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Coadministration of human secretory IgA (sIgA) together with subtherapeutic vancomycin enhanced survival in the Clostridioides difficile infection (CDI) hamster model. Vancomycin (5 or 10 mg/kg × 5 days) plus healthy donor plasma sIgA/monomeric IgA (TID × 21 days) or hyperimmune sIgA/monomeric IgA (BID × 13 days) enhanced survival. Survival was improved compared to vancomycin alone, P = .018 and .039 by log-rank Mantel-Cox, for healthy and hyperimmune sIgA, respectively. Passive immunization with sIgA (recombinant human secretory component plus IgA dimer/polymer from pooled human plasma) can be administered orally and prevents death in a partially treated CDI hamster model.

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BACKGROUND: Previous population-based analyses of emergency department (ED) visits for anaphylaxis have been limited to small populations in limited geographic areas and focused on children or have included patients who had allergic conditions other than anaphylaxis. OBJECTIVE: We sought to describe the epidemiology and risk factors among patients with anaphylaxis presenting to Florida EDs. METHODS: Two thousand seven hundred fifty-one patients with anaphylaxis were identified for 2005-2006 within ED records by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and a validated ICD-9-CM-based algorithm. Age- and sex-specific rates were calculated. Regression analyses were used to determine relative risks for anaphylaxis caused by various triggers (food, venom, and medication) and risk factors (age, sex, race, and ethnicity). RESULTS: The highest observed rates were among the youngest male subjects (8.2/100,000 Floridians aged 0-4 years) and among adult female subjects (15-54 years) grouped in 10-year age categories (9.9-10.9/100,000 Floridians). Male and black subjects were 20% and 25%, respectively, more likely to have a food trigger than female and white subjects. White, male, and older subjects were more likely to have an anaphylaxis-related ED visit caused by insect stings. Venom-induced anaphylaxis was more likely in August through October. Children were less likely than those older than 70 years (referent) to have medication-induced anaphylaxis (P < .03). CONCLUSION: This is the only ED-based population study in a US lower-latitude state. The overall rate is considerably lower than other US ED-based population studies. The rates of anaphylaxis by age group differed by sex. Male and black subjects were more likely to have a food trigger.

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Anaphylaxis incidence rates and time trends in the United States have been reported using different data sources and selection methods. Larger studies using diagnostic coding have inherent limitations in sensitivity and specificity. In contrast, smaller studies using chart reviews, including reports from single institutions, have better case characterization but suffer from reduced external validity due to their restricted nature. Increasing anaphylaxis hospitalization rates since the 1990s have been reported abroad. However, we report no significant overall increase in the United States. There have been several reports of increasing anaphylaxis rates in northern populations in the United States, especially in younger people, lending support to the suggestion that higher anaphylaxis rates occur at higher latitudes. We analyzed anaphylaxis hospitalization rates in comparably sized northern (New York) and southern (Florida) states and found significant time trend differences based on age. This suggests that the relationship of latitude to anaphylaxis incidence is complex.

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BACKGROUND: The assumption that the assessment of forced expiratory flow between 25% and 75% of vital capacity (FEF(25-75)) does not provide additional information in asthmatic children with normal FEV(1) percent predicted has not been adequately tested. OBJECTIVE: We sought to determine whether the measurement of FEF(25-75) percent predicted offers advantages over FEV(1) percent predicted and FEV(1)/forced vital capacity (FVC) percent predicted for the evaluation of childhood asthma. METHODS: This is a secondary analysis of data from the Pediatric Asthma Controller Trial and the Characterizing the Response to a Leukotriene Receptor Antagonist and Inhaled Corticosteroid trials. Pearson correlation coefficients, Pearson partial correlation coefficients, canonical correlations, and receiver operating characteristic (ROC) curves were constructed. RESULTS: Among 437 children with normal FEV(1) percent predicted, FEF(25-75) percent predicted, and FEV(1)/FVC percent predicted were (1) positively correlated with log(2) methacholine PC(20), (2) positively correlated with morning and evening peak expiratory flow percent predicted, and (3) negatively correlated with log(10) fraction of exhaled nitric oxide and bronchodilator responsiveness. Pearson partial correlations and canonical correlations indicated that FEF(25-75) percent predicted was better correlated with bronchodilator responsiveness and log(2) methacholine PC(20) than were FEV(1) percent predicted or FEV(1)/FVC percent predicted. In the ROC curve analysis, FEF(25-75) at 65% of predicted value had a 90% sensitivity and a 67% specificity for detecting a 20% increase in FEV(1) after albuterol inhalation. CONCLUSION: FEF(25-75) percent predicted was well correlated with bronchodilator responsiveness in asthmatic children with normal FEV(1). FEF(25-75) percent predicted should be evaluated in clinical studies of asthma in children and might be of use in predicting the presence of clinically relevant reversible airflow obstruction.

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BACKGROUND: Epidemiologic studies of anaphylaxis have been limited by significant underdiagnosis. OBJECTIVE: The purpose of this study was to develop and validate a method for capturing previously unidentified anaphylaxis cases by using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) based datasets. METHODS: Florida emergency department data for the years 2005 and 2006 from the Florida Agency for Health Care Administration were used. Patients with anaphylaxis were identified by using ICD-9-CM codes specifically indicating anaphylaxis or an ICD-9-CM algorithm based on the definition of anaphylaxis proposed at the 2005 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network symposium. Cases ascertained with the algorithm were compared with the traditional case-ascertainment method. Comparisons included demographic and clinical risk factors, proportion of monthly visits, and age/sex-specific rates. Cases ascertained with anaphylaxis ICD-9-CM codes were excluded from those ascertained with the algorithm. RESULTS: One thousand one hundred forty-nine patients were identified by using anaphylaxis ICD-9-CM codes, and 1,602 patients were identified with the algorithm. The clinical risk factors and demographics of cases were consistent between the 2 methods. However, the algorithm was more likely to identify older subjects (P < .0001), those with hypertension or heart disease (P < .0001), and subjects with venom-induced anaphylaxis (P < .0001). CONCLUSION: This study introduces and validates an ICD-9-CM-based diagnostic algorithm for the diagnosis of anaphylaxis to capture subjects missed by using the ICD-9-CM anaphylaxis codes. Fifty-eight percent of anaphylaxis cases would be missed without the use of the algorithm, including 88% of venom-induced cases.

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BACKGROUND: Patients with chronic kidney disease have been reported to have increased concentrations of blood tryptase. Detection of tryptase in the urine of healthy subjects has been reported. OBJECTIVE: The objective is to determine whether tryptase is indeed cleared by the kidneys. METHODS: Blood and urine collections were performed in healthy and systemic mastocytosis subjects. Total and mature tryptase concentrations in blood and total tryptase concentrations in urine were determined. RESULTS: Total tryptase levels in urine were below the limit of detection in both healthy subjects and those with systemic mastocytosis, even after concentrating the urine 10-fold. Thus, both mature and protryptase levels in urine are <0.2 ng/ml. CONCLUSION: Tryptase is not cleared by the kidneys into the urine.

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Transient wheezing in young children has been reported to be independent of atopy. Although persistence of early wheezing has been associated with factors related to allergy in multiple studies, transient wheezing has not been similarly studied. The Childhood Allergy Study birth cohort was the source of these data. Transient wheezing was defined as history of wheezing in the past 12 months at ages 1, 2, and/or 4 years, but not at 6 years, and evaluated in relationship to aeroallergen-specific circulating IgE and positive skin testing as markers of an atopic profile. Testing for IgE and skin-prick testing to dust mites, dogs, cats, ragweed, and timothy were performed at the age of 6 years. Other variables in logistic regression analyses were sex; breast-feeding; birth order; parental allergy and smoking history; and household pets, daycare, fever, and antibiotic use in the 1st year of life. Of 372 children, 128 (34.4%) experienced transient wheezing and 175 (47.0%) never wheezed. Atopy was not associated with transient wheezing (adjusted odds ratio for a positive allergen-specific IgE test = 1.2, p = 0.66; skin-prick test = 0.8, p = 0.47). Boys were more likely to be transient wheezers (adjusted relative risk [RR] = 1.7; 95% confidence interval [CI], 1.1-2.8; p = 0.018). Transient wheeze was associated with antibiotic treatment in the first 6 months of life (adjusted RR = 1.6; 95% CI, 1.0-2.6; p = 0.048). We confirm previous observations that transient wheezing in young children is not associated with an atopic predisposition.

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OBJECTIVE: To review the role of nitric oxide production in anaphylaxis. DATA SOURCES: We performed MEDLINE searches of the literature. In addition, some references known to the authors but not listed in MEDLINE, such as abstracts and a CD-ROM, were included. Finally, additional clinical details of the cases were provided by one of the authors. STUDY SELECTION: Primary reports were preferentially selected for inclusion. However, some secondary publications are also cited. RESULTS: Histamine along with other mediators, such as leukotrienes, tumor necrosis factor, and platelet-activating factor, induce the production of nitric oxide. Nitric oxide can inhibit the release and effects of catecholamines. Sympathetic amines may inhibit production of nitric oxide. Studies in animals have demonstrated the generation of nitric oxide during anaphylaxis. Inhibition of nitric oxide synthase improves survival in an animal model of anaphylaxis. Nitric oxide causes vasodilation indirectly by increasing the activation of guanylyl cyclase, which then causes smooth muscle relaxation by increasing the concentration of smooth muscle cyclic guanosine monophosphate. Methylene blue is an inhibitor of guanylyl cyclase, which increases systemic vascular resistance and reverses shock in animal studies. The previously reported successful treatment with methylene blue of 11 patients with anaphylactic hypotension is reviewed. CONCLUSION: Nitric oxide plays a significant role in the pathophysiology of anaphylaxis. Treatment with methylene blue should be considered in patients with anaphylactic hypotension that has not responded to other interventions.

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BACKGROUND: Previous epidemiologic studies of anaphylaxis have been single-institution investigations. The objective of this study was to determine the annual hospital discharge rate and risk factors for anaphylaxis outcomes throughout Florida. METHODS: 464 patients who were hospitalized in Florida for anaphylaxis and discharged in 2001 were identified using a statewide database and ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) codes. Linear regression was used to determine the predictors of length of stay (LOS) and total charges. Relative risks (RR) for ventilator-assisted respiration and anaphylaxis due to food were calculated using binomial regression. RESULTS: Annual hospital discharge rate for anaphylaxis was 2.8/100,000 population. Hospital mortality rate was 0.86%. Median LOS was 1 day. Median total charges was USD 4,982. Asthmatics had increased risk of receiving ventilator-assisted respiration (adjusted RR = 2.72, p = 0.04). Likelihood of hospitalization for anaphylaxis increased with age for both sexes (p < 0.0001). Patients who were <18 years old were three times as likely to be hospitalized for food anaphylaxis (versus other causes) compared to patients who were 71+ years old (adjusted RR = 3.25, p = 0.004). CONCLUSION: Young age was associated with increased risk of hospitalization for anaphylaxis to foods. Asthmatics had increased risk of receiving ventilator-assisted respiration. Likelihood of hospitalization increased with age.

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The objective of this study is to assess the FEF(25-75) and FEF(25-75)/FVC in relation to the FEV1 in patients who have had a methacholine inhalation challenge study for a variety of clinical indications. The study is a retrospective review of methacholine challenge results at the university medical center. One hundred twenty-one consecutive patients who had a methacholine challenge performed for clinical indications were included in the study with no intervention. Methacholine was administered in successively increasing twofold concentrations in doses from 0.62 mg to a final concentration of 10 mg. A 20% drop in FEV1 compared to the prechallenge value was considered a positive test. We considered > or = 25% decrease in FEF(25-75) as a significant change. The > or = 25% decrease in FEF(25-75) occurred sooner than the 20% drop in FEV1 with a positive response occurring at least one full dose sooner in 23 of the 55 subjects. Thirty two subjects reacted at the same dose. The dose at which the FEF(25-75) decreased by > or = 25% was significantly different from the corresponding dose causing a 20% decrease in FEV1. The FEF(25-75) decreases more per mg methacholine. There were no subjects in whom there was > or = 20% decrease in FEV1 without a > or = 25% decrease in FEF(25-75). The mean FEF(25-75)/FVC after diluent inhalation = 0.87 +/- 0.27 standard deviation with a range of 0.23 to 1.67. The doses at which the FEF(25-75)/FVC decreased by > or = 20% and by > or = 30% was significantly lower than the corresponding doses causing a 20% decrease in FEV1. FEF(25-75) and the FEF(25-75)/FVC are more sensitive but less specific than the FEV1 as indicators of a positive response to a methacholine challenge. The FEF(25-75)/FVC does not provide additional information to that provided by the FEF(25-75).

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Dystonia-associated features of anaphylaxis, including tongue swelling, and chest and throat tightness, have been rarely reported with selective serotonin reuptake inhibitor (SSRI) use. The patient is a 44-year-old woman who presented with palpitations, diaphoresis, dyspnea, swelling of the lips and tongue, and fixed upward deviation of her right eye following inadvertent ingestion of 20 mg of escitalopram in addition to her usual 10-mg dose. She reported transient resolution of all symptoms after autoinjector aqueous epinephrine administration (0.3 mg), with recurrence of symptoms after 35 min. The patient presented with one prior episode of anaphylactic symptoms and dystonia. She also reported one episode with purely anaphylactic features of swelling of lips and tongue, difficulty breathing and syncope. This case represents a unique dose-dependent episode of escitalopram-associated oculogyric dystonia with anaphylactic features. The transient resolution of the associated features of dystonia with intramuscular epinephrine administration is unique and suggests a common pathophysiology of the dystonic and anaphylactic symptoms.

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OBJECTIVE: To test the effects of written emotional disclosure on the health of adolescents with asthma and to examine how language in disclosures predicts outcomes. METHODS: We randomized 50 adolescents with asthma to write for 3 days at home about stressful events (disclosure) or control topics. At baseline and 2 months after writing, we assessed symptoms, affect, disability, internalizing behavior problems, and lung function; parents independently rated internalizing behavior and disability. RESULTS: Compared with control writing, disclosure writing led to improved positive affect and internalizing problems. Disclosure also decreased asthma symptoms and functional disability among adolescents with baseline elevations of these difficulties. Lung function was not changed. Disclosures with more negative emotion, insight, and causal words--and increased causal or insight words over days--predicted improved health. CONCLUSIONS: Written emotional disclosure improves emotional and behavioral functioning among adolescents with asthma, particularly those whose writings suggest emotional processing and cognitive restructuring.

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BACKGROUND: High osmolal ionic radiocontrast media (RCM) cause vascular release of endothelin-1 (ET-1) and activate mast cells. Iomeprol, a nonionic RCM, has recently been reported not to activate cardiac mast cells. This coronary angiography study was performed to extend those findings using another nonionic RCM, iopromide, and to further determine whether iopromide causes release of ET-1. METHODS: Pulmonary artery plasma ET-1, histamine and serum tryptase were determined before and 30 min following angiography with iopromide in 11 subjects. ET-1, histamine and tryptase were measured using immunoassays. RESULTS: The concentrations of ET-1 (1.36 +/- 0.66 pg/ml), histamine (2.63 +/- 1.15 nM), and beta (<1 microg/l) as well as total tryptase (8.25 +/- 4.63 microg/l) in the preangiography samples were within the normal range. Following angiography, the concentrations of ET-1 (0.95 +/- 0.80 pg/ml), histamine (3.08 +/- 1.06 nM), and beta (<1 microg/l) and total tryptase (7.00 +/- 5.56 microg/l) were not significantly different. None of the subjects demonstrated a postangiography increase in mediator concentration. CONCLUSIONS: This study demonstrates the lack of release of ET-1 by iopromide. The lack of cardiac mast cell activation by iopromide is consistent with the report that iomeprol also does not activate cardiac mast cells.

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Se presenta un paciente masculino de 67 años de edad con asma mixta (alérgica e intrínsica) que presentó un episodio de anafilaxia después de una inyección de antígeno durante la inmunoterapia. Previamente el paciente describió dolor en el abdomen quemante de su episodio a nafiláctica se refiere al hecho de que el dolor quemante en el epigástrico desapareció al mismo tiempo que los otros signos y síntomas de anafilaxia después del tratamiento con epinefrina. La histamina actuando a través de los receptores H2 de la mucosa gástrica provoca seccreción de pepsina y ácido síntomas del paciente. Si la dispepsia se presentaraen otros pacientes con anafilaxia, especialemtne en aquellos sin previo dolor dispético o enfemedad ulcerosa, sería posible incluir este síntoma en el síndrome de anafilaxia

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