Omalizumab in the treatment of Morbihan syndrome in an adolescent girl – case report and literature review

Morbihan syndrome (MS) is characterized by solid facial edema, usually related to rosacea or acne vulgaris. The facial edema deforms the patient’s features, can impair peripheral vision, and affects quality of life. Its pathophysiology remains unclear. The disease usually has a slow and chronic course. MS most commonly affects middle-aged Caucasian men with rosacea and is rare in people below 20 years of age. MS is a diagnosis of exclusion. There is no standard treatment for MS, though systemic isotretinoin and antihistamines are mainly used. We present the case of an adolescent girl with MS nonresponding to 19 months of isotretinoin treatment with add-on antihistamines. Therapy with monthly administration of omalizumab (anti-IgE) for 6 months was an effective therapeutic option, improving the quality of life. Our case is the second description of omalizumab use in Morbihan syndrome, the first in an adolescent. (AU)

Omalizumab in the treatment of Morbihan syndrome in an adolescent girl - case report and literature review.

Morbihan syndrome (MS) is characterized by solid facial edema, usually related to rosacea or acne vulgaris. The facial edema deforms the patient's features, can impair peripheral vision, and affects quality of life. Its pathophysiology remains unclear. The disease usually has a slow and chronic course. MS most commonly affects middle-aged Caucasian men with rosacea and is rare in people below 20 years of age. MS is a diagnosis of exclusion. There is no standard treatment for MS, though systemic isotretinoin and antihistamines are mainly used. We present the case of an adolescent girl with MS nonresponding to 19 months of isotretinoin treatment with add-on antihistamines. Therapy with monthly administration of omalizumab (anti-IgE) for 6 months was an effective therapeutic option, improving the quality of life. Our case is the second description of omalizumab use in Morbihan syndrome, the first in an adolescent.

A longitudinal study of perceived social position and health-related quality of life.

BACKGROUND: A large body of evidence suggests that there is a social gradient in the association between perceived social position and various health outcomes. Yet only a fraction of this research uses longitudinal data, and these studies usually rely on two data points in time, consider a single health outcome measure, overlook non-linear effects of perceived social position, and come almost exclusively from the Western welfare democracies. METHODS: Using data for 1921 individuals from three waves (2008, 2013, 2018) of the Polish Panel Survey (POLPAN), we fit between- and within-individuals hybrid-effects models with cluster-robust standard errors to investigate the association between one's perceived social position (self-placement on a socioeconomic hierarchy scale varying 1 to 10) and subsequent health-related quality of life (HRQoL) measured using the Nottingham Health Profile (NHP) and its six components. RESULTS: We find that the association between perceived social position and health-related quality of life is larger when estimated between individuals than within individuals, yet in fixed- and hybrid-effects models perceived social position remains significantly and negatively linked with both the aggregated NHP measure as well as with its components such as emotional reaction, physical abilities, sleep, and social isolation. We also identify that starting to perceive oneself at the lower end of the social hierarchy is associated with a deteriorating health-related quality of life but a change at the top of the perceived social hierarchy is not linked with an improvement in NHP scores. CONCLUSIONS: We provide new evidence on the significant and non-linear links between perceived social position and health-related quality of life and highlight possible pathways linking these two aspects of individuals' lives.

Atopic dermatitis and gestational age - is there an association between them? A review of the literature and an analysis of pathology.

Introduction: The connection between prematurity and atopic dermatitis (AD) is an intensively investigated topic with existing knowledge gaps. The last review with a meta-analysis in this field was published in 2018. Since then, there have been great advances in the comprehension of AD pathophysiology. Aim: To update the knowledge and to discuss the recent findings in the field of AD and its association with prematurity in light of the newest publications. Material and methods: An electronic search of Medline was conducted, limited to the last eleven years. The screening of the full version of English articles was performed to ensure the fulfilment of the selection criteria. Results: Thirteen articles met the inclusion criteria, with a total of over 4 million participants. In the majority of the studies (n = 8), prematurity was associated with a lower risk of atopic dermatitis, although there were also publications (n = 5) that did not find an association between these factors. Conclusions: According to this study, prematurity is associated with a lower risk of atopic dermatitis.

Skin prick tests are not useful for the qualification for venom immunotherapy in children.

Background: The basis for qualification for venom immunotherapy (VIT) is the fulfilment of both the clinical and immunological criteria. Diagnostic tests that confirm the immunological criterion of an IgE-mediated sensitization include skin prick tests (SPT), intradermal tests (IDT), and serum specific IgE (sIgE) for the culprit venom. Objective: This study aimed to assess the usefulness of SPT as the immunological marker in the diagnosis of insect venom sensitization in children with history of systemic reaction (SR) to insect sting evaluated by means of I-IV-grades Mueller's scale. There are no such studies in children. Methods: This cross-sectional study sample consisted of 416 children aged 3-18 years (mean age 10.6 ± 3.8), 76% males, all with the history of a systemic reaction (SR) after a Hymenoptera sting (48% of grade III/IV according to Mueller scale), diagnosed between 1999 and 2019 in the tertiary referral centre. The standard diagnostic tests were used. Specificity, sensitivity, and positive and negative predictive values were computed to assess the diagnostic properties of the clinical tests to distinguish between mild and severe SR. To assess the relative value of an individual test in predicting the qualification to VIT we incorporated the Shapley value (SV). Results: Positive SPT results were found in up to no more than 3% of children; among them less than 1% had only positive SPT and were negative for sIgE and IDT. Approximately 85% of the children had detectable venom sIgE, followed by positive IDT (75%). Almost 70% of children had positive both sIgE and IDT results. In children with grade III/IV reaction, about 80% of children had positive results of both of these tests. sIgE and IDT had sensitivity >0.80, whereas SPT had high specificity (>0.97) in differentiating between mild and severe SR. Relative value of diagnostic tests in predicting qualification to VIT varied between venoms. Bee venom IDT had higher SV (0.052) than sIgE (0.041). In contrast, wasp venom sIgE had higher SV (0.075) than IDT (0.035). Conclusion: SPTs are not an useful immunological marker of venom sensitization in children, and eliminating SPT does not result in a loss of diagnostic accuracy. Limiting diagnostics to venom sIgE and IDT would shorten the procedure and reduce costs. Future studies are needed to determine if venom sIgE as the first line diagnostic test, with IDT added only if the venom sIgE is undetectable, is an optimal diagnostic process.

Stinging insect identification in children with Hymenoptera venom allergy and their parents.

Introduction: The treatment of Hymenoptera venom allergy (HVA) is based among others on the proper identification of the culprit insect. Aim: To assess the accuracy in identifying stinging insects by children with HVA and their parents. Material and methods: Participants were recruited from a paediatric medical centre. The data on their demographics, sting history and ability of insect identification (based on pictures) were obtained using a questionnaire. The study sample consisted of 102 children with HVA and their parents as well as 98 children without HVA and their parents. Results: The rates of subjects correctly identifying insects in the groups were 91.2%, 92.5%, 78.8%, 82.4%, respectively. When compared to children with HVA, those without HVA were less likely to correctly identify the bee, bumblebee and hoverfly. In this group, the correct identification of the wasp was more common among children living in the countryside. The correct identification of the bee and bumblebee by children without HVA was more common among children living in the city. Conclusions: Some children with HVA and their parents cannot correctly identify stinging insects despite previous life-threatening allergic reactions. The ability to identify stinging insects may depend on the HVA diagnosis and place of residence.

Cow's milk and hen's egg anaphylaxis: A comprehensive data analysis from the European Anaphylaxis Registry.

BACKGROUND: Cow's milk (CM) and hen's egg (HE) are leading triggers of anaphylaxis in early childhood. The aim of this study was to identify clinical phenotypes and therapeutic measures for CM anaphylaxis (CMA) compared to HE anaphylaxis (HEA) in children up to 12 years of age, based on a large pan-European dataset from the European Anaphylaxis Registry. METHODS: Data from 2007 to 2020 on clinical phenotypes and treatment from 10 European countries, as well as Brazil, were analysed. The two-step cluster analysis was used to identify the most frequent phenotypes. For each trigger, three clusters were extracted based on sex, age, and existence of symptoms in four vitally important systems. RESULTS: Altogether 284 children with CMA and 200 children with HEA were identified. They were characterised as male (69% vs. 64%), infants (65% vs. 61%), with a most frequent grade III of Ring&Messmer classification (62% vs. 64%), in CMA versus HEA, respectively. Respiratory symptoms occurred more often in CMA (91% vs. 83%, p = 0.010), especially in infants (89% vs. 79%, p = 0.008). Cardiovascular symptoms were less frequent in CMA (30% vs. 44%, p = 0.002), in both infants (33% vs. 46%, p = 0.027), and older children (25% vs. 42%, p = 0.021). The clusters extracted in the CMA group were characterised as: (1) mild dermal infants with severe GI (40%), 2. severe dermal (35%), 3. respiratory (25%). While in HEA group: 1. infants with severe GI and/or reduction of alertness (40%), (2) conjunctival (16%), (3) mild GI without conjunctivitis (44%). The severity of the reaction was independent from the amount of ingested allergen protein, regardless of trigger. The first-line adrenaline application differed between the countries (0%-92%, as well as the reasons for not administering adrenaline, p < 0.001). CONCLUSIONS: Despite the similarity of their age, sex, and severity grade, the clinical profiles differed between the CMA and HEA children. Adrenaline was underused, and its administration was country dependent. Further studies are needed to assess to what extent the differences in the clinical profiles are related to matrix and/or absorption effects, and/or the allergen itself.

Food-Induced Anaphylaxis: Data From the European Anaphylaxis Registry.

BACKGROUND: Food is one of the most common elicitors of anaphylaxis, with an increasing incidence over recent years. OBJECTIVES: To characterize elicitor-specific phenotypes and identify factors enhancing the risk or severity of food-induced anaphylaxis (FIA). METHODS: We analyzed data from the European Anaphylaxis Registry applying an age- and sex-matched analysis of associations (Cramer's V) for single food triggers and calculated odds ratios (ORs) for severe FIA. RESULTS: We identified 3,427 cases of confirmed FIA showing an age-dependent elicitor ranking (for children: peanut, cow's milk, cashew, and hen's egg; and for adults: wheat flour, shellfish, hazelnut, and soy). The age- and sex-matched analysis revealed defined symptom patterns for wheat and cashew. Wheat-induced anaphylaxis was more frequently associated with cardiovascular symptoms (75.7%; Cramer's V = 0.28) and cashew-induced anaphylaxis with gastrointestinal symptoms (73.9%; Cramer's V = 0.20). Furthermore, concomitant atopic dermatitis was slightly associated with anaphylaxis to hen's egg (Cramer's V = 0.19) and exercise was strongly associated with anaphylaxis to wheat (Cramer's V = 0.56). Additional factors influencing the severity were alcohol intake in wheat anaphylaxis (OR = 3.23; CI, 1.31-8.83) and exercise in peanut anaphylaxis (OR = 1.78; CI, 1.09-2.95). CONCLUSIONS: Our data show that FIA is age-dependent. In adults, the range of elicitors inducing FIA is broader. For some elicitors, the severity of FIA seems to be related to the elicitor. These data require confirmation in future studies considering a clear differentiation between augmentation and risk factors in FIA.

Subjective Well-Being of Primary and Secondary School Students During the COVID-19 Pandemic: A Latent Profile Analysis.

This study employs a person-oriented approach to examine the heterogeneity of samples of primary school students (N = 2,333; 56.5% girls) and secondary school students (N = 2,329; 62.9% girls) in terms of levels of subjective well-being (SWB) in five domains: family, friends, school experience, body, and the local area. The study was conducted in Poland during the second wave of the COVID-19 pandemic. The latent profile analysis revealed five profiles among primary school students and six profiles among secondary school students. The profiles identified among primary school students had their counterparts among secondary school students and included "highly satisfied," "moderately satisfied," "highly dissatisfied," "satisfied with their family life and local area and dissatisfied with their friends," and "satisfied with their family life and friends and dissatisfied with their local area" profiles. In both samples, the profile with high levels of satisfaction in all domains was the most numerous. Moreover, in secondary school students, we identified the sixth profile, which was highly satisfied with their friends and dissatisfied in other domains. We also noted that gender, age, type of school and positive relationships with others predicted the latent profile membership. The results of this study indicate the need to utilize the person-oriented approach to gain insight into various patterns of children's SWB. Moreover, the study provides some practical recommendations for preparing tailored interventions aimed at improving children's SWB. Supplementary Information: The online version contains supplementary material available at 10.1007/s12187-022-09952-2.

The 2020 update on anaphylaxis in paediatric population.

The objective of the review is to present recent updates on anaphylaxis in paediatric population worldwide. The article summarizes the results of epidemiological studies, diagnostic methods and treatments. We present a new WAO definition of anaphylaxis (2019), which broader criteria excluding dermal symptoms should facilitate faster life-saving adrenaline use. Adrenaline remains the best treatment to manage severe symptoms and to prevent biphasic reactions. There is ongoing effort to increase adrenaline use, such as modified autoinjectors, individual training, and diversified dosing. There are five independent risk factors of lethal anaphylaxis in children, including history of asthma, almost immediate onset of symptoms, unwell appearance, tachycardia and hypotension. We also report improvements in diagnostics, like component-resolved diagnostics, and novel therapies stimulating immunotolerance. We signal the development of ICD-11 with updated coding of anaphylaxis, which corresponds better to clinical observations.

What makes life enjoyable at an older age? Experiential wellbeing, daily activities, and satisfaction with life in general.

OBJECTIVES: This study uses a broad range of activities to examine how the type of activity, its social context, associated stress, importance, and the level of effort required are linked with activity enjoyment. Using aggregated data from all activities, it analyses the association between the experiential wellbeing of individuals and their satisfaction with life in general. METHOD: The data set included 1809 activities, reported by 200 non-institutionalised adults, aged 65 and above, living in Poland. Activity data were collected using the experience sampling method. Multilevel mixed effects models examined what makes an activity enjoyable for older adults. Linear regression models examined the relationship between aggregated subjective activity characteristics and satisfaction with life in general. RESULTS: The most enjoyable activities were religious practice, childcare, and socialising. Enjoyment was positively associated with perceived activity importance, inversely associated with stress, and formed a U-shaped association with effort. On the aggregated level, a higher mean enjoyment predicted a higher satisfaction with life in general, whereas the opposite was the case for the mean importance. However, having greater variance in importance was associated with higher satisfaction with life. CONCLUSIONS: Enjoyable daily activities may boost the global wellbeing of older adults. Balancing high-effort and low-effort activities may provide additional benefits. This study points to new directions for research and shows that activities rarely studied in the existing literature have significant effects on the wellbeing of older adults.

BMI and dissatisfaction with life: contextual factors and socioemotional costs of obesity.

PURPOSE: In this study, we investigate whether individuals' BMI categories are associated with being dissatisfied with one's life, how this association is affected by the social comparison that individuals make, and what the role of the overall BMI levels in this process is. METHODS: We use data for 21,577 men and 27,415 women, collected in 2016 by the European Bank for Reconstruction and Development, from 34 countries in Europe, the Middle East, and Central Asia. To understand the moderating effect of contextual environment, we use multilevel mixed effect logistic regression models and data for national, regional, and cohort-specific BMI levels. RESULT: We find that the association of BMI and dissatisfaction with life differs by gender, with overweight men being less likely to be dissatisfied with life than men with normal weight and obese women being more likely to be dissatisfied with life compared to women with normal weight. For contextual effects, we find that obese women in regions with low BMI levels are more likely to be dissatisfied with life. The effect of obesity on female life dissatisfaction is not observed in regions with high BMI levels. As for men, regional BMI levels affect the levels of life dissatisfaction but only for underweight men. CONCLUSIONS: Our study adds additional nuance to the quality-of-life research by showing that the association between BMI and decreased life satisfaction is, at least partially, moderated by the contextual environment, and that the character of these effects differs by gender.

Is the clinical manifestation of anaphylaxis in children influenced by the trigger of reaction?

INTRODUCTION: The number of anaphylaxis diagnoses in children is rising, being still based on the clinical picture. AIM: To determine whether triggers of anaphylaxis influence its clinical characteristics in children and adolescents. MATERIAL AND METHODS: The study group included 114 children (5 months-17 years, mean age: 8.0 ±4.8 years), (66%: boys) with the episode of anaphylaxis up to 1 year back. Medical data were entered to the NORA Registry by means of a validated structured on-line questionnaire. RESULTS: Three most frequent triggers of anaphylaxis were: insect venom (47.4%), food (35.1%), drugs (5.3%), with a predominance of food (egg white, cow's milk, nuts and peanuts) in the 0-6 years age group, while insect venom (bee predominance) in the 7-17 years age group (p = 0.016). Clinical manifestations differed between food vs. venom allergic reactions and presented as gastro-intestinal (GI) (61.4%) (p = 0.004), respiratory (RS) (93.9%) (p = 0.036), and cardiovascular (CVS) (74.6%) (p = 0.022) symptoms. Among objective symptoms, vomiting was the most common symptom in the 0-2 years age group (47.1%) (p = 0.006), while hypotension in those aged 7-12 years (40%) (p = 0.010). Severity of symptoms evaluated as Mueller's grade (IV - 74.5%) and as Ring and Messmer's grade (III - 65.8%), depended on the trigger (p = 0.028, p = 0.029, respectively). Life-threatening symptoms occurred in 26 children (fall of the blood pressure - 22%, loss of consciousness - 4.4%). CONCLUSIONS: The clinical manifestation of anaphylaxis in children is both trigger and age dependent, irrespective of the gender. A typical patient with food anaphylaxis was younger, presenting predominantly GI symptoms, while a typical patient with venom anaphylaxis was older, with mostly cardiovascular symptoms.

Intervention in anaphylaxis: the experience of one paediatric centre based on NORA reports.

Introduction: Intramuscular adrenaline administration is the primary intervention in anaphylaxis. Aim: To analyse the data on intervention in children admitted due to anaphylaxis to the tertiary paediatric centre and compare them to the data from the Network for Online-Registration of Anaphylaxis. Material and methods: A validated structured on-line questionnaire was used to collect data concerning the first and second-line intervention in anaphylaxis. The study was conducted in cooperation with the European Anaphylaxis Registry. Results: The study group comprised 114 children (76 boys, 66.87%) aged 5 months-17 years with the predominance of moderate-to-severe anaphylaxis (grade III in Ring and Messmer's, and grade IV in Mueller's scale). In 103 (90.4%) children the first line of medical intervention was provided by medical staff. In the first-line intervention 39 (34.8%) children were given adrenaline. Five (4.4%) children were given the second dose of adrenaline and were admitted to the intensive care unit. In the second-line intervention adrenaline was given to 12 (15.6%) children. In one third it was at least the second reaction to the same trigger. Children treated with adrenaline were older (9.3 ±4.8 years), in comparison to those not treated (7.3 ±4.6 years, p = 0.034). Directly after the episode of anaphylaxis the children got the prescription for the adrenaline autoinjector in 35.1%, emergency training in 7.9%, and counselling on the avoidance of the anaphylaxis trigger in 30.7%. Grade III R&M reaction increased 3-fold the odds of AAI prescription (95% CI: 1.08-8.15). Conclusions: There is a strong need to continue education on proper management of anaphylaxis in children.

Current practices in diagnosis of Hymenoptera venom allergy in Poland.

Introduction: Hymenoptera venom allergy (HVA) is associated with a high risk of anaphylaxis. Effective treatment of HVA patients requires allergologists' familiarity with the latest HVA recommendations. Aim: Evaluation of current practices in HVA diagnosis in Poland. Material and methods: A survey questionnaire was conducted in 32 HVA centres in Poland. Results: The response rate was 97%. There were 1829 patients evaluated due to HVA in 2015. Sixty six percent (n = 21) of the centres used skin prick tests, out which 90% (n = 19) used 100 µg/ml of the venom extract as the highest concentration. All the centres performed intradermal tests (IDT) and serum specific IgE (sIgE), an initial diagnostic tool in 91% (n = 29). The highest venom concentration in IDT was 1 µg/ml in 75% (n = 24), 0.1 µg/ml in 16% (n = 5), 0.01 µg/ml in 3% (n = 1) and 10 µg/ml in 6% (n = 2). Baseline serum tryptase was assessed in 84% of the centres (n = 27), out of which 53% (n = 17) tested all their patients, whereas 31% (n = 10) checked only those with life-threatening reactions. In case of negative IDT/sIgE, 59% of the centres (n = 19) performed components evaluation, while 19% (n = 6) did the basophil activation test. In case of no identification of the culprit insect and sensitization to both venoms, VIT employed venom with higher sIgE. Conclusions: Most allergology centres in Poland follow HVA guidelines. We identified two inaccuracies in their HVA management including non-adequate venom concentration in IDT and a false belief in correspondence between sIgE concentration and severity of allergic reactions.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry.

BACKGROUND: Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. METHODS: Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. RESULTS: 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). CONCLUSIONS: The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Atopic Dermatitis - Current State of Research on Biological Treatment.

Atopic dermatitis (AD) is the most common atopic disease in young children and most common skin disease in childhood. In the Polish population, the incidence of AD in the group of children aged 6-14 is about 4% and it is underestimated. The disease is chronic and recurrent, and the leading symptom is skin pruritus that in the mechanism of the vicious circle is accompanied by scratching that causes generalized infections. The overall problems lead to a decrease in the quality of life of the child and its parents and to an increased risk of psychosomatic diseases. The complex pathomechanism of AD is due to chronic inflammation of the skin, in which various cell phenotypes are involved. The management is comprehensive and it is aimed at reducing inflammation, improving the skin barrier function, reducing the symptoms of dryness and itching of the skin and secondarily improving the quality of life. The treatment includes intensive skincare, anti-inflammatory treatment based on the proactive use of topical glucocorticosteroids and topical calcineurin inhibitors. Periods of exacerbation of lesions require intensified treatment. In particularly severe, recurrent cases, treatment options can be extended to systemic immunosuppressive drugs, with awareness of their adverse effects. Previous year has brought significant progress in the current treatment of AD in the form of biological treatment. Cytokines and other mediators that play an important role in the pathogenesis of skin inflammation have become a target for new forms of therapy. Drugs for which interleukin (IL)-4 and IL-13 are the targets are particularly represented. Dupilumab is the first biological drug approved for the general treatment of children aged >12 years with moderate to severe AD. Another therapeutic option for topical use is crisaborole, a phosphodiesterase-4 inhibitor. This study presents the current state of research on biological drugs in AD.

Risk Factors and Characteristics of Biphasic Anaphylaxis.

BACKGROUND: Anaphylaxis is an immediate hypersensitivity reaction. However, a biphasic course with the second onset of symptoms can occur hours after the initial phase. Little is known about the causes of biphasic anaphylaxis making the identification of patients at risk difficult. OBJECTIVE: To identify factors predisposing for biphasic anaphylaxis for the better understanding of these reactions. METHODS: Data from the Anaphylaxis Registry (from 11 countries) including 8736 patients with monophasic and 435 biphasic anaphylaxis were analyzed. RESULTS: The rate of biphasic reactions in this large cohort was 4.7%. The identified risk factors were reaction severity (grade III/IV vs grade II: odds ratio [OR] = 1.34; 95% confidence interval [CI]: 1.1-1.62); multiorgan involvement; skin, gastrointestinal, severe respiratory, and cardiac symptoms; anaphylaxis caused by peanut/tree nut (OR = 1.78; 95% CI: 1.38-2.23) or an unknown elicitor (OR = 1.96; 95% CI: 1.41-2.72); exercise as a cofactor (OR = 1.44; 95% CI: 1.17-1.78); chronic urticaria as a comorbidity (OR = 2.12; 95% CI: 1.19-3.78); a prolonged interval between the contact with the elicitor and start of primary symptoms (OR for >30 vs <30 min: 1.38; 95% CI: 1.08-1.76); and antihistamine treatment (OR = 1.52; 95% CI: 1.14-2.02). CONCLUSION: A biphasic course of anaphylaxis occurs more frequently in severely affected patients with multiorgan involvement. However, we identified multiple additional predictors, suggesting that the pathogenesis of biphasic reactions is more complex than being a rebound of a severe primary reaction.

How do perceived changes in inequality affect health?

Individuals do not possess an entirely accurate assessment of the level of income differences in their society and so changes in quantitative measures of income inequality may not always align with changes in the perceptions of income inequality. This disconnect is partly driven by how people form their opinions about the level of inequality. In this study we explore whether there is an association between perceptions of inequality and health, and if so, how it differs depending on the specific channel through which people formed their opinions about changes in income inequality. Drawing on data from 31 European and Eurasian countries, we find that both men and women are more likely to report bad health when their perceptions of increasing inequality are formed through experiences of inequality in their communities than through media and other channels.

Parental education, health literacy and children's adult body height.

Human anthropometric traits, while significantly determined by genetic factors, are also affected by an individual's early life environment. An adult's body height is a valid indicator of their living conditions in childhood. Parental education has been shown to be one of the key covariates of individuals' health and height, both in childhood and adulthood. Parental functional literacy has been demonstrated to be another important determinant of child health, but this has largely been overlooked in studies on height. The objective of this study was to analyse the associations between parents' education, their functional literacy and their children's adult body height. The study used data for 39,240 individuals from the 2016 wave of the nationally representative Life in Transition Survey (LITS) conducted in 34 countries in Southern and Eastern Europe, the Middle East and Central Asia. Using linear and Poisson models, regression adjustment treatment estimators and multilevel mixed-effects linear regressions, the study analysed the links between mother's and father's educational attainment, parental functional literacy, measured by the number of books in the childhood home, and children's adult height. The models also included other individual and contextual covariates of height. The results demonstrated that mother's educational attainment and parental functional literacy have independent associations with children's adult body height. Sufficient literacy skills of the parent may have a positive effect on children's growth even if parental education is low. These associations remained significant across time. The study also provides evidence of a widening of the height gap for men born in the period just before and after systemic transition in post-socialist societies, which may suggest an increase in social differences in early living standards.