Anaphylaxis: Recognition and Management.

Anaphylaxis is a life-threatening systemic reaction, normally occurring within one to two hours of exposure to an allergen. The incidence of anaphylaxis in the United States is 2.1 per 1,000 person-years. Most anaphylactic reactions occur outside the hospital setting. Urticaria, difficulty breathing, and mucosal swelling are the most common symptoms of anaphylaxis. The most common triggers are medications, stinging insect venoms, and foods; however, unidentified triggers occur in up to one-fifth of cases. Coexisting asthma, mast cell disorders, older age, underlying cardiovascular disease, peanut and tree nut allergy, and drug-induced reactions are associated with severe or fatal anaphylactic reactions. Clinicians can obtain serum tryptase levels, reflecting mast cell degranulation, when the clinical diagnosis of anaphylaxis is not clear. Acute management of anaphylaxis involves removal of the trigger; early administration of intramuscular epinephrine; supportive care for the patient's airway, breathing, and circulation; and a period of observation for potential biphasic reactions. Only after epinephrine administration should adjunct medications be considered; these include histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon. Patients should be monitored for a biphasic reaction (i.e., recurrence of anaphylaxis without reexposure to the allergen) for four to 12 hours, depending on risk factors for severe anaphylaxis. Following an anaphylactic reaction, management should focus on developing an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector.

Military Occupational Disability Risk Surveillance: A Retrospective Cohort Study of Modifiable Risk Factors.

INTRODUCTION: Occupational disability among military service members is an important target for preventive screening. The specific aim of this study was to quantify disability risk levels among soldiers with selected risk factors (body mass index extremes, poor or absent physical fitness scores, and tobacco and opioid use) and combinations thereof, suggesting priorities for preventive actions. MATERIALS AND METHODS: This was a retrospective cohort study of 607,006 active-duty soldiers who served in the U.S. Army during 2011-2014. Official medical and administrative data were combined to produce a person-month-based panel dataset with identifiers removed. The subjects were observed longitudinally for incident disability (termed medical nonreadiness) during 1,305,618 person-years at risk. We employed Weibull parametric survival regression models to determine the adjusted medical nonreadiness hazard for selected variables. We then computed individual adjusted risk scores and the population proportions affected by risk factors and combinations thereof in postregression analyses. The project was approved by the Stanford University's Institutional Review Board and underwent secondary review by the Human Research Protections Office of the Defense Health Agency. RESULTS: During the observed time, 81,571 (13.4%) of subjects were found medically not ready. High or low body mass index, low or missing physical fitness test scores, tobacco use, and the highest levels of opioid use were each associated with increased adjusted hazards of medical nonreadiness. The hazards increased substantially when multiple risk factors were present, albeit while affecting reduced population proportions. CONCLUSIONS: We identified marked disability hazard increases, especially in association with opioid use and high body mass index. These factors, in addition to tobacco use and low physical fitness, are potential early prevention targets for clinicians who screen military service members.

The prevalence of vitamin B(12) deficiency in patients with type 2 diabetes: a cross-sectional study.

PURPOSE: The purpose of this study is to define the prevalence of vitamin B(12) deficiency in a type 2 diabetic population within a primary care practice. Metformin use and advanced age are associated with vitamin B(12) deficiency and often present in type 2 diabetic patients, yet the prevalence of vitamin B(12) deficiency in the diabetic population is unknown. METHODS: We conducted a cross-sectional study of 203 outpatient type 2 diabetic patients at a large military primary care clinic. Patients completed a survey and had B(12) levels measured. Patients with borderline B(12) levels also had methylmalonic acid and homocysteine levels drawn. Serum B(12) levels <100 pg/mL or serum B(12) levels of 100 to 350 pg/mL with elevation of serum methylmalonic acid >243 nmol/L or homocysteine >11.9 nmol/L defined B(12) deficiency. Descriptive statistics described frequency and means. chi(2) and student's t tests were used to analyze associations between categorical and continuous variables, respectively. Multivariate logistical regression identified covariates independently associated with B(12) deficiency. RESULTS: Twenty-two percent (n = 44) of diabetic patients had metabolically confirmed B(12) deficiency. Patients on metformin had lower serum B(12) levels (425.99 pg/mL vs 527.49 pg/mL; P = .012) and were at increased risk for B(12) deficiency (P = .04), as defined by a serum B(12) level <350 pg/mL. Prevalence of B(12) deficiency was significantly lower for patients using a multivitamin (odds ratio, 0.31; 95% CI, 0.15-0.63). CONCLUSIONS: Our results found a 22% prevalence of metabolically confirmed B(12) deficiency in the primary care type 2 diabetic population. Although further research needs to be performed to determine the clinical implications of our findings, B(12) deficiency should be considered in type 2 diabetic patients, especially those taking metformin. Furthermore, a daily multivitamin may protect against B(12) deficiency.