A clinical case of the uterine complete rupture along with the previous scar during pregnancy with atypical clinical features

This article presents an unusual case of rupture of the scarred uterus at 36-37 weeks of gestation. The patient presented with pain in the pubic and hip joint area, growing stronger while her walking, seated and changing position. No clinical manifestations of hemorrhagic shock were observed. External obstetric examination revealed a normotonic uterus and satisfactory fetus condition. Provocation tests were conducted to exclude subluxation of the pubic joint. Pubic symphysis diastasis palpation, long dorsal sacroiliac ligament palpation, P4 test, Patricks test, and the modified Trendelenburg test were negative. Pelvic examination revealed sharp pain in lower uterus segment. Ultrasound scan revealed deformation and thinning of the scar up to 1 mm, and no abnormalities in pubic symphysis. A threatening uterine rupture was diagnosed, and emergency cesarean section was performed. Intraoperative examination showed that the scar located in the lower segment consisted of connective tissue. In addition, there was a 4 5 cm scar defect with the overlying amniotic sac, no hemorrhage being noted. After removing the fetus, scar excision was performed. The uterine defect was repaired with a double layer running-locking suture. The patient was discharged from hospital on day 5 of postpartum period. The infant was exposed in the neonatal intensive care unit to provide an early developmental care.

Perspectives and Management of Atypical Asthma in Chinese Specialists and Primary Care Practitioners—A Nationwide Questionnaire Survey

Background and objective: To evaluate the awareness/knowledge and clinical practice for the treatment of atypical asthma among respiratory specialists and primary care practitioners (PCPs) in China.Methods: A total number of 1,997 physicians participated in the survey via WeChat. The questionnaire included six main items: physician demographic characteristics, awareness, diagnosis, medical prescription, assessment/education, and proposal.Results: Cough variant asthma (CVA) was recognized by 97.51% of physicians (1,166 respiratory specialists and 799 PCPs), followed by chest tightness variant asthma (CTVA, 83.72%) and occult asthma (73.54%). Specialists were more likely to follow diagnostic recommendations than PCPs (P < 0.01); however, 34.15% of physicians reported the utility of bronchodilation tests, airway provocation tests, and peak expiratory flow monitoring. A total of 91.70% and 92.01% of physicians prescribed inhaled corticosteroids (ICS) or ICS plus long-acting beta-agonists (LABA) for CVA and CTVA, respectively. Physicians prescribed an ICS or ICS/LABA for 4 (2–8) or 8 (4–12) weeks for CVA and 4 (2–8) or 5 (4–12) weeks for CTVA, and the prescription durations were significantly shorter for PCPs than for specialists (P < 0.01). Further, 52.42% and 35.78% reported good control of CVA and CTVA, respectively, with significantly lower control rates for PCPs than for specialists (P < 0.01). Additionally, specialists exhibited better assessment and educational habits than PCPs.Conclusion: While atypical asthma was identified by most specialists and PCPs, there remains a gap between management in real clinical practice and guideline recommendations, especially for PCPs. Further training of PCPs and clinical studies of atypical asthma are required to improve practice.

Comparison of Sodium Lactate Infusion and Carbon Dioxide Inhalation Panic Provocation Tests: A Meta-analysis

Background Sodium lactate (NaL) infusion and carbon dioxide (CO2) inhalation are proven to provoke acute panic attacks (PAs) in patients with panic disorder (PD). A systematic literature search and meta-analysis were performed to compare the effect sizes of these methods. Methods Odds ratios were calculated for each of the original studies and were pooled using the random-effects model. Results Either NaL or CO2 provocations significantly increased the rates of PAs in individuals with PD compared to those in healthy controls. However, the effect size of NaL infusion (OR=25.13, 95% CI=15.48–40.80) was significantly greater than that of CO2 inhalation (OR=10.58, 95%CI=7.88–14.21). Conclusion The evidence for the efficacy of the two panic provocation tests is very strong. Yet, the results support the superiority of NaL infusion over CO2 inhalation challenge as a panic provocation test. Thus, lactate seems a much stronger stimulus than CO2 for the brain suffocation detector.

Allergic reactions due to concomitant administration of multiple drugs in intravenous fluid in emergency departments in Turkey

The present study aimed to evaluate patients who were referred to adult allergy clinic due to allergic reactions after concomitant multiple intravenous-drug administrations in Emergency Department (ED). Between January 2017 and January 2019, patients admitted to our allergy clinic with hypersensitivity reactions to intravenous drugs administered in ED were included retrospectively. Fifty-seven patients who developed allergic reactions after intravenous drug administration in EDs were evaluated. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) were the most common cause of allergic reactions (n = 40, 70.2%). Skin Prick Tests (SPT) were positive in 6 (10.5%) patients. Drug Provocation Tests (DPT) were positive in 10 (17.5%) patients. No significant correlation was found between the total number of drugs in the intravenous fluid and the degree of allergic reaction (r = -0.145, p = 0.282). There was no statistically significant difference between the degree of allergic reaction and history of atopic disease (p = 0.579). In conclusion, concomitant administration of multiple drugs in intravenous fluids may increase the risk of allergic reactions.

Does Drug Allergy Workup in Children Satisfy Their Parents?

<b><i>Introduction:</i></b> Although drug allergy workup for pediatric patients (skin and drug provocation tests [DPT]) is performed, the procedures are troublesome, painful, and time-consuming. The aim of this study was to assess parents’ perception of and satisfaction with their child’s drug allergy workup. Further, to evaluate parents’ tendency to use the tested drug following a negative DPT and the consequences of re-exposure. <b><i>Methods:</i></b> Parents of children that underwent drug allergy workup from January 2017 to August 2020 in the Pediatric Allergy Department of Trakya University Medical Faculty were included. Satisfaction levels were assessed via a telephone questionnaire (3 open-ended, 7 multiple-choice questions). Satisfaction was scored on a Likert scale (1: very unsatisfied and 5: very satisfied). <b><i>Results:</i></b> A total of 102 parents participated the study. Fifty-two (51%) of patients were male, and median age was 6.2 years and a median time interval between admission and test appointment of 1 month; 16.7% had a positive drug allergy workup, with 88.3% reporting being satisfied (56.9%) or very satisfied (31.4%) with the workup. Satisfaction levels were inversely related to the time between admission and test appointment (rho: −0.254, <i>p</i> = 0.01), with 8.2% reporting they did not use the tested drug when necessary despite a negative result. The tested drug was used by 35 individuals (41.1%), 33 (94.2%) tolerating without reaction. <b><i>Conclusion:</i></b> Most parents were satisfied with the workup, but levels were inversely related to the admission and procedure time interval. Drug allergy workup should be performed as soon as possible to relieve parents’ anxiety and achieve more patient satisfaction.

Macrolide Allergy in Children and the Negative Predictive Value of Drug Provocation Tests in Mild Index Reactions

ABSTRACT Objective: Macrolide allergy is rarely reported, and there is limited knowledge of hypersensitivity reactions (HRs) in children. The negative predictive value (NPV) of drug provocation tests (DPTs) for macrolides is unresolved. We aim to evaluate the clinical features of macrolide allergy in children, and determine the NPV of macrolide DPTs. Materials and Methods: Pediatric patients who were referred to our allergy department with a suspicion of macrolide allergy were evaluated by DPTs with or without prior skin tests between 2011 and 2020. Characteristics of the HRs and patients, the results of skin and DPTs were recorded. At least three months after evaluation of the patients with allergy work up, telephone interviews were performed. Patients were asked whether they had reused the suspected macrolide or not. Patients who reported HR during subsequent drug intake were invited for reevaluation. Results: A total of 160 children (161 reactions) (55.6% male) with a suspicion of macrolide allergy were enrolled for the study, and all children had a mild index reaction. The median age was 48 (18-102) months, and the median time between the suspected allergic reaction and allergy work-up was 3 (2-8) months. The most frequently reported suspected agent was clarithromycin, in 151 patients (94.4%). Macrolide allergy was confirmed in 8 (5%) patients. Only one patient reported skin eruptions upon reuse despite a negative DPT and he was invited to be reevaluated. A second DPT was performed resulting in urticarial lesions. The NPV was found to be 97.4% for negative DPT with macrolides. Conclusion: Confirmed macrolide allergy is rare in children, and DPTs are the gold standard to assess suspected macrolide allergy. The NPV of macrolide provocation tests seems to be high in children. Keywords: Children, drug hypersensitivity, drug provocation test, macrolide, negative predictive value

Diagnosing and Managing Patients with Reactions to Radiocontrast Media

Purpose of the review Iodinated radio contrast media (RCM) belong to the most common elicitors of drug hypersensitivity reactions (HR). Urticaria or anaphylaxis may occur ≤ 1(−6) hour(s) (immediate HR) and exanthems (non-immediate HR) develop > 6 h after application of RCM. Evidence for an immunologic mechanism of RCM HR against the different RCM benzene ring molecules and the benefit of allergological testing in patients with previous hypersensitivity reactions is progressively increasing. Recent findings Positive skin tests can confirm allergy in patients with previous reactions to RCM and help to select alternative better tolerated RCMs. Severe hypersensitivity reactions are mainly caused by an allergic mechanism, whereas the majority of non-severe reactions appear to be non-allergic. Skin testing is highly recommended to help identify allergic hypersensitivity reactions and to select alternatives. Using structurally different RCM is more effective than premedication for the prevention of future reactions. Drug provocation tests to RCM have been increasingly used, but are not yet standardized among different centers. Summary In patients with previous severe hypersensitivity reactions to RCM, skin testing is recommended. For future RCM-enhanced examinations in patients with previous reactions, structurally different, skin test-negative preparations should be applied. Drug provocation tests do confirm or exclude RCM hypersensitivity or may demonstrate tolerability of alternative RCMs.

Diagnosis and Management of Antibiotic Allergies

Drug allergies encompass a spectrum of immune-mediated hypersensitivity reactions with various mechanisms and clinical presentations. β-lactam drugs are common causes of drug allergies. A detailed clinical history as well as skin and drug provocation tests, are essential to diagnose drug allergies. The key to successful treatment is avoidance or discontinuation of the offending drug, and replacing it with a safe alternative. Cross-reactivities among β-lactam antibiotics should be considered when choosing alternative medications. Proper management of β-lactam allergies is important at the individual and population levels, to reduce the likelihood of drug allergies and prevent antibiotic-related adverse outcomes.