Anaphylaxis-related posttraumatic stress disorder

Abstract

RATIONALE: Post-traumatic stress disorder (PTSD) is a chronic and disabling entity, which negatively impacts health and quality of life. It occurs after events that are perceived as life-threatening and has a lifetime rate of 7%. Strikingly, there is very little data on anaphylaxis-related PTSD. We hypothesized that the emotional sequelae of severe anaphylaxis have been overlooked thus far and warrant investigation. METHODS: We recruited subjects with hymenoptera-venom allergy in 4 medical centers in Jerusalem, Israel. Patients were divided according to local reactions (LR) or anaphylaxis. For each subject, 3 questionnaires were used: 1) Demographic and medical data form; 2) Life Events Checklist for DSM-5 (LEC5); 3) PTSD checklist for DSM-5 (PCL5). RESULTS: A total of 89 subjects were enrolled with an average age of 38 yrs (615.1). Of these, 46 (52%) had anaphylaxis and 43 (48%) had LR. Among patients with anaphylaxis, the rate of probable PTSD was 15.2 % (N57) compared to 2.3% in the LR group (N51) (p<0.001). Patients with anaphylaxis also reported significantly more previous traumatic events. CONCLUSIONS: Our study suggests that PTSD rates are increased in individuals with a history of anaphylaxis. Therefore routine follow-up of these individuals should include surveillance for this disorder. Our investigation is limited by the number of enrollees with hymenoptera venom allergy and future studies are needed to lend further support to our conclusions. RATIONALE: Children experiencing anaphylaxis at school may lack access to a personal epinephrine device, prompting legislation allowing undesignated (e.g., non-student specific) stock epinephrine auto-injector units at school. However, the cost-effectiveness of undesignated school stock epinephrine (SE) is uncharacterized. We therefore undertook a simulation and cost-effective analysis to define value-based strategies for school undesignated SE programs. METHODS: We conducted Markov simulations of the Chicago public school system (371,382 students, previously characterized for epinephrine utilization) over extended time horizons to model two school SE policies. We compared a policy where undesignated SE units were provided to supplement designated SE units provided by known allergic students (supplemental model) to a model where undesignated SE units were universally provided for all students at school, without allergic students providing additional designated units (universal model). The base-case model assumed a 10-fold reduced fatality risk with having undesignated SE units versus no units. SE unit costs were evaluated from a societal perspective and shared by children at-risk for anaphylaxis. Cost-effective care was defined as care costing <0.01). Children with FPIAP were significantly more likely than healthy controls to develop FA to milk (3.9% v. 0.5%, p<0.01) and egg (5.9% v. 2.5%, p<0.05). There were non-significant trends toward higher rates of FA to peanut as well. CONCLUSIONS: Infants with FPIAP were significantly more likely to develop IgE-mediated food allergies to milk and egg, with trends toward higher rates of FA to other foods. FPIAP may represent an early step on the atopic march, possibly compounded by subsequent allergen avoidance, to potentially increase the risk of developing some IgE-mediated food allergies.