Donald Stark

Canadian hereditary angioedema guideline

Hereditary angioedema (HAE) is a disease which is associated with random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased Health Related Quality of Life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada is neither optimal nor uniform across the country. It lags behind other countries where there are more organized models for HAE management, and where additional therapeutic options are licensed and available for use. The objective of this guideline is to provide graded recommendations for the management of patients in Canada with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. It is anticipated that by providing this guideline to caregivers, policy makers, patients and their advocates, that there will be an improved understanding of the current recommendations regarding management of HAE and the factors that need to be considered when choosing therapies and treatment plans for individual patients. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency physicians, gastroenterologists, dentists and otolaryngologists, who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.

Latex allergy in operating room nurses

OBJECTIVE To determine the prevalence of allergy to natural rubber latex and potential crossreacting foods in operating room nurses. METHOD Two hundred forty-seven operating room nurses completed a latex allergy questionnaire. They were questioned about symptoms of latex reactivity and about other allergies particularly to foods that may crossreact with latex. Informed consent was obtained and skin prick testing was performed with natural rubber latex and five latex extracts representing low (0.08 to 0.25 microgram/mL) and high (18 to 106 micrograms/mL) natural rubber latex protein gloves. Skin prick tests were done with four potentially crossreacting foods (banana, avocado, kiwi, and potato), saline, and histamine controls. RESULTS One hundred thirty-five (54.7%) nurses described allergic symptoms they attributed to latex exposure. Of these 12 (4.9%) tested positive to latex extracts alone, 12 (4.9%) tested positive to food extracts alone, and 5 (2.0%) tested positive to both latex and crossreactive foods. Three of the 17 (17.6%) nurses testing positive to latex gave no history of reactivity to latex. Indirect latex ELISA was done on the serum of skin test-positive patients with a 70.6% sensitivity. CONCLUSION Of the nurses tested, 6.9% had positive skin prick tests to latex extracts; 17.6% of these were asymptomatic and 29.4% had associated food positive skin prick tests.

Skin testing to evaluate oculo-respiratory syndrome (ORS) associated with influenza vaccination during the 2000–2001 season

A syndrome of red eyes and respiratory symptoms was noted following receipt of influenza vaccine in Canada during the 2000-2001 influenza season. We conducted intra-dermal skin testing to determine if oculo-respiratory syndrome (ORS) was related to failure of the splitting process during vaccine manufacturing, if it was associated with a particular viral strain and to identify individuals at risk for subsequent ORS reaction. Skin testing with minute quantities of vaccine antigen induced ORS symptoms at a higher rate amongst persons previously affected by this syndrome compared to previously unaffected persons. Skin test reaction size or quality could not identify persons at risk of ORS. Skin testing could not identify a specific strain or the stage in the manufacturing process during which the trigger may have been introduced.

Management of anaphylaxis in primary care: Canadian expert consensus recommendations

To cite this article: Waserman S, Chad Z, Francoeur MJ, Small P, Stark D, Vander Leek TK, Kaplan A, Kastner M. Management of anaphylaxis in primary care: Canadian expert consensus recommendations. Allergy 2010; 65: 1082–1092.

Does antigen-specific cytokine response correlate with the experience of oculorespiratory syndrome after influenza vaccine?

During the 2000-2001 season in Canada, a newly identified oculorespiratory syndrome (ORS) was observed in patients after immunization with inactivated influenza vaccine. ORS was associated with a high proportion of microaggregates of unsplit virions in the implicated vaccine and had clinical features suggesting delayed-onset hypersensitivity. We explore the association between in vitro cytokine balance (type 1 vs. type 2) and clinical ORS after influenza vaccination. We report the balance of interferon (IFN)-gamma, interleukin (IL)-10, IL-5, and IL-13 expression by peripheral blood mononuclear cells (PBMC) among unvaccinated, vaccinated ORS-affected, and vaccinated ORS-unaffected persons after in vitro challenge with implicated and nonimplicated vaccines. Antigen-stimulated PBMC from vaccinated persons produced significantly more IFN-gamma than did those from unvaccinated persons. There was a statistically significant type 2 polarization among unvaccinated compared with vaccinated persons. Although vaccinated ORS-affected individuals had less of a type 1 basis than did vaccinated unaffected individuals, this difference was not statistically significant.

Oral allergy syndrome and risk of food-related anaphylaxis: a cross-sectional survey analysis

Background Oral Allergy Syndrome (OAS) is an IgE-mediated allergic response to fresh fruits, nuts and vegetables caused by cross-reactivity between pollen allergens and structurally similar food proteins. Alder pollen is a prominent allergen in coastal British Columbia, present at high levels from FebruaryApril. We hypothesized that this exposure may lead to increased prevalence of Alder pollen allergy and OAS. We sought to determine our population-based prevalence, cross-reactivity patterns, and incidence of food-related anaphylaxis.

Unusual presentation of a patient with complement deficiency and immunoglobulin deficiency

Background The complement system is a vital component of innate immunity. Deficiencies in any part of the complement pathway characteristically present with recurrent infections. C2 factor deficiency is the most common complement deficiency. The presentation can vary from being asymptomatic to developing recurrent infections. Thus empiric vaccinations have been recommended, despite the lack of substantial evidence to support this practice. Recently, Jonnson and colleagues revisited this controversial topic and demonstrated the importance of vaccinations in this patient population. They further established that C2 deficient patients can mount an immune response to vaccination, undergo class-switching and develop a ‘more efficient’ phagocytosis. C2 deficiency is inherited in an autosomal recessive pattern. Homozygotes generally present with increased severity of disease as compared to heterozygotes. Alper and colleagues state that 25% of C2-deficient homozygotes have increased susceptibility to severe bacterial infections. Furthermore, they found that these C2-deficient patients had significantly lower mean levels of IgG4 and IgA than those patients that did not demonstrate an increased susceptibility for recurrent infections.

A pilot study of quality of life, mood, sleepiness and fatigue in patients with primary humoral immunodeficiency transitioning to subcutaneous immunoglobulin therapy

Background Immunoglobulin replacement therapy is standard of care for patients with primary humoral immunodeficiency [1]. Compared with intravenous immunoglobulin (IVIG), subcutaneous immunoglobulin (SCIG) offers comparable efficacy, lower costs and reduced systemic reactions [2,3]. However, little is known about effects on quality of life when patients transition from IVIG to SCIG. It was our objective to assess changes in quality of life, mood, sleepiness and fatigue in patients transitioning from IVIG to SCIG.