Impact of COVID-19 Restrictions on Anaphylaxis Presentations to the Emergency Department

Background: The Cross-Canada Anaphylaxis Registry (C-CARE) assesses the triggers and management of anaphylaxis and identifies predictors of the development of severe allergic reactions and of epinephrine use. Here, we present data from an urban adult tertiary care emergency department (ED) in Montreal, Canada. Methods: Potential anaphylaxis cases were identified using ICD-10 codes related to anaphylaxis or allergic reactions. Putative cases underwent chart review to ensure they met anaphylaxis diagnostic criteria. Demographic, clinical and management data were collected. Multivariate logistic regressions were conducted to assess the effect of demographic characteristics, triggers, and comorbidities on severity and management of reactions. Results: Among 37,730 ED visits, 0.26% (95% CI 0.21, 0.32) fulfilled the definition of anaphylaxis. Food was the suspected trigger in almost 60% of cases. Epinephrine was not administered in almost half of moderate-to-severe cases, and similar numbers of individuals with moderate-to-severe reactions were not prescribed an epinephrine autoinjector. Reaction to shellfish was associated with more severe reactions (OR 13.9; 95% CI 2.2, 89.4). Older individuals and those not receiving steroids were more likely managed without epinephrine (OR 1.04; 95% CI 1.01, 1.07 and OR 2.97; 95% CI 1.05, 8.39, respectively). Conclusions: Anaphylaxis accounted for a substantial number of ED visits in adults, and the most common trigger was food. There is non-adherence to guidelines recommending epinephrine use for all cases of anaphylaxis. We postulate that this may be related to concerns regarding the side effects of epinephrine in adults.

No information exists on how the knowledge or the practice of pediatricians regarding anaphylaxis episodes vary with episode severity. The aim of this study was to assess and compare pediatrician knowledge on the management of mild and severe anaphylaxis using clinical scenarios and to determine factors that affect their decisions. A questionnaire consisting of eight questions on the diagnosis and management of anaphylaxis was distributed at two national congresses. A uniform answer box including possible response choices was given below each question, and respondents were asked to check the answers that they thought appropriate. The management of mild and severe anaphylaxis was examined using two clinical case scenarios involving initial treatment, monitoring, and discharge recommendations. Four hundred and ten questionnaires were analyzed. The percentage of pediatricians who correctly answered all questions on the management of mild and severe anaphylaxis scenarios was 11.3% and 3.2%, respectively. Pediatricians did significantly better with initial treatment, but they were less knowledgeable with respect to observation time and discharge criteria in the mild anaphylaxis case scenario compared with the severe one (both P < 0.001). Multiple logistic regression analysis identified only working in an emergency department or intensive care unit as significantly predicting correct diagnosis of anaphylaxis among pediatricians (P = 0.01, 95% confidence interval: 0.11-0.57). No pediatrician-related factors predicted physician knowledge on the management of anaphylaxis. Pediatricians have difficulty with different steps in managing mild and severe anaphylaxis. Their deficiencies in management may result in failure to prevent recurrences of mild anaphylaxis and may increase mortality in severe anaphylaxis.

283 The Preschool Child and Anaphylaxis: Knocking Down the Blocks of Epinephrine Administration

Background: COVID-19 restrictions disrupted paramedic higher education, clinical placements and university-based simulation. Understanding how students adapted to these changes is crucial for future educational strategies. Aim: This study explores the perceived impact of COVID-19 on the education and clinical experience of undergraduate paramedics during the 2020–2021 academic year. Methods: This study used a quantitative, cross-sectional design. Third-year paramedic students from three universities partnered with one UK ambulance service were surveyed using a five-point Likert scale questionnaire. A total of 29 responses were collected online between April and June 2021. Findings: Students reported benefits from COVID-secure simulations and the flexibility of home learning. However, decreased confidence in practice and reduced placement hours were significant negative impacts. Conclusion: Students enjoy clinical placements and smaller simulation groups, but felt isolated when learning from home. It is clear there are lessons to be learned for future lockdowns regarding undergraduate paramedic education and clinical practice.

BackgroundRestrictions during the COVID-19 pandemic are thought to have impacted both the physical health and well-being of individuals where lockdown was applied. The United Arab Emirates (UAE) was one of the leading countries in implementing the international guidelines to limit the intensely contagious nature of the outbreak.AimTo identify the impact of COVID-19 on changes to exercise and general physical activity habits, changes to the consumption of various foods and potential weight gain, as well as any differences in smoking habits among individuals residing in the UAE during the COVID-19 quarantine.MethodsThis is a cross-sectional analytical study that used a quantitative electronic questionnaire sent by the Ministry of Health and Prevention to individuals on its platform in order to collect data on the physical health and well-being of a UAE sample population. A total of 2,362 responses were received to specific questions on physical activity, eating habits, and tobacco use for the period before, during, and after the COVID-19 lockdown. Descriptive statistical analysis was used to display the sample’s demographic data and the changes in physical health and well-being. Paired t-test was used to show the changes in dietary habits.ResultsThis study reveals concerning changes in health risk behaviors during the COVID-19 lockdown in the UAE. Physical activity levels declined across mild, moderate and vigorous ranges in most participants. Alarmingly, sedentary behavior dramatically increased with 71% of participants spending an average of 4–8 h per day sitting and over 54% of participants spending more than 4 h watching TV on an average day during lockdown. Fast-food consumption and snacking rose, hence weight gain was observed in over 53% of participants. Smoking habits, especially among cigarette smokers, may have worsened, with 45.2% reporting an increase in cigarette smoking, 16.8% declaring an increase in shisha smoking and 35.3% reporting an increase in smoking other tobacco products. These unfavorable behaviors during confinement could have serious long-term health consequences.ConclusionThis study demonstrates that long periods of home quarantine may have led to unhealthy consequences that increase the risk of developing disease. This study therefore aims to highlight these health impacts, and recommend strategies and policies that can encourage healthy habits.

S De Schryver, A Clarke, S La Vieille. Pediatr Allergy Immunol. 2017;28(7):715–717 To survey a group of children who presented with food-induced anaphylaxis to a known food allergen. The authors sought to estimate the percentage of anaphylaxis cases attributed to food labeling issues, to assess the presence or lack of adult supervision, and to identify risk factors associated with unsupervised reactions. The study included a subgroup of children from the Cross-Canada Anaphylaxis Registry, recruited from emergency departments of 3 hospitals in Ontario and Quebec. Within 18 months of recruitment, participants were contacted to complete a telephone survey. The median age of respondents was 6.1 years, and 60.9% were boys. Emergency department physicians who attended the anaphylactic reactions (involvement of 2 …

This study evaluated the need for additional emergency treatment following food-induced anaphylaxis in children who received appropriate prehospital epinephrine.Children younger than 18 years with known immunoglobulin E–mediated food allergies who presented to one of 7 Canadian pediatric emergency departments (EDs) (2011-2023) and received at least 1 prehospital epinephrine dose. Patients not meeting National Institute of Allergy and Infectious Diseases criteria for anaphylaxis were excluded.Outcomes of interest included use of at least 2 prehospital epinephrine doses, ED epinephrine administration, and hospital admission. Data collected included demographics, suspected food triggers, symptoms, severity, and comorbidities. Reactions were categorized by the most severe symptom as mild, moderate, or severe.A total of 1127 children were studied (median age: 7 years; 60.6% male). Mucocutaneous reactions were the most common (pruritus: 47.3%, urticaria: 55.4%, angioedema: 51.9%), followed by respiratory symptoms (throat tightness: 39.5%, breathing difficulties: 40.3%), gastrointestinal symptoms (36.8%), and cardiovascular symptoms (cyanosis: 1.9%, circulatory collapse: 0.4%, hypotension: 2.4%); 7.9% of patients had severe reactions. Every patient received at least 1 prehospital dose of epinephrine; 84.3% received 1 dose, 12.4% received 2, and 3.3% received 3 or more prehospital doses. In the ED, 18.5% received additional intramuscular epinephrine and 0.9% received it intravenously. Other treatments included antihistamines, beta-agonists, corticosteroids, and intravenous fluids. Overall, 6.2% required 3 or more epinephrine doses, and 2.7% were hospitalized. Factors associated with needing additional epinephrine in the ED included reaction due to tree nuts and more severe reactions.Only a minority of patients who received prehospital epinephrine required further treatment in the ED. This supports the use of shared decision-making when talking to families about ED evaluation after epinephrine use.These results highlight how caregiver education can lead to safer care out of the hospital—ideally encouraging earlier epinephrine use and reducing associated health care costs.

IntroductionTo describe the impact of COVID-19 on a large, urban emergency department (ED) in Los Angeles, California, we sought to estimate the effect of the novel coronavirus 2019 (COVID-19) and “safer-at-home” declaration on ED visits, patient demographics, and diagnosis-mix compared to prior years.MethodsWe used descriptive statistics to compare ED volume and rates of admission for patients presenting to the ED between January and early May of 2018, 2019, and 2020.ResultsImmediately after California’s “safer-at-home” declaration, ED utilization dropped by 11,000 visits (37%) compared to the same nine weeks in prior years. The drop affected patients regardless of acuity, demographics, or diagnosis. Reductions were observed in the number of patients reporting symptoms often associated with COVID-19 and all other complaints. After the declaration, higher acuity, older, male, Black, uninsured or non-Medicaid, publicly insured, accounted for a disproportionate share of utilization.ConclusionWe show an abrupt, discontinuous impact of COVID-19 on ED utilization with a slow return as safer-at-home orders have lifted. It is imperative to determine how this reduction will impact patient outcomes, disease control, and the health of the community in the medium and long terms.

Cardiovascular symptoms/signs in infants and toddlers with anaphylaxis

Knowledge gaps in the diagnosis and management of anaphylaxis

COVID-19 Special Collection

Background The impact of COVID-19 pandemic on Emergency Department (ED) was remarkable throughout Europe. We focused upon ED utilization among integrated home care (IHC) recipients comparing ED between pandemic period with pre-pandemic (February -December 2020 and 2019, respectively) in Piedmont, Italy. Methods A retrospective observational study was conducted. All recipients of IHC during the two periods studied were enrolled and all ED visits that occurred among IHC recipients were accounted for. Several variables related to IHC admission, reason of ED visits and demographic characteristics were collected. The average of ED visits in pre-pandemic and pandemic periods were calculated. Analyses were stratified by all variables. Results Patients enrolled were 11968 in 2019 and 8938 in 2020. In 2019, 3573 patients had at least one ED visit and 1668 patients in 2020. Number of ED visits was 5503 in 2019 and 2197 in 2020. The average of ED visits in 2020 has reduced in comparison with 2019 (0.464 C.I. [0.44-0.489] and 0.24 C.I. [0.227-0.252], p &amp;lt; 0.001 in 2019 and 2020 respectively). This reduction is regardless of sex, age, duration of IHC, presence of a non-family caregiver or reason for ED visits, except for abdominal pain, cardiac rhythm alteration and gynaecological symptoms. The averages of ED visits were significantly lower for IHC recipients with neoplasm (0.549 C.I. [0.513-0.585] and 0.328 C.I. [0.298-0.358], p &amp;lt; 0.001, and with low level of emergency (1.77 C.I. [1.662-1.877] and 1.397 C.I. [1.348-1.447], p &amp;lt; 0.036), but an increase in mortality rate was not registered. Conclusions Our results showed a reduction of ED visits among integrated home care recipients in pandemic period in comparison with pre-pandemic period. If the reduction can be the consequence of an unprepared health service that needs of necessary changes in its organization, these results suggest a great potential of the home care system to reduce the use of the hospital especially for low-risk conditions. Key messages • The COVID-19 pandemic overwhelmed health services of all European Countries. A reduced utilization of ED has been shown by literature, especially during the early phase of the COVID-19 pandemic. • We showed a reduction in IHC recipients and a great decrease in ED visits among IHC patients in 2020 versus 2019, mainly in oncological patients, while an increase in mortality rate was not reported.

We aimed to evaluate how coronavirus (COVID-19) restrictions had altered individual's drinking behaviours, including consumption, hangover experiences, and motivations to drink, and changing levels of depression and anxiety. We conducted an online cross-sectional self-report survey. Whole group analysis compared pre- versus post-COVID restrictions. A correlation coefficient matrix evaluated the associations between all outcome scores. Self-report data was compared with Alcohol Use Disorders Identification Test (AUDIT) scores from the 2014 Adult Psychiatric Morbidity Survey. Multiple linear modelling (MLM) was calculated to identify factors associated with increasing AUDIT scores and post-restriction AUDIT scores. In total, 346 individuals completed the survey, of which 336 reported drinking and were therefore analysed. After COVID-19 restrictions 23.2% of respondents reported an increased AUDIT score, and 60.1% a decreased score. AUDIT score change was positively correlated with change in depression (P < 0.01, r = 0.15), anxiety (P < 0.01, r = 0.15) and drinking to cope scores (P < 0.0001, r = 0.35). MLM revealed that higher AUDIT scores were associated with age, mental illness, lack of a garden, self-employed or furloughed individuals, a confirmed COVID-19 diagnosis and smoking status. COVID-19 restrictions decreased alcohol consumption for the majority of individuals in this study. However, a small proportion increased their consumption; this related to drinking to cope and increased depression and anxiety.

This study aimed to investigate the influence of COVID-19 restrictions on the prevalence of allergen sensitivity in children. This study included patients who underwent allergen testing at our hospital before deregulation, after deregulation, and during the corresponding period in 2021. Changes in allergen-specific IgE (sIgE) positivity, IgE levels, and polysensitization were analyzed to to evaluate the impact of lifting COVID-19 restrictions on allergic diseases. Compared with those in the prederegulation period and the same period in 2021, the number of children with allergies visiting the hospital decreased following deregulation. The rate of allergen positivity was lower after deregulation than before but higher than that during the same period in 2021. After deregulation, allergen sIgE levels were lower than those before deregulation but higher than those in the same period in 2021. The correlation between milk and beef sensitivity was weaker after deregulation than before but stronger than that in 2021 (R values: 0.814, 0.854, and 0.104, respectively). During the period of COVID-19 restrictions, lower levels of allergic disease activity were observed compared to the pre-deregulation period. However, following the deregulation and the subsequent surge in COVID-19 infections, levels of allergic disease activity appeared to increase relative to the same observation period in 2021.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-23547-1.

<b>Background:</b> Physical inactivity and sedentary behaviour is associated with worse clinical and inflammatory outcomes and impaired quality of life in people with severe asthma (pwSA) (Cordova-Rivera et al. JACI:IP 2018;6(3):814-22). Since March 2020, national lockdowns have been periodically implemented in the UK to reduce the transmission of COVID-19, however, the impact of these restrictions on physical activity in pwSA has yet to be evaluated. <b>Aims:</b> To compare physical activity levels prior to and during COVID-19 lockdown in pwSA. <b>Method:</b> A preliminary retrospective analysis of physical activity (step count objectively assessed via an in-built smartphone pedometer (Reilly et al. J Asthma 2021:1-9)) between March-June 2019 (usual daily living) versus March-June 2020 (first UK lockdown) in adults attending a specialist asthma service. <b>Results:</b> Twelve adults with severe asthma receiving biological therapies (male: n = 4) (age: 52 ± 16; FEV₁ % predicted: 64 ± 16) were recruited. A significant and clinically meaningful reduction in daily step count was observed between 2019 and 2020 for all months: March (-25%) (P=0.02); April (-40%) (P=0.02); May (-33%) (P = 0.04); June (-38%) (P = 0.001). Total absolute reduction in daily step-count: 4627 ± 1833 versus 3054 ± 1967 (-34%) (P&lt;0.001). <b>Conclusions:</b> COVID-19 restrictions reduced step-based physical activity by approximately one-third in pwSA. These findings underline the importance of monitoring and promoting physical activity during routine asthma review given the potential adverse impact on health and disease-related outcomes.