Publications by authors named "Sofianne Gabrielli"

25 Publications

  • Page 1 of 1

Clinical Characteristics, Management, and Natural History of Chronic Inducible Urticaria in a Pediatric Cohort.

Int Arch Allergy Immunol 2021 Apr 1:1-8. Epub 2021 Apr 1.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, Québec, Canada.

Background: Some forms of chronic urticaria (CU) can be specifically attributed to a response to a definite trigger, referred to as chronic inducible urticaria (CIndU). We aimed to assess the demographics, clinical characteristics, comorbidities, natural history, and management of pediatric patients with CIndU.

Methods: Over a 6-year period, children presenting to the allergy clinic at the Montreal Children's Hospital (MCH) with CIndU were prospectively recruited. CU was defined as the presence of wheals and/or angioedema, occurring for at least 6 weeks. A standardized diagnostic test was used to establish the presence of a specific form of urticaria. Resolution was defined as the absence of hives for 1 year without treatment.

Results: Sixty-four patients presented with CIndU, of which 51.6% were male, with a median age of 12.5 (interquartile range 7.3, 15.9) years. Cold CU and cholinergic CU were the most common subtypes (60.3 and 41.3%, respectively). Basophil counts were undetectable in 48.4% of the cases, and C-reactive protein levels were elevated in 7.8% of patients. Of all cases, 71.4% were controlled with second-generation antihistamines. The resolution rate was of 45.3% (95% confidence interval 33.1-57.5%), based on per-protocol population within the 6-year course of the study. Resolution was more likely in patients who presented with well-controlled urticaria control test scores and elevated CD63 counts and in those suffering from thyroid comorbidity.

Conclusion: The natural history of CIndU resolution in pediatric patients was relatively low and was associated with elevated CD63 levels, as well as thyroid comorbidity.
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http://dx.doi.org/10.1159/000514757DOI Listing
April 2021

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

J Allergy Clin Immunol Pract 2021 Mar 13. Epub 2021 Mar 13.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.
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http://dx.doi.org/10.1016/j.jaip.2021.02.055DOI Listing
March 2021

Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis.

J Allergy Clin Immunol Pract 2021 Feb 4. Epub 2021 Feb 4.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.

Background: Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines.

Objectives: A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis.

Methods: Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis.

Results: Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine.

Conclusion: The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.
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http://dx.doi.org/10.1016/j.jaip.2021.01.038DOI Listing
February 2021

Specific IgE antibody levels during and after food-induced anaphylaxis.

Clin Exp Allergy 2021 Feb 9;51(2):364-368. Epub 2020 Dec 9.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/cea.13796DOI Listing
February 2021

Management and diagnosis of exercise-associated anaphylaxis cases in the paediatric population.

Clin Exp Allergy 2021 Jan 28;51(1):148-150. Epub 2020 Oct 28.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/cea.13763DOI Listing
January 2021

Risk of peanut- and tree-nut-induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children.

CMAJ 2020 Sep;192(38):E1084-E1092

Division of Allergy and Clinical Immunology (Leung, Gabrielli, Ben-Shoshan), Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que.; Division of Rheumatology (Clarke, Shand), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Morris), Hôpital Sacré-Coeur; Division of Pediatric Emergency Medicine (Gravel), Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Division of Pediatric Emergency Medicine (Lim), Department of Pediatrics, Children's Hospital at London Health Sciences Centre, London, Ont.; Divisions of Allergy and Immunology (Chan) and Emergency Medicine (Goldman, Enarson), Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC; Department of Pediatrics (O'Keefe), Faculty of Medicine, Memorial University, St. John's, NL; Food Allergy Canada (Gerdts), Toronto, Ont.; Division of Clinical Immunology & Allergy (Chu), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Chu), McMaster University, Hamilton, Ont.; Division of Immunology and Allergy (Upton), Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Centre for Outcomes Research and Evaluation (Zhang), Research Institute of McGill University Health Centre, Montréal, Que.

Background: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children.

Methods: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression.

Results: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children.

Interpretation: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.
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http://dx.doi.org/10.1503/cmaj.200034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532006PMC
September 2020

Beyond Skin Tumors: A Systematic Review of Mohs Micrographic Surgery in the Treatment of Deep Cutaneous Fungal Infections.

Dermatol Surg 2021 01;47(1):94-97

Penn Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Deep cutaneous fungal infections (DCFIs) can cause significant morbidity in immunocompromised patients and often fail medical and standard surgical treatments because of significant subclinical extension. Although rarely considered in this setting, Mohs micrographic surgery (MMS) offers the advantages of comprehensive margin control and tissue conservation, which may be beneficial in the treatment of DCFIs that have failed standard treatment options.

Objective: To review the benefits, limitations, and practicality of MMS in patients with DCFIs.

Methods: A systematic review of PubMed and EMBASE was conducted to identify all cases of fungal skin lesions treated with MMS.

Results: Eight case reports were identified consisting of a total of 8 patients. A majority of patients had a predisposing comorbidity (75%), with the most common being a solid organ transplant (n = 3, 37.5%). The most commonly diagnosed fungal infection was phaeohyphomycosis (n = 5, 62.5%), followed by mucormycosis (n = 2, 25%). No recurrence or complication post-MMS was noted at a mean follow-up of 11.66 months.

Conclusion: Although not a first-line treatment, MMS can be considered as an effective treatment alternative for DCFIs in cases of treatment failure and can be particularly helpful in areas where tissue conservation is imperative.
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http://dx.doi.org/10.1097/DSS.0000000000002761DOI Listing
January 2021

Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge.

J Allergy Clin Immunol Pract 2021 Feb 6;9(2):916-921. Epub 2020 Sep 6.

Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Serum sickness-like reactions (SSLRs) are defined by the presence of rash (primarily urticaria) and joint complaints (arthralgia/arthritis) that are believed to occur due to a non-IgE-mediated response to medications. However, similar reactions can occur due to viral infections, and it can be difficult to distinguish between the two. This may lead to unnecessary avoidance of the culprit antibiotic.

Objective: We aimed to evaluate children presenting with suspected SSLRs through a graded oral challenge (GOC).

Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy (β-lactam or other antibiotics) and a clinical presentation compatible with SSLR were recruited for the study between March 2013 and February 2020. A standardized survey with questions on treatment, symptoms, and associated factors was completed, and a GOC (10% and subsequently 90% of the oral antibiotic dose) was conducted. Patients with a negative GOC were contacted annually to query on subsequent antibiotic use.

Results: Among 75 patients presenting with suspected SSLRs, the median age was 2.0 years and 46.7% were males. Most reactions were attributed to amoxicillin. Among the 75 patients, 2.7% reacted immediately (within 1 hour) to a GOC and 4.0% had a nonimmediate reaction. Of the 43 patients successfully contacted, 20 reported subsequent culprit antibiotic use of whom 25.0% had a subsequent mild reaction (macular/papular rash).

Conclusions: This is the first and largest pediatric study to assess SSLR using a GOC. Our findings suggest that using a GOC is safe and appropriate for differentiating between β-lactam-induced SSLR and viral exanthem in this population.
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http://dx.doi.org/10.1016/j.jaip.2020.08.047DOI Listing
February 2021

Reply to "Comment on: 'Children with chronic urticaria can be effectively controlled with updosing second-generation antihistamines'".

J Am Acad Dermatol 2020 11 1;83(5):e365-e366. Epub 2020 Jul 1.

Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaad.2020.06.997DOI Listing
November 2020

COVID-19 and comorbidities: a systematic review and meta-analysis.

Postgrad Med 2020 Nov 14;132(8):749-755. Epub 2020 Jul 14.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre , Montreal, Quebec, Canada.

SARS-CoV-2 has caused a worldwide pandemic that began with an outbreak of pneumonia cases in the Hubei province of China. Knowledge of those most at risk is integral for treatment, guideline implementation, and resource allocation. We conducted a systematic review and meta-analysis to evaluate comorbidities associated with severe and fatal cases of COVID-19. A search was conducted on PubMed and EmBase on 20 April 2020. Pooled estimates were collected using a random-effects model. Thirty-three studies were included in the systematic review and twenty-two in the meta-analysis. Of the total cases 40.80% (95%CI: 35.49%, 46.11%) had comorbidities, while fatal cases had 74.37% (95%CI: 55.78%, 86.97%). Hypertension was more prevalent in severe [47.65% (95%CI: 35.04%, 60.26%)] and fatal [47.90% (95%CI: 40.33%, 55.48%)] cases compared to total cases [14.34% (95%CI: 6.60%, 28.42%)]. Diabetes was more prevalent among fatal cases [24.89% (95%CI: 18.80%, 32.16%)] compared to total cases [9.65% (95%CI: 6.83%, 13.48%)]. Respiratory diseases had a higher prevalence in fatal cases [10.89% (95%CI: 7.57%, 15.43%)] in comparison to total cases [3.65% (95%CI: 2.16%, 6.1%)]. Studies assessing the mechanisms accounting for the associations between severe cases and hypertension, diabetes, and respiratory diseases are crucial in understanding this new disease, managing patients at risk, and developing policies and guidelines that will reduce future risk of severe COVID-19 disease.
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http://dx.doi.org/10.1080/00325481.2020.1786964DOI Listing
November 2020

Anaphylaxis as a presenting symptom of food allergy in children with no known food allergy.

J Allergy Clin Immunol Pract 2020 09 26;8(8):2811-2813.e2. Epub 2020 Apr 26.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.04.033DOI Listing
September 2020

Reply to: "Comment on 'Efficacies and merits of the cotton swab technique for diagnosing tinea capitis in the pediatric population'".

J Am Acad Dermatol 2020 09 13;83(3):e195-e196. Epub 2020 Apr 13.

Division of Allergy, Immunology and Dermatology, McGill University, Montreal, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.04.029DOI Listing
September 2020

Rates of anaphylaxis for the most common food allergies.

J Allergy Clin Immunol Pract 2020 Jul - Aug;8(7):2402-2405.e3. Epub 2020 Mar 31.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.03.014DOI Listing
March 2020

Diagnosis of Ibuprofen allergy through oral challenge.

Clin Exp Allergy 2020 05 3;50(5):636-639. Epub 2020 Apr 3.

Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1111/cea.13596DOI Listing
May 2020

Chronic urticaria in children can be controlled effectively with updosing second-generation antihistamines.

J Am Acad Dermatol 2020 Jun 21;82(6):1535-1537. Epub 2020 Feb 21.

Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaad.2020.02.041DOI Listing
June 2020

Efficacies and merits of the cotton swab technique for diagnosing tinea capitis in the pediatric population.

J Am Acad Dermatol 2020 Sep 12;83(3):920-922. Epub 2020 Jan 12.

Division of Allergy, Immunology and Dermatology, McGill University, Montreal, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.01.009DOI Listing
September 2020

Anaphylaxis to goat/sheep's milk in a 4-year-old boy tolerant to cow's milk.

BMJ Case Rep 2020 Jan 8;13(1). Epub 2020 Jan 8.

Department of Pediatrics, Division of Allergy, Immunology and Dermatology, Montreal Children's Hospital, Montreal, Québec, Canada.

Immune-mediated reactions to dairy products may vary depending on the mammalian source. We present a case of anaphylaxis to goat/sheep's milk with tolerance to cow's milk. A 4-year-old boy of Eastern European descent presented with gastrointestinal and respiratory symptoms within minutes after eating a goat/sheep's milk-derived food product. The tryptase level measured 1 hour post initial symptoms and 1 month after the allergic reaction were 14.6 µg/L and 5.1 µg/L, respectively (norm: 0.0-13.5 µg/L), confirming the diagnosis of anaphylaxis. A skin prick test performed 1 month after the reaction was highly positive for goat/sheep's milk, but negative for cow's milk. Skin prick tests may establish a life-threatening goat/sheep's milk allergy. Goat/sheep's milk allergy should always be considered in cow's milk-tolerant patients who present with an allergic reaction to dairy products, or when undergoing/have completed of oral immunotherapy for cow's milk allergy.
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http://dx.doi.org/10.1136/bcr-2019-232844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954805PMC
January 2020

Management Strategies Of Idiopathic Anaphylaxis In The Emergency Room: Current Perspectives.

Open Access Emerg Med 2019 1;11:249-263. Epub 2019 Nov 1.

Division of Allergy, Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.

Background: Idiopathic anaphylaxis (IA) is a diagnosis of exclusion and represents a major diagnostic and management challenge. There are no current guidelines for diagnosis and management of IA. We aim to present a systematic review of the literature on adult and pediatric IA.

Methods: We conducted a systematic review of original articles published in the past 22 years regarding diagnosis and management strategies of adult and pediatric IA.

Results: The current proposed diagnostic approach and treatment regimens are based on a few small studies. Future large-scale studies are required. IA is a diagnosis of exclusion and should be made only after extensive evaluation excludes potential anaphylaxis triggers as well as non-allergic conditions with a similar presentation. There is currently no diagnostic consensus for IA. Furthermore, the current proposed treatment regimens are limited and rely on prophylactic treatment with antihistamines and prednisone for patients with frequent episodes. However, daily treatment with systemic steroids has well-recognized serious adverse effects. More recently, the use of biologics was suggested to benefit patients with IA, although the optimal management protocol is not yet established.

Conclusion: Future studies are needed to optimize diagnosis and treatment strategies in adult and pediatric cases of IA. Omalizumab may be a promising novel therapeutic option for adult and pediatric IA.
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http://dx.doi.org/10.2147/OAEM.S200342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830385PMC
November 2019

When and how pediatric anaphylaxis cases reach the emergency department: Findings from the Cross-Canada Anaphylaxis Registry.

J Allergy Clin Immunol Pract 2020 04 31;8(4):1406-1409.e2. Epub 2019 Oct 31.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2019.10.009DOI Listing
April 2020

Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort.

J Allergy Clin Immunol Pract 2019 Sep - Oct;7(7):2232-2238.e3. Epub 2019 Apr 26.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Background: Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect.

Objective: To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED).

Methods: The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis.

Results: A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age.

Conclusions: Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.
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http://dx.doi.org/10.1016/j.jaip.2019.04.018DOI Listing
September 2020

Emergency Management of Anaphylaxis Due to an Unknown Trigger: An 8-Year Follow-Up Study in Canada.

J Allergy Clin Immunol Pract 2019 04 23;7(4):1166-1173.e1. Epub 2018 Nov 23.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Anaphylaxis due to unknown trigger (AUT) is anaphylaxis not explained by a proved or presumptive cause or stimulus at the time of the reaction. Research describing the management and follow-up of AUT is limited.

Objective: To assess and compare the demographic and clinical characteristics and the management of adult and pediatric AUT cases across Canada.

Methods: Participants were identified between 2011 and 2018 in emergency departments at 8 centers across Canada as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting the reaction and management in children and adults was completed. Patients were contacted for follow-up to determine assessment by an allergist.

Results: A total of 295 AUT cases (7.5%) were recruited among 3,922 cases of anaphylaxis. In the prehospital setting, children (adjusted odds ratio [aOR], 1.20; 95% CI, 1.05-1.37) and those with a known food allergy (aOR, 1.14; 95% CI, 1.02-1.28) were more likely to receive treatment with epinephrine. Children were also more likely to be assessed by an allergist after their reaction (aOR, 1.43; 95% CI, 1.13-1.81) and were more likely to have an identified trigger for their reaction (aOR, 1.35; 95% CI, 1.07-1.70). Among patients contacted for follow-up, food was identified as the cause of reaction in 11 of 76 patients. A new food allergy was diagnosed in 4 patients (2 children and 2 adults).

Conclusions: Our findings highlight important differences between management and follow-up of adult and pediatric AUT cases. It is crucial to follow up all cases of AUT and establish appropriate treatment and management guidelines.
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http://dx.doi.org/10.1016/j.jaip.2018.11.015DOI Listing
April 2019

Teenagers and those with severe reactions are more likely to use their epinephrine autoinjector in cases of anaphylaxis in Canada.

J Allergy Clin Immunol Pract 2019 03 28;7(3):1073-1075.e3. Epub 2018 Aug 28.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaip.2018.07.044DOI Listing
March 2019

Short- and long-term management of cases of venom-induced anaphylaxis is suboptimal.

Ann Allergy Asthma Immunol 2018 08 12;121(2):229-234.e1. Epub 2018 Apr 12.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Background: Venom-induced anaphylaxis (VIA) accounts for severe reactions. However, little is known about the short- and long-term management of VIA patients.

Objective: To assess the short- and long-term management of VIA.

Methods: Using a national anaphylaxis registry (C-CARE), we identified VIA cases presenting to emergency departments in Montreal and to emergency medical services (EMSs) in western Quebec over a 4-year period. Data were collected on clinical characteristics, triggers, and management. Consenting patients were contacted annually regarding long-term management. Univariate and multivariate logistic regressions were used to identify factors associated with epinephrine use, allergist assessment, and administration of immunotherapy.

Results: Between June 2013 and May 2017, 115 VIA cases were identified. Epinephrine was administered to 63.5% (95% confidence interval [CI], 53.9%-72.1%) of all VIA cases by a health care professional. Treatment of reactions without epinephrine was more likely in reactions occurring at home and in nonsevere cases (no hypotension, hypoxia, or loss of consciousness). Among 48 patients who responded to a follow-up questionnaire, 95.8% (95% CI, 84.6%-99.3%) were prescribed epinephrine auto-injector, 68.8% (95% CI, 53.6%-80.9%) saw an allergist who confirmed the allergy in 63.6% of cases, and 81.0% of those with positive testing were administered immunotherapy. Among cases with follow-up, seeing an allergist was less likely in patients with known ischemic heart disease.

Conclusion: Almost 30% of patients with suspected VIA did not see an allergist, only two thirds of those seeing an allergist had allergy confirmation, and almost one fifth of those with confirmed allergy did not receive immunotherapy. Educational programs are needed to bridge this knowledge-to-action gap.
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http://dx.doi.org/10.1016/j.anai.2018.04.006DOI Listing
August 2018

Prevalence of Hypersensitivity Reactions in Children Associated with Acetaminophen: A Systematic Review and Meta-Analysis.

Int Arch Allergy Immunol 2018 3;176(2):106-114. Epub 2018 Apr 3.

Background: Acetaminophen is the most commonly used antipyretic in children. However, there are limited data assessing hypersensitivity reactions related to acetaminophen usage.

Objectives: To conduct a systematic review to characterize reported reactions to acetaminophen in adults and children, and perform a meta-analysis to assess the prevalence of acetaminophen hypersensitivity in children with a suspected acetaminophen allergy.

Methods: We performed a systematic review of studies reporting hypersensitivity reactions to acetaminophen by searching 2 electronic databases. From the selected studies, we included those assessing the prevalence of acetaminophen hypersensitivity by performing oral challenge in our meta-analysis.

Results: Eighty-five studies were included in the systematic review, assessing a total of 1,030 participants. Immediate (within 1 h of exposure) hypersensitivity reactions were reported in > 25% of the articles, while cutaneous nonimmediate reactions were similarly reported in about 25% of the articles. The remaining articles reported Steven-Johnson syndrome/toxic epidermal necrolysis, fixed drug eruptions, and cross-intolerance reactions. Five pediatric studies were included in our meta-analysis. The prevalence of acetaminophen hypersensitivity reaction among children undergoing oral challenge was 10.1% (95% confidence interval 4.5-15.5).

Conclusion: Future studies assessing the risk of immediate and nonimmediate hypersensitivity reactions to acetaminophen and elucidating the mechanism of acetaminophen hypersensitivity reactions are required.
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http://dx.doi.org/10.1159/000487556DOI Listing
June 2018

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada.

Immun Inflamm Dis 2018 03 1;6(1):3-12. Epub 2017 Nov 1.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Introduction: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

Objective: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada.

Methods: Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests.

Results: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases.

Conclusions: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.
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http://dx.doi.org/10.1002/iid3.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818453PMC
March 2018