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Trends in Reporting of Physician-Diagnosed Food Allergy in New York City Schools
AB220 Abstracts
692
Paradoxical Effect of Epinephrine Administration During Anaphylaxis
Jay Jin, MD, PhD, Joseph H. Butterfield, MD, FAAAAI, and Rohit Divekar, MBBS, PhD; Mayo Clinic, Rochester, MN. RATIONALE: Bradycardia is an unexpected effect of epinephrine administration. Clinical factors that predispose to this paradoxical reaction are infrequently appreciated by healthcare providers and patients administering epinephrine. METHODS: Three patients presented here were referred for outpatient Allergy evaluation following episodes of anaphylaxis. RESULTS: History of anaphylaxis was the presenting concern in all cases. The cause of anaphylaxis was identified as tree nut (n51) and unknown (n52). Peak tryptase levels were 2.6ng/ml (tree nut anaphylaxis), 26.2ng/ ml, and 72.6ng/ml (normal <11.5 ng/ml). Management of anaphylaxis was complicated with bradycardia ensuing within 15 minutes of epinephrine administration. Heart rate nadir was 33-42 bpm. EKGs showed no underlying conduction abnormalities. Glucagon (n51) and atropine (n52) were administered with resolution of arrhythmia shortly. Chart review was significant for use of non-selective beta-blockers (NSBB; oral: n52; ophthalmic: n51) at the time of reaction. NSBB use was for anxiety (n51), headache prophylaxis (n51), and glaucoma (n51). Discussion with patients’ care providers was undertaken to assess alternatives to betablocker use. CONCLUSIONS: Paradoxical bradycardia following epinephrine administration is well-documented but rare. NSBB use can be a likely modifiable factor. Once paradoxical bradycardia is recognized, discussion with other healthcare team members may prevent future episodes by finding alternatives to NSBBs where permitted, or having risk-benefit discussions when beta-blocker use is mandated. Allergists are in a unique position to educate patients and other providers about potential adverse effects of epinephrine.
693
Trends in Reporting of Physician-Diagnosed Food Allergy in New York City Schools
MONDAY
Elizabeth J. Feuille, MD1, Cheryl Lawrence, MD2, Caroline Volel, MD, MPH3, Scott H. Sicherer, MD1, and Julie Wang, MD1; 1Icahn School of Medicine at Mount Sinai, New York, NY, 2New York City Department of Health and Mental Hygiene, Queens, NY, 3Mailman School of Public Health, Columbia University, New York, NY. RATIONALE: Food allergy (FA) prevalence appears to have increased, but the reporting rate of medically documented FA to schools is not well established. METHODS: Medically-documented reporting of FA (‘‘cases’’) in the New York City (NYC) public school system, which includes over 1 million students, was retrospectively reviewed for the school years 2007-08 to 2012-13. Cases included students whose FA was entered into schools’ electronic health records (EHR), which require physician documentation on a health examination form, medication administration form, or other communication. Collated and de-identified data from citywide school EHR were provided to investigators by the NYC Department of Health and Mental Hygiene. RESULTS: Prevalence of medically-documented FA increased each year from 0.4% (4,007/1,037,560) in 2007-08 to 1.4% (15,944/1,116,346) in 2012-13. Reporting was higher for younger children: 1.3%, 0.8%, and 0.4% in elementary, middle, and high schools, respectively. Overall, there was a male predominance (OR 1.33, p<0.001). Cases were more likely to be white (OR 2.4), Asian (OR 1.1), or identifying as ‘‘other’’(OR 1.3) than black (OR 0.8) or Hispanic (OR 0.64; all preceding p<0.001). Those eligible for free lunch (proxy socioeconomic status) were less likely to have medically-documented FA (OR 0.53, p<0.001). Only 48% of those with medically-documented FA provided an epinephrine auto-injector (EAI) to the school. CONCLUSIONS: Medically-documented FA has increased among NYC students, and varied with age, gender, race/ethnicity, and socioeconomic
J ALLERGY CLIN IMMUNOL FEBRUARY 2017
status. Additional study is needed to explore differences in medicallydocumented and undocumented FA, as well as the unexpectedly low rate of families providing EAIs for school emergencies.
694
Anaphylactic Triggers in Schools: Results of the 2014-2015 EPIPEN4SCHOOLSÒ Survey
Martha V. White, MD, FAAAAI1, Rafael Muniz2, Chris Herrem2, Suyapa Silvia3, and Susan Hogue, PharmD, MPH3; 1Institute for Asthma and Allergy, Wheaton, MD, 2Mylan Specialty L.P., Canonsburg, PA, 3RTI International, Research Triangle Park, NC. RATIONALE: In August 2012, Mylan Specialty L.P. created the EpiPen4SchoolsÒ program to provide stock EpiPenÒ(epinephrine injection) Auto-Injectors and educational materials to >60,000 qualifying schools across the United States. A survey of these schools was conducted to characterize all occurrences of anaphylaxis during the 2014-2015 school year. METHODS: A cross-sectional, web-based survey of schools participating in the EpiPen4SchoolsÒprogram during the 2014-2015 school year was conducted. RESULTS: A total of 2191 anaphylactic events were reported in 12,181 responding schools during the 2014-2015 school year. Of those individuals who experienced an anaphylactic attack, 24.5% had no history of allergies (491/2001), and 51.3% had no history of asthma (1026/2000). Triggers were not identified in 21.8% of events (436/1998), while the most commonly identified triggers were food (54.0%; 1079/1998) and insect venom (8.8%; 176/1998). The most frequent food triggers were nuts (40.9%; 440/1077), fruit (13.0%; 140/1077), fish (4.6%; 50/1077), dairy (2.6%; 28/1077), and eggs (1.9%; 21/1077). The most common insect venom triggers were bees (76.0%; 130/171), wasps/hornets (8.8%; 15/ 171), and ants (8.2%; 14/171). Epinephrine was used on school property to treat 63.7% (1272/1998) of events for which data on treatment were available. For the events with available data on the source of epinephrine on school property, 49.8% (631/1267) were treated with EpiPenÒ AutoInjectors from the EpiPen4SchoolsÒ program and 45.9% (582/1267) were treated with the individual’s prescribed epinephrine auto-injector. CONCLUSIONS: These results demonstrate the diversity of anaphylactic triggers and highlight the unpredictability of anaphylaxis in schools, emphasizing the importance of programs that provide undesignated stock epinephrine auto-injectors.
692
Paradoxical Effect of Epinephrine Administration During Anaphylaxis
Jay Jin, MD, PhD, Joseph H. Butterfield, MD, FAAAAI, and Rohit Divekar, MBBS, PhD; Mayo Clinic, Rochester, MN. RATIONALE: Bradycardia is an unexpected effect of epinephrine administration. Clinical factors that predispose to this paradoxical reaction are infrequently appreciated by healthcare providers and patients administering epinephrine. METHODS: Three patients presented here were referred for outpatient Allergy evaluation following episodes of anaphylaxis. RESULTS: History of anaphylaxis was the presenting concern in all cases. The cause of anaphylaxis was identified as tree nut (n51) and unknown (n52). Peak tryptase levels were 2.6ng/ml (tree nut anaphylaxis), 26.2ng/ ml, and 72.6ng/ml (normal <11.5 ng/ml). Management of anaphylaxis was complicated with bradycardia ensuing within 15 minutes of epinephrine administration. Heart rate nadir was 33-42 bpm. EKGs showed no underlying conduction abnormalities. Glucagon (n51) and atropine (n52) were administered with resolution of arrhythmia shortly. Chart review was significant for use of non-selective beta-blockers (NSBB; oral: n52; ophthalmic: n51) at the time of reaction. NSBB use was for anxiety (n51), headache prophylaxis (n51), and glaucoma (n51). Discussion with patients’ care providers was undertaken to assess alternatives to betablocker use. CONCLUSIONS: Paradoxical bradycardia following epinephrine administration is well-documented but rare. NSBB use can be a likely modifiable factor. Once paradoxical bradycardia is recognized, discussion with other healthcare team members may prevent future episodes by finding alternatives to NSBBs where permitted, or having risk-benefit discussions when beta-blocker use is mandated. Allergists are in a unique position to educate patients and other providers about potential adverse effects of epinephrine.
693
Trends in Reporting of Physician-Diagnosed Food Allergy in New York City Schools
MONDAY
Elizabeth J. Feuille, MD1, Cheryl Lawrence, MD2, Caroline Volel, MD, MPH3, Scott H. Sicherer, MD1, and Julie Wang, MD1; 1Icahn School of Medicine at Mount Sinai, New York, NY, 2New York City Department of Health and Mental Hygiene, Queens, NY, 3Mailman School of Public Health, Columbia University, New York, NY. RATIONALE: Food allergy (FA) prevalence appears to have increased, but the reporting rate of medically documented FA to schools is not well established. METHODS: Medically-documented reporting of FA (‘‘cases’’) in the New York City (NYC) public school system, which includes over 1 million students, was retrospectively reviewed for the school years 2007-08 to 2012-13. Cases included students whose FA was entered into schools’ electronic health records (EHR), which require physician documentation on a health examination form, medication administration form, or other communication. Collated and de-identified data from citywide school EHR were provided to investigators by the NYC Department of Health and Mental Hygiene. RESULTS: Prevalence of medically-documented FA increased each year from 0.4% (4,007/1,037,560) in 2007-08 to 1.4% (15,944/1,116,346) in 2012-13. Reporting was higher for younger children: 1.3%, 0.8%, and 0.4% in elementary, middle, and high schools, respectively. Overall, there was a male predominance (OR 1.33, p<0.001). Cases were more likely to be white (OR 2.4), Asian (OR 1.1), or identifying as ‘‘other’’(OR 1.3) than black (OR 0.8) or Hispanic (OR 0.64; all preceding p<0.001). Those eligible for free lunch (proxy socioeconomic status) were less likely to have medically-documented FA (OR 0.53, p<0.001). Only 48% of those with medically-documented FA provided an epinephrine auto-injector (EAI) to the school. CONCLUSIONS: Medically-documented FA has increased among NYC students, and varied with age, gender, race/ethnicity, and socioeconomic
J ALLERGY CLIN IMMUNOL FEBRUARY 2017
status. Additional study is needed to explore differences in medicallydocumented and undocumented FA, as well as the unexpectedly low rate of families providing EAIs for school emergencies.
694
Anaphylactic Triggers in Schools: Results of the 2014-2015 EPIPEN4SCHOOLSÒ Survey
Martha V. White, MD, FAAAAI1, Rafael Muniz2, Chris Herrem2, Suyapa Silvia3, and Susan Hogue, PharmD, MPH3; 1Institute for Asthma and Allergy, Wheaton, MD, 2Mylan Specialty L.P., Canonsburg, PA, 3RTI International, Research Triangle Park, NC. RATIONALE: In August 2012, Mylan Specialty L.P. created the EpiPen4SchoolsÒ program to provide stock EpiPenÒ(epinephrine injection) Auto-Injectors and educational materials to >60,000 qualifying schools across the United States. A survey of these schools was conducted to characterize all occurrences of anaphylaxis during the 2014-2015 school year. METHODS: A cross-sectional, web-based survey of schools participating in the EpiPen4SchoolsÒprogram during the 2014-2015 school year was conducted. RESULTS: A total of 2191 anaphylactic events were reported in 12,181 responding schools during the 2014-2015 school year. Of those individuals who experienced an anaphylactic attack, 24.5% had no history of allergies (491/2001), and 51.3% had no history of asthma (1026/2000). Triggers were not identified in 21.8% of events (436/1998), while the most commonly identified triggers were food (54.0%; 1079/1998) and insect venom (8.8%; 176/1998). The most frequent food triggers were nuts (40.9%; 440/1077), fruit (13.0%; 140/1077), fish (4.6%; 50/1077), dairy (2.6%; 28/1077), and eggs (1.9%; 21/1077). The most common insect venom triggers were bees (76.0%; 130/171), wasps/hornets (8.8%; 15/ 171), and ants (8.2%; 14/171). Epinephrine was used on school property to treat 63.7% (1272/1998) of events for which data on treatment were available. For the events with available data on the source of epinephrine on school property, 49.8% (631/1267) were treated with EpiPenÒ AutoInjectors from the EpiPen4SchoolsÒ program and 45.9% (582/1267) were treated with the individual’s prescribed epinephrine auto-injector. CONCLUSIONS: These results demonstrate the diversity of anaphylactic triggers and highlight the unpredictability of anaphylaxis in schools, emphasizing the importance of programs that provide undesignated stock epinephrine auto-injectors.