BACKGROUND:Anaphylaxis is a life-threatening emergency of which reliable epidemiological data are lacking. This study aimed to analyze how quickly patients presenting with anaphylaxis were treated in emergency and whether treatment followed the European Academy of Allergy and Clinical Immunology (EAACI) guidelines.METHODS:Patient data were collected between April 2009 and April 2013. Emergency doctors completed a questionnaire for adult patients presenting at the emergency department (ED) of the St. Pierre hospital in Brussels with anaphylaxis. Inclusion criteria were based on the Sampson criteria of anaphylaxis. Data were analyzed using a Microsoft Excel database.RESULTS:About 0.04% (100/230878) of all emergency visits in adults presented with anaphylaxis. 64% of patients received their first medical help later than 30 min after symptom onset. 67% of patients received adrenaline, 85% oral antihistamines, and 89% received IV glucocorticosteroids. 46/100 patients were discharged directly from the ED, of which 87% received further medical prescriptions for self-administration: 67% corticosteroids, 83% antihistamines, and 9% intramuscular adrenaline. 74% were instructed to consult an allergologist for adequate diagnosis. 54/100 patients were hospitalized.CONCLUSION:The majority of patients were treated according to the EAACI guidelines for management of anaphylaxis, but only a minority received the recommended adrenaline auto-injector for self-administration at discharge. Because the majority of patients received medical help later than 30 min after symptom onset, adrenaline auto-injector prescription is a necessity. The low rate of doctors prescribing adrenaline auto-injectors in the ED setting underlines the need to train doctors of various backgrounds in prevention and treatment of anaphylaxis and the close collaboration with allergologists.

Objectives: Anaphylaxis is an emergency condition of which reliable epidemiological data are lacking. This study focusses on epidemiology and aetiology of anaphylactic reactions in an urban Belgian emergency department (ED). Methods: Patient data were collected from 04/2009 to 04/2013.During this period, emergency doctors completed a questionnaire for adult patients (>15 years) with anaphylaxis presenting at the ED. Inclusion criteria were based on the Sampson criteria of anaphylaxis. Data were analysed using a Microsoft Excel database. Results: Anaphylaxis accounted for 0.04% of all emergency visits in this 4-year period. In both women and men, dyspnoea and urticaria were noted most frequently. 51.7% of cases were possibly elicited by foods, 46.1% by drugs and 3.4% by hymenoptera stings. Women more often reported allergic diseases in their personal history. 55.7% of patients, who had a history of allergy, reported a suspected food-related allergy, 24.6% a drug-related allergy and 8.2% a hymenoptera venom-related allergy. In 76.5% of patients who reported a history of food allergy, food was the presumed elicitor of anaphylaxis. For patients with history of drug allergy, 88.2% had a presumed drug anaphylaxis at the time of presentation at the ED. 81% of cases presented with grade 4 or 5 anaphylaxis. With increasing age, the severity of anaphylaxis increased. Higher tryptase levels correlated with a higher grade of anaphylaxis. Conclusion: In this Belgian urban population, foods and drugs were by far the most common suspected elicitors of anaphylaxis. Personal history of allergic diseases was present in more than half of the cases.

La première enquête menée par le réseau d’allergovigilance concerne les réactions anaphylactiques sévères, survenue pendant un mois (avril ou mai 2001). Les 100 premières réponses ont été analysées et correspondent à 74 allergologues généralistes, 15 pédiatres, huit pneumologues et trois dermatologues. Cent soixante-trois réactions sévères ont été recensées : œdème laryngé (51,5 %), choc anaphylactique (39,9 %), asthme aigu (8,6 %). Ces réactions surviennent chez des enfants de moins de 15 ans dans 46,6 % des cas et chez des adultes dans 53,4 % des cas. Les allergènes les plus fréquents sont : l’arachide et les noix diverses (27,6 %), les aliments croisant avec le latex (11 %), les œufs (8,6 %), le poisson (6,7 %), les crustacés (5,5 %), le lait (4,3 %), le sésame (4,3 %), le blé (3,6 %), les légumineuses (3,6 %), les coquillages (3 %), la moutarde (1,8 %), le céleri (1,8 %), les additifs (carmin de cochenille, alpha-amylase et sulfites : 1,8 %). La fréquence des réactions sévères en France peut être évaluée entre 15 000 et 30 000 par an. L’asthme aigu grave est rarement rapporté, principalement par les allergologues pneumologues : sa fréquence est probablement sous-estimée. Le rôle prépondérant des fruits à coque dans la genèse des réactions graves est confirmé. Cette enquête souligne la fréquence des réactions allergiques aux fruits croisant avec le latex et au sésame. La fréquence des allergènes incriminés peut varier avec la saison. C’est pourquoi la même enquête sera reconduite en janvier 2002.The first questionnaire of the ‘Allergy Vigilance Network’ concerns severe anaphylactic reactions that occurred during 1 month (April or May 2001). The first results obtained from 100 members of the Network (74 allergologists-GPs, 15 pediatricians-allergologists, eight lung specialists-allergologists and three dermatologists-allergologists) were collected. The analysis of these 100 answers reveals the occurrence of 163 severe reactions: laryngeal angioedema (51.5%), anaphylactic shock (39.9%), acute asthma (8.6%). These reactions concern 46.6% children under 15 years of age and 53.4% adults. The most frequent allergens are peanuts and nuts (27.6%), food cross-reacting with latex (11%), egg (8.6%), fish (6.7%), crustaceans (5.5%), milk (4.3%), sesame (4.3%), wheat (3.6%), legumes (3.6%), shellfish (3%), mustard (1.8%), celery (1.8%), and additives (carmine, alpha-amylase and sulfites: 1.8%). Severe reactions in France could be estimated between 15,000 and 30,000 per year. Acute asthma is less commonly reported, mainly by lung specialists, and is probably underestimated. The ability of nuts to induce severe allergic reactions is confirmed. This survey underlines the increased frequency of severe reactions to food cross-reacting with latex and to sesame. The frequency of food allergens could be influenced by the season; this enquiry will be renewed in January 2002.

Le but du travail a consiste a quantifier la valeur pronostique de parametres cardiaques obtenus a partir de l'electrocardiogramme, de la scintigraphie myocardique et de la fraction d'ejection ventriculaire gauche et droite chez des patients atteints d'une bronchopneumopathie chronique obstructive severe. Ces parametres ont ete compares a des facteurs pronostiques classiques, a savoir le volume expire maximum en une seconde (VEM1sec), la pression arterielle pulmonaire moyenne (PAPm), la PO 2 et la saturation (SO 2 ) du sang arteriel et veineux mele. Les donnees cliniques de 117 patients BPCO severes ont ete revues. Aucun parmi eux ne souffrait d'angine de poitrine, d'hypertension arterielle ou de valvulopathie. Les resultats montrent que la frequence des anomalies des parametres cardiaques est importante. Dans plus de 40 % des cas, une chute importante de la fraction d'ejection ventriculaire droite et une fixation anormale du thallium-201 sont observees. Une reduction de la fraction d'ejection du ventricule gauche est souvent constatee (26 % des cas). A l'ECG, une hypertrophie ventriculaire ou auriculaire droite sont trouvees respectivement dan 18 et 21 % des cas. Toutefois, aucun de ces parametres cardiaques ne permet de predire le pronostic de maniere significative. Ceci contraste avec la valeur pronostique tres importante du VEMs, de la PaO 2 , SaO 2 , PvO 2 , SvO 2 et de la PAPm.

Considering that in Brussels the first-aid ambulance team reaches the patient in cardiac arrest 10 min before the physician-manned ambulance, we instituted a feasibility study of early defibrillation by emergency medical technicians (EMTs). Three hundred EMTs received a 20-h automatic external defibrillation (AED) training course followed by a refresher course every 6 months. Of 316 cardiac arrests included in this study, asystole was encountered in 53% and ventricular fibrillation/ventricular tachycardia (VF/VT) in 33% of the cases on arrival of the EMTs. In the VF/VT group, defibrillation was performed by EMTs with a Laerdal Heartstart 7-9 min before the medical team arrived. The overall cardiac arrest survival rate improved from 7% in 1989 to 19% in 1992. However, the long-term survival rate (14/105) of ventricular fibrillation remained low because of excessive delays in emergency medical service (EMS) access and in early ACLS. In conclusion, this work shows that in Brussels: (1) early defibrillation of cardiac arrest victims in VF is feasible by EMTs when a training and a follow-up program are implemented; (2) the weakest link of the chain of survival is the early EMS access, and the early ACLS; and (3) AED program increases the interest and the efficacy of EMTs and medical teams in the management of cardiac arrests.

To evaluate how nifedipine influences systolic and diastolic ventricular function, the effects of 20 mg sublingual nifedipine were studied in 13 stable COPD patients. Nifedipine induced no change in mean pulmonary arterial pressure, decreased mean arterial pressure, pulmonary and systemic vascular resistance index, and increased heart rate and cardiac index. It also caused an increase in right and left ventricular ejection fractions. The end-diastolic volume index of both ventricles remained unchanged, whereas the end-systolic volume index tended to decrease without reaching a significant level, and the right ventricular contractility increased. After nifedipine administration, right and left ventricular compliance increased. This study suggests that short-term administration of nifedipine improves the systolic function by a decrease in ventricular afterload and an increase in ventricular contractility and increases the ventricular compliance by a reflex sympathetic stimulation and an afterload reduction.

The effects of aminophylline on pulmonary vascular tone, systemic hemodynamics, and ventricular ejection fractions reported in the literature show some discrepancies. We therefore studied in COPD patients the effects of aminophylline on hemodynamics, on ventricular ejection fractions, and on systolic and diastolic functions of each ventricle, and we measured simultaneously the blood level of the drug. The analysis of the data revealed a relationship between the blood level of aminophylline and the variations of right ventricular ejection fraction (RVEF) (r = 0.83, p = 0.005), left ventricular ejection fraction (LVEF) (r = 0.76, p = 0.017), pulmonary vascular resistance index (PVRI) (r = -0.58, p = 0.096), systemic vascular resistance index (SVRI) (r = -0.60, p = 0.08), and right ventricular peak systolic pressure/end-systolic volume index (RVPSP/ESVI) (r = -0.75, p = 0.02). Modifications of ejection fractions and vascular resistance indices were correlated for both ventricles (RVEF vs PVRI, r = -0.77, p = 0.01; LVEF vs SVRI, r = -0.76, p = 0.02). Finally, RVEF modifications was also correlated to RVPSP/ESVI variation (r = 0.78, p = 0.01). These results suggest that even within the therapeutic range (10 to 20 mg/L), the effects of aminophylline seemed to depend on its blood level. This dose dependency could explain the contradictory data reported in the literature concerning the effects of aminophylline on pulmonary and systemic hemodynamics and on ventricular function.

Right ventricular (RV) adaptation to supine exercise has been studied in 10 young male volunteers by 81mKr electrocardiogram (ECG)-gated radionuclide ventriculography. During progressive supine exercise, the ejection fraction gradually increased from a mean value of 46% at rest up to 60% at a maximal exercise level. End-diastolic volume however remained unchanged at a low exercise level and even slightly decreased at a higher exercise level. Little or no change in end-diastolic volume and an increase in ejection fraction produced a significant decrease in end-systolic volume and a net increase in stroke volume. These results indicate that the Frank-Starling mechanism does not contribute to the increase in right ventricular stroke volume during progressive supine exercise, but the increase in right ventricular stroke volume rather seems related to an increased contractility, presumably mediated by an increased sympathetic activity.

Pulmonary arterial hypertension represents an important parameter for the assessment of the severity of chronic bronchitis. The measurement of the pulmonary arterial pressure, however, requires invasive techniques of limited routine use because of costs and associated risks. The aim of this study is to evaluate whether the 81mKr right ventricular ejection fraction and parameters derived from equilibrium 99mTc red blood cells' right ventricular curve allow a better estimation of PAP than the 99mTc RVEF. In 41 patients with severe chronic bronchitis, the linear correlation between PAP and 99mTc RVEF was -0.61 (p less than 0.001). None of the parameters derived from the right ventricular curve was better correlated to PAP than the 99mTc RVEF. In 16 other chronic bronchitis patients, the 81mKr RVEF correlated moderately to PAP. In conclusion, the alternative isotopic methods proposed in this work do not provide a reliable estimation of pulmonary arterial pressure in patients with chronic bronchitis.

To evaluate the influence of beta 2 mimetics on ventricular contractility and pump function, radionuclide ventriculography and right heart catheterization were simultaneously performed in 10 patients with severe chronic obstructive pulmonary disease. After a 60 min constant infusion of 17 micrograms/min salbutamol, cardiac index increased by 60%, heart rate by 39%, and stroke volume index by 14%. Mean pulmonary artery pressure remained unchanged and mean arterial pressure decreased slightly but not significantly. Right ventricular (RV) function improved as attested to by an increase of RV ejection fraction (+8%), a decrease of RV end-diastolic pressure (-5 mm Hg), and RV end-systolic volume index (-18%). Simultaneously, the pulmonary vascular resistance index decreased by 33% and RV contractility, appreciated by RV dP/dtmax, RV (dP/dtmax)/P, and RV end-systolic pressure/volume ratio, increased by 44, 77, and 27%, respectively. Left ventricular (LV) function also improved. The LV ejection fraction increased by 18% and LV end-systolic volume decreased by 34%. Concomitantly, the systemic vascular resistance index decreased by 40% and the LV end-systolic pressure/volume ratio increased by 50%. Our results suggest that the infusion of salbutamol improves ventricular performance by a decrease of ventricular afterload and by a positive inotropic effect.

Ten patients with acute myocardial infarction (AMI) underwent coronarographic studies before, immediately after and ten days after an intravenous infusion of 1 500 000 I.U. streptokinase (STK). Mean time between onset of symptoms to initiation of STK infusion was 03 hours 34 minutes. Occlusion of the infarct-related vessel was present in all of them and successful thrombolysis was obtained in 8 of the patients. Systemic fibrinolytic activity was present in 9 patients, one of whom required a transfusion of blood because of severe bleeding. At ventriculography, the global left ventricular ejection fraction and the regional ventricular ejection fraction, whatever the area involved, showed no significant improvement 10 days after the procedure. This suggests that high-dose intravenous STK in AMI, although causing an effective thrombolysis, does not seem to improve early myocardial function.

Legionnaires' disease may cause severe multisystem damage. We report the case of a patient in whom Legionnaires' disease induced an acute pancreatitis.

The effects of regular aspirin ingestion after aspirin-desensitization were evaluated in 10 aspirin-intolerant asthmatic patients. Chronic aspirin ingestion was not observed to be associated with either a significant improvement of mean FEV1 values or with a decrease in daily corticosteroid requirements. This study suggests that regular aspirin ingestion in aspirin-intolerant asthmatic patients does not induce a measurable improvement of the respiratory status.

An aspirin- and tartrazine-sensitive asthmatic patient underwent a desensitization to the adverse effects of aspirin by oral aspirin challenges. After a month of daily aspirin ingestion, the patient's reactivity to tartrazine, tested by oral challenge, was observed to the blunted. This report suggests that desensitization to the adverse effects of aspirin might protect the patient against the adverse effects of tartrazine.