need for further refinement and dissemination of practical guidelines for splenic salvage.
Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines.
Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data.
2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time.
There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted.
In Ontario, health care spending has grown to 45% of total government expenditures. In a public health care system, changes in demographics and the emergence of innovative technologies challenge our ability to adapt to evolving patient needs. To maintain a high standard of clinical effectiveness, there is a need to identify opportunities to improve health care delivery. This study was structured to meet the following objectives: to understand the operating room (OR) inventory practices at a tertiary academic hospital, to mathematically model this process to ascertain service levels based on changes in inventory and demand, and to define the appropriate level of reusable inventory for open and laparoscopic colorectal surgery.
We retrospectively reviewed OR throughput for all cases of colorectal cancer from January 1, 2010, to January 31, 2011. The process flow of OR instrumentation was studied to understand delays in the provision of inventory. Combining total surgeries performed with surgeon-specific instrument preferences generated daily instrument demand. We fitted parametric demand distributions for two instrument sets for major colon resections. Markovian models were used to estimate the distribution of available inventory and the likelihood of insufficient instruments on any given day.
We reviewed 1,458 cases, 39.5% of which involved major open surgery, whereas 26.2% involved laparoscopic surgery. Demand for open and laparoscopic instrument sets was observed to fit binomial (20, 0.15) and Poisson (1.41) distributions, respectively. On the basis of these curves, we estimated the probability distribution of the in-stock inventory and, subsequently, the probability that demand would exceed supply on any given day (Table 1). In particular, with 10 open and six laparoscopic sets currently owned by the institution, the probabilities that there would be insufficient inventory were 3.02% and 2.17%, respectively.
Probability of Running Out of Stock Based on Number of Units Owned
This analysis will guide purchasing decisions based on desired service levels and forecasted changes in demand. Furthermore, by ensuring that demand is being serviced, this analysis will help to curb loss of revenue, decrease wait times, and limit potential patient morbidity. Strategic purchasing can also reduce excessive inventory and therefore minimize shrinkage and obsolescence and increase working capital and institutional flexibility.