Self-administration of adrenaline for anaphylaxis during in-hospital food challenges improves health-related quality of life.

OBJECTIVE: To assess the impact of anaphylaxis on health-related quality of life (HRQL) and self-efficacy in food-allergic patients undergoing in-hospital food challenge. DESIGN: Secondary analysis of a randomised controlled trial. SETTING: Specialist allergy centre. PATIENTS: Peanut-allergic young people aged 8-16 years. INTERVENTIONS: Double-blind, placebo-controlled food challenge to peanut, with HRQL and self-efficacy assessed using validated questionnaire, approximately 2 weeks prior to and 2 weeks after challenge. Where possible, anaphylaxis was treated with self-injected adrenaline (epinephrine). MAIN OUTCOME MEASURES: Change in HRQL and self-efficacy. RESULTS: 56 participants had reactions at food challenge, of whom 16 (29%) had anaphylaxis. Overall, there was an improvement in HRQL (mean 2.6 points (95% CI 0.3 to 4.8); p=0.030) and self-efficacy (mean 4.1 points (95% CI 2.4 to 5.9); p<0.0001), independent of whether anaphylaxis occurred. Parents also reported improved HRQL (mean 10.3 points (95% CI 5.9 to 14.7); p<0.0001). We found evidence of discordance between the improvement in HRQL and self-efficacy as reported by young people and that perceived by parents in their child. CONCLUSIONS: Anaphylaxis at food challenge, followed by self-administration of injected adrenaline, was associated with an increase in HRQL and self-efficacy in young people with peanut allergy. We found no evidence that the occurrence of anaphylaxis had a detrimental effect. Young people should be encouraged to self-administer adrenaline using their autoinjector device to treat anaphylaxis at in-hospital challenge. TRIAL REGISTRATION NUMBER: NCT02149719.

Self-injectable epinephrine: doctors' attitude and patients' adherence in real-life.

PURPOSE OF REVIEW: Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues. RECENT FINDINGS: This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices. SUMMARY: Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.

An adolescent girl with signs and symptoms of anaphylaxis and negative immunologic workup: a case report.

BACKGROUND: The increasing incidence of allergies and allergic reactions among children and adults has become a major public health concern. The etiology of allergic reactions can often be confirmed based on a detailed history and supportive testing. However, there are cases where the underlying factors are more complex and difficult to identify. CASE PRESENTATION: Here we present the case report of a 14-year-old Caucasian  girl with weight loss and a 3-year history of reported angioedema culminating in five intensive care unit admissions over the course of 2.5 months. Her initial clinical presentation included hypotension, dyspnea, and reported facial edema, but allergy and immunological workup were negative. A psychiatric workup identified an eating disorder with food restriction, comorbid major depression, obsessive compulsive disorder, and posttraumatic stress disorder. A close collaboration between Adolescent Medicine, Allergy and Immunology, and Psychiatry helped disentangle medical from psychiatric problems, including fluoxetine medication effects, as well as develop a treatment plan that was acceptable to the family. The angioedema was ultimately diagnosed as factitious disorder. CONCLUSIONS: This patient's treatment highlights the importance of a multidisciplinary team approach, a multifactorial etiology that needed to be addressed by multiple specialists, and the importance of long-term treatment and support.

Childrens' and Parents' Willingness to Join a Smartphone-Based Emergency Response Community for Anaphylaxis: Survey.

BACKGROUND: Medical emergencies such as anaphylaxis may require immediate use of emergency medication. Because of the low adherence of chronic patients (ie, carrying anti-anaphylactic medication) and the potentially long response time of emergency medical services (EMSs), alternative approaches to provide immediate first aid are required. A smartphone-based emergency response community (ERC) was established for patients with allergies to enable members to share their automatic adrenaline injector (AAI) with other patients who do not have their AAI at the onset of anaphylactic symptoms. The community is operated by a national EMS. In the first stage of the trial, children with food allergies and their parents were invited to join. OBJECTIVE: This study aimed to identify the factors that influence the willingness to join an ERC for a group of patients at risk of anaphylaxis. METHODS: The willingness to join an ERC was studied from different perspectives: the willingness of children with severe allergies to join an ERC, the willingness of their parents to join an ERC, the willingness of parents to enroll their children in an ERC, and the opinions of parents and children about the minimum age to join an ERC. Several types of independent variables were used: demographics, medical data, adherence, parenting style, and children's autonomy. A convenience sample of children and their parents who attended an annual meeting of a nonprofit organization for patients with food allergies was used. RESULTS: A total of 96 questionnaires, 73 by parents and 23 by children, were collected. Response rates were approximately 95%. Adherence was high: 22 out of 23 children (96%) and 22 out of 52 parents (42%) had their AAI when asked. Willingness to join the community was high among parents (95%) and among children (78%). Willingness of parents to enroll their children was 49% (36/73). The minimum age to join an ERC was 12.27 years (SD 3.02) in the parents' opinion and 13.15 years (SD 3.44) in the children's opinion. CONCLUSIONS: Parents' willingness to join an ERC was negatively correlated with parents' age, child's age, and parents' adherence. This can be explained by the free-rider effect: parents who carried an AAI for their young child, but had low adherence, wanted to join the ERC to get an additional layer of emergency response. Children's willingness to join the community was positively correlated with age and negatively correlated with the child's emotional autonomy. Parents' willingness to enroll their children in an ERC was positively correlated with child's age and negatively correlated with parents' adherence: again, this can be explained by the aforementioned free-rider effect. Parents' and children's opinions about the minimum age to join an ERC were negatively correlated with protective parenting style and positively correlated with monitoring parenting style.

Health-related quality of life in children and adolescents after systemic sting reaction.

INTRODUCTION AND OBJECTIVES: Insect stings are the second trigger of anaphylaxis in children and adolescents, causing a potentially life-threatening reactions. Hence health-related quality of life (HRQoL) is an important issue for Hymenoptera venom allergy (HVA) patients. The aim of this cross-sectional study was to evaluate the impact of HVA on young patients' HRQoL, including their socio-demographic characteristics. MATERIAL AND METHODS: The study sample included 102 patients aged 8-17 (Mean 12.5 years, SD=3.0), who were under diagnosis or venom immunotherapy due to systemic reaction after an insect sting in one of the tertiary referential centers in Poland. They were mostly boys (70%), and mainly from rural areas (63%). HRQoL of studied patients was measured with the Children's Hymenoptera Venom Allergy Quality of Life Scale, a questionnaire covering 6 dimensions: anxiety, caution, limitations, discomfort, support received from parents and a feeling of safety, each measured from 1 to 5. Independent predictors of HRQoL were estimated using the Generalized Linear Model. RESULTS: In the group of children being dermal reactors, girls reported a higher level of anxiety (B=1.17, 95%CI=(0.30;2.03), p=0.008). In the group of children with grade 2 it was the girls who reported lower anxiety (B=-1.33, 95%CI=(-2.38;-0.29), p=0.013). Boys treated longer than 3 years had their level of anxiety significantly lower than those studied at diagnosis (B=-0.65, 95%CI=(-1.23;-0.07), p=0.028). The feeling of safety was higher in children living in villages than in those living in towns (B=0.30, 95%CI=(0.03;0.56), p=0.031). CONCLUSIONS: The gender, treatment duration and stage of anaphylactic reaction influenced level of anxiety. The level of feeling of safety was related to the place of living.

Leaving the nest: Improving food allergy management on college campuses.

BACKGROUND: The transition from adolescence to young adulthood marks a developmental period in which responsibility for management of chronic conditions such as food allergy shifts from the caregiver to the young adult. Fatal food-induced anaphylaxis is most common among adolescents and young adults. However, colleges are currently not well positioned to provide integrated support for students with food allergies. OBJECTIVE: The study objective was to explore the systems, structures, and policies that currently support students with food allergies at college, assess unmet needs, and develop pilot interventions through the use of patient-centered design processes. METHODS: Key informant interviews were conducted with stakeholders in the campus management of food allergies (n = 26) between April and May 2016. Data were coded and assessed for relative frequencies of each code to determine challenges and potential solutions. RESULTS: The convergence of stakeholder-identified themes indicated that the transition to college for students with food allergy would be improved by providing support for: (1) Notification of others in the student's campus network about food allergy; (2) Establishing clearly defined roles/responsibilities; and (3) Increasing campus awareness of food allergy signs, symptoms, and lethality. To better provide comprehensive support for students, 5 interventions-collectively called Spotlight-were developed. CONCLUSION: The use of qualitative research methods, patient-centered design processes, and collaborations with diverse stakeholders-including pediatricians that care for adolescents-can provide a framework for designing coordinated systems and policies to provide comprehensive support to college students with food allergy. Next steps include rigorously testing implementation of the Spotlight intervention prototypes.

Preliminary psychometric analyses and clinical performance of a caregiver self-efficacy scale for food allergy self-management.

BACKGROUND: Food allergy health-related quality of life has been defined, but self-efficacy is poorly described. OBJECTIVE: To examine the preliminary reliability, validity, and clinical performance of a novel food allergy self-efficacy index. METHODS: An 8-item Food Allergy Self-Efficacy Questionnaire (FASEQ) was adapted for food allergy-related themes and coadministered with the Food Allergy Quality of Life Parental Burden (FAQL-PB) index to caregivers self-reporting a food allergic child (group A) and those with children followed up at a food allergy referral center clinic (group B). FASEQ split-half reliability, 2-week recall, factor analysis, and construct and discriminative validity were assessed. Multiple linear regression was used to explore predictive associations between the FAQL-PB and the FASEQ. RESULTS: Among 2,308 caregivers, the mean FASEQ score was 2.69 (95% CI, 2.66-2.73) and was lower (better) among group A (mean FASEQ score, 2.52; 95% CI, 2.49-2.56) vs group B (mean FASEQ score, 3.75; 95% CI, 3.66-3.84; P < .001). The FASEQ Cronbach α was 0.87, and the 2-week intraclass correlation coefficient (ICC) was 0.75. Total and 6 of 8 individual FASEQ domain scores were significantly lower among caregivers with children having anaphylaxis or epinephrine use vs none and peanut or tree nut allergy vs milk or egg allergy, demonstrating good discriminative validity. Total FASEQ score was associated with FAQL-PB score (ICC, 0.13; 95% CI, 0.06-0.19; P < .001), with 6 of 8 FASEQ individual domains significantly associated (ICC range, -0.17 to 0.3; P < .01 for all). Factor analysis revealed 2 domains (medical care and social functioning) with construct validity. CONCLUSION: We present preliminary evidence the FASEQ is a valid tool to assess caregiver food allergy self-efficacy. Self-efficacy is a distinct but related concept that captures aspects of self-management that are an important companion to health-related quality of life.

'Because it kind of falls in between, doesn't it? Like an acute thing and a chronic': The psychological experience of anaphylaxis in adulthood.

Anaphylaxis is a serious, rare condition increasing in prevalence. This study explored the psychological experience of adult-onset anaphylaxis from patient, family and staff perspectives. Semi-structured interviews were conducted with 12 participants. Two global themes emerged from thematic analysis: 'controllability' ('an unknown and distressing experience', 'the importance of control over triggers' and 'responsibility but no control: the impact on others') and 'conflict' ('rejecting illness identity', 'minimisation of risk', 'accessing specialist care: running in slow motion' and 'patient-centred versus service-centred care'). Findings highlight the importance of perceived control and emphasise the presence of conflict in the experience of this complex, episodic condition.

Anaphylaxis and intimate behaviour.

PURPOSE OF REVIEW: Intimate behaviours may represent an unusual way of exposure to a culprit allergen, or the frame for sex-related allergies due to triggers typically linked to that situation. The present review aims at summarizing the state of the art about the topic, in order to spread the awareness and the basic know-how in the field of sexual-related allergies. RECENT FINDINGS: Kiss-related IgE-mediated reactions are caused in sensitized partners mainly by the passive transport of allergenic molecules through saliva, skin or oral mucosa. It has also been recently suggested that kissing may act as an epicutaneous way for induction of allergic sensitization. Among food and drugs, not only but mostly, peanuts and beta-lactams, respectively, are the usual trigger. Although controversial, 1-hour wait before kissing and a proper mouth cleaning have been suggested as prevention strategies. Sexual intercourse related local or systemic symptoms can be caused by seminal plasma hypersensitivity, an IgE-mediated/type IV reaction due to prostate-specific antigen, which carries high homology to the canine prostatic kallikrein (Can f 5). Although applied to few patients, successful desensitization and immunotherapy protocols have been proposed. SUMMARY: Intimate behaviours are possible modalities of contact with the allergen. The exact prevalence of such hypersensitivity reactions is not known, but for its implications on Quality of Life and reproductive wishes, the possible link between sex and allergy should become part of the personal culture of clinical allergists and every clinician, in order to extend and improve the diagnosis of unusual or unexplained conditions.

Qualitative research in teen experiences living with food-induced anaphylaxis: A meta-aggregation.

AIM: To describe the central experiences of teens living with food-induced anaphylaxis as a first step in responding to healthcare needs in this population. BACKGROUND: As prevalence of allergy increases and commonly outgrown allergies persist longer, chronic management for teens becomes increasingly important. Synthesizing existing research helps to recognize management needs specific to teens with food allergy. DESIGN: Meta-aggregation for qualitative systematic review, to create synthesis for clinical improvement; guided by Joanna Briggs Institute methods and their Qualitative Assessment and Review Instrument. DATA SOURCES: Seven relevant databases were searched for original qualitative research July 2015; 10 studies (published 2007-2015) met inclusion criteria. REVIEW METHODS: Both authors undertook critical appraisal, with consensus by discussion. Findings from line-by-line extraction were grouped into categories and syntheses. In studies with mixed populations, we included only teens (age 12-19) with food-induced anaphylaxis. RESULTS: We developed three syntheses from nine categories and 64 subcategories to reflect central experiences of teens with food-induced anaphylaxis, including: (1) defining the allergic self; (2) finding a balance and (3) controlling the uncontrollable. The syntheses encompass importance of allergic identity/understanding, difficulties in coping with burdens of food allergy and reflect the complex risk interactions teens must negotiate in social contexts. CONCLUSION: There is a need to respect teens as active participants in managing food-induced anaphylaxis, while recognizing that social expectations and a lack of public awareness/safety can dangerously affect one's needs and decisions. This helps broaden how we conceptualize the needs of teens living with food-induced anaphylaxis, informing ongoing care and management.

Food Allergy-Related Risk-Taking and Management Behaviors Among Adolescents and Young Adults.

BACKGROUND: Food allergy (FA) affects 8% of children and adolescents in the United States. Nearly 40% of those affected have experienced severe reactions. Fatal food-induced anaphylaxis is most common among adolescents and young adults (AYA); however, FA-related risk behaviors persist in this population and factors associated with these behaviors remain unclear. OBJECTIVE: To characterize FA-related risk-taking and self-management behaviors of AYA with FA. METHODS: A cross-sectional survey was administered to 200 AYA with FA. Latent class analysis was used to identify distinct behavioral risk classes and predictors of risk class membership. RESULTS: Two distinct FA behavioral risk classes were identified, representing less (N = 120) and more (N = 80) risky subpopulations. After adjusting for age, sex, and anaphylaxis history, odds of more risky class membership were significantly reduced for AYA with peanut allergy (odds ratio [OR], 0.27; 95% CI, 0.11-0.65), supportive female friends (OR, 0.27; 95% CI, 0.07-0.99), overprotective mothers (OR, 0.42; 95% CI, 0.18-0.97), teachers who are aware of their FA (OR, 0.39; 95% CI, 0.17-0.91), a history of being bullied (OR, 0.22; 95% CI, 0.09-0.51), and an established 504 education plan (OR, 0.35; 95% CI, 0.15-0.81). AYA also reported numerous positive outcomes of their FA, such as greater responsibility, empathy, and improved diet, which was significantly associated with reduced odds of risky class membership (OR, 0.38; 95% CI, 0.18-0.80). CONCLUSIONS: Among AYA, increased FA-related risk-taking was associated with clinical, demographic, and social factors, including peanut allergy, greater age, as well as absence of social support and specific school FA policies. These associations may be used to inform future interventions designed to address FA-related risk and management behaviors.

Anaphylaxis Knowledge Among Pediatric Intensivists in Brazil: A Multicenter Survey.

OBJECTIVE: To assess the knowledge and practice preferences of anaphylaxis treatment among pediatric intensivists in 5 Brazilian pediatric intensive care unit (PICU) settings. STUDY DESIGN: The cohort was a cross-sectional sample from 5 PICUs; a 7-question survey was personally applied to participants regarding their professional clinical experience and the first-line drug choices when treating an anaphylaxis episode. RESULTS: Of 43 participant physicians, the majority (83.8%) correctly identified epinephrine as the treatment of choice for anaphylaxis, yet only 41.9% chooses the intramuscular route of administration. CONCLUSION: This study shows that the knowledge of anaphylaxis treatment is deficient among pediatric intensivists in Brazil. The dissemination of recent World Allergy Organization guidelines on anaphylaxis should be encouraged.

Clinical and laboratory features, and quality of life assessment in wheat dependent exercise-induced anaphylaxis patients from central China.

Wheat dependent exercise-induced anaphylaxis (WDEIA) is a rare but potentially severe food allergy caused by the combination of wheat ingestion and physical exercise. The impact of WDEIA on quality of life (QOL) is unclear. This study characterized the clinical and laboratory features and investigated the QOL in WDEIA patients from Central China. Twenty-eight WDEIA patients were analyzed, and QOL was measured by validated Chinese version Food Allergy Quality of Life Questionnaire-Adult Form (FAQLQ-AF) and Food Allergy Independent Measure (FAIM) after obtaining the diagnosis. The results showed that half of the patients were females. The median onset age was 37 years old. The symptoms occurred within 1 h after wheat ingestion (26/28). Symptoms of anaphylaxis included cutaneous (26/28), respiratory (11/28), gastro-intestinal (5/28) and cardiovascular manifestations (27/28). Skin prick tests were positive to salt soluble (89.3%) and salt insoluble wheat allergen extracts (100%). Positive rate to wheat, gluten and omega-5 gliadin specific IgE was 64.3%, 92.9% and 92.9% respectively. Specific IgE to omega-5 gliadin with a cut-off value 0.83 KU/L offered highly efficient diagnostic criterion for WDEIA (sensitivity: 89.3%; and specificity: 88.9%). The mean scores of FAQLQ-AF and FAIM were 4.70 and 4.98 respectively and level of anti-omega-5 gliadin IgE had positive correlations with FAQLQ scores. Thereby, WDEIA is commonly found in mid-age adults. In most cases, multi-organs especially skin and cardiovascular systems are involved. Salt insoluble wheat allergen skin test and serum specific IgE to gluten and omega-5 gliadin help to diagnose WDEIA. QOL in WDEIA patients is severely impaired.

Memory for Allergies and Health Foods: How Younger and Older Adults Strategically Remember Critical Health Information.

OBJECTIVES: While older adults often display memory deficits, with practice, they can sometimes selectively remember valuable information at the expense of less value information. We examined age-related differences and similarities in memory for health-related information under conditions where some information was critical to remember. METHOD: In Experiment 1, participants studied 3 lists of allergens, ranging in severity from 0 (not a health risk) to 10 (potentially fatal), with the instruction that it was particularly important to remember items to which a fictional relative was most severely allergic. After each list, participants received feedback regarding their recall of the high-value allergens. Experiment 2 examined memory for health benefits, presenting foods that were potentially beneficial to the relative's immune system. RESULTS: While younger adults exhibited better overall memory for the allergens, both age groups in Experiment 1 developed improved selectivity across the lists, with no evident age differences in severe allergen recall by List 2. Selectivity also developed in Experiment 2, although age differences for items of high health benefit were present. DISCUSSION: The results have implications for models of selective memory in older age, and for how aging influences the ability to strategically remember important information within health-related contexts.

Quality-of-life issues in survivors to anaphylactic reactions to drugs.

The aim of this cross-sectional observational study was to explore quality of life and well-being in patients with drug-induced anaphylaxis. Two validated tools were used: the Drug Hypersensitivity Quality-of-Life Questionnaire (DrHy-Q) and the Psychological General Well-Being Index (PGWBI). Sixty-five patients (13 males) underwent data analysis. The mean DrHy-Q score was 62.82 ± 12.1. Mean PGWBI score was 64.03 ± 17.66. DrHy-Q score was significantly correlated with PGWBI total score (r = -0.314; P = 0.011) and with the following domains: Anxiety (r = -0.260; P = 0.036), Depressed mood (r = -0.406; P = 0.001), Positive well-being (r = -0.251; P = 0.004), and General Health (r = -0.352; P = 0.004). Compared with the Italian reference population, patients had a significantly reduced PGWBI total and domain score. Our results highlight for the first time how impaired HRQoL and distress commonly feature in survivors to anaphylactic reactions to drug.

Factors impacting parental burden in food-allergic children.

AIM: This study aims to determine factors impacting the parental burden in immunoglobulin E (IgE)-mediated food-allergic children (FAC), focusing on attitudes towards adrenaline autoinjectors (AAIs). METHODS: Questionnaires were sent to parents of diagnosed IgE-mediated FAC attending follow-up allergy clinic appointments at two Sydney hospitals in May-September 2013. The questionnaires ascertained parental attitudes, confidence and knowledge regarding AAIs and included the validated, Food Allergy Quality of Life-Parental Burden (FAQL-PB) questionnaire. RESULTS: The response rate was 68%. Of FAC, 62% were male aged 1-17 years (median 6.0). There was a high proportion of children with multiple food allergies (52% allergic to >2 foods), coexistant eczema (85%) and asthma (54%). Sixty-three per cent reported a past history of anaphylaxis and 42% reported reactions in the last 6 months. AAI had been prescribed for 84%. FAC with a history of anaphylaxis were more likely to have had an AAI prescribed (P < 0.0001). There was no difference in FAQL-PB mean scores with age or AAI prescription status. The PB score was greater if the parent had administered the AAI (P = 0.02) and where the child was allergic to >2 foods (P < 0.0001).The Ninety per cent of parents reported that the AAI increased or did not change the child's quality of life, the family or FACs freedom. Three per cent of parents whose FAC children were prescribed an AAI reported increased stress related to AAI prescription. CONCLUSION: Severity of food allergy, number of food allergens and past anaphylaxis rather than prescription of an AAI appear to be major influences on parental burden.