abseie 2009-12-23 11:29
超過半數的過敏性休克病患延遲尋求醫療
作者：Jacquelyn K. Beals, PhD
出處：WebMD醫學新聞
December 8, 2009 (阿根廷布宜諾斯艾利斯) —一篇研究分析病患之過敏性休克藥物使用及其延遲尋求醫療的原因，發現有自我注射腎上腺素(self-injectable epinephrine，SIE)處方的病患有將近三分之二在抵達急診室前並未使用它。
在美國，每年有1000到2000人死於過敏反應－通常是青少年和年輕人之致命的食物相關過敏性休克－其中有許多是可以預防的。這篇新研究由梅約診所醫學院急診室Wyatt W. Decker醫師發表於世界過敏組織第21屆世界過敏研討會。
Decker醫師指出，過敏研究中缺乏有關病患對其疾病知識的表述，他表示，教育是避免病患延遲抵達急診就醫和使用其SIE的關鍵因素。這篇研究的資訊來自給予急診病患的問卷以及日後的電話追蹤。
研究樣本包括因為過敏症狀至急診就醫的42名病患(26名女性)，年紀13-52歲(中位數為30歲)。這些調查對象剛好有超過半數(22人)報告指出延遲前往急診室，其中15人表示因為預期症狀會消失，不過，Decker醫師表示，過敏反應是無法預期的，治療可能緩不濟急，他提醒聽眾，過去輕微的反應現在可能變成嚴重反應。
引起這些研究對象發生過敏的原因包括食物、昆蟲、藥物、其他過敏原或是未知因素，症狀發生時間6-39分鐘(中位數為15分鐘)。幾乎所有病患(95.2%)在獲得醫療照護之前都有使用某種藥物，包括抗組織胺(19名病患)、albuterol吸入劑(4名病患)以及氣霧器 (1名病患)。
Decker醫師的報告聚焦在19名有SIE處方的病患，其中14個在發生過敏反應時有SIE藥物者僅7人有使用。
Decker醫師向Medscape Allergy Clinical Immunology表示，未使用SIE的最常見原因，據說是病患希望在自己注射一劑腎上腺素之前等看看，看症狀是否會好轉。或者他們認為，如果幫自己注射，之後就必須再前往醫院，所以他們對於幫自己注射感到勉強。這不是我們樂見的。
問卷中詢問病患不使用SIE的原因：3個病患不認為他們的症狀夠嚴重；1個找不到他的SIE；1個認為使用上不安全；1個不確定是否可以使用SIE；1個的SIE已經過期。
Medscape Allergy Clinical Immunology問道，使用SIE是否會增加病患的就醫需求，Decker醫師表示並非如此。Decker醫師強調，前往醫院的最重要適應症是反應的嚴重度，你必須及早使用SIE，因為病患無法分辨他們的反應是否會變得危險，所以，在他們自己前往醫院或者在提供到院前照護者抵達之前自行注射，就像保險一樣。如果立即注射，就像專家已經抵達；如果等待，就可能是延遲時機。少數過敏致命案例就是因為等等看造成的；當呼救時已經變嚴重，而為時已晚。等待是相當危險的。
在很罕見的案例中，腎上腺素對心律的效果會誘發心肌梗塞。有其他研究者檢視這些案例，幾乎都是不小心造成腎上腺素過量。Decker醫師指出，使用EpiPen或SIE幾乎不可能會過量，因為它們是適當劑量。他表示，病患對腎上腺素有點害怕，可能是過度擔心的，只要給藥之後前往醫院即可。
會議小組共同主持人、美國過敏、氣喘與免疫學院理事長候選人Nova Southeastern大學助理臨床教授、佛羅里達州羅德岱堡開業醫師Dana V. Wallace提出病患對SIE的另一個顧慮：當我問病患何以不使用腎上腺素時，他們表示「因為我不想去急診」。Wallace醫師指出，在美國，並非每個人都可以負擔昂貴的救護車費用，所以他們不想花費。
Wallace醫師向Medscape Allergy Clinical Immunology表示，我們必須強調，最糟糕的就是不使用SIE以及不前往急診。所以，至少須做到，知道要用並且使用它，就算因為經濟因素選擇不前往急診還是要用它。她也指出，有些人會怕自己打針或怕幫自己的小孩打針。
Wallace醫師表示，曾經有一個很好的研究，過敏科醫師在病患未發生過敏時，在診間的適當環境下教一群健康的年輕病患、青少年與成人自己使用SIE，他們與家人都很開心的離開，因為他們知道自己可以執行這件注射任務，知道不會有恐怖的副作用。她結論表示，我認為或許有時候應當嘗試給健康人們一些訊息。
Decker醫師報告接受非營利組織、「食物、過敏與過敏反應網絡」的資金。Wallace醫師報告擔任Schering-Plough、Aventis、Pfizer以及Merck藥廠的發言人，也是AstraZeneca藥廠的諮詢顧問。
世界過敏組織第21屆世界過敏研討會(WAC)：摘要434。發表於2009年12月7日。
More than Half of Patients With Anaphylaxis Delay Seeking Medical Attention
By Jacquelyn K. Beals, PhD
Medscape Medical News
December 8, 2009 (Buenos Aires, Argentina) — A study assessing patients' use of medication for anaphylaxis and reasons for their delay in seeking medical attention indicates that nearly two thirds of patients with prescriptions for self-injectable epinephrine (SIE) failed to use it before reaching the emergency department.
In the United States, 1000 to 2000 people die each year as a result of anaphylactic reactions — often fatal food-related anaphylaxis in adolescents and young adults — and many of these fatalities are preventable. The new study was presented here at the World Allergy Organization XXI World Allergy Congress by Wyatt W. Decker, MD, from the Department of Emergency Medicine, Mayo Clinic College of Medicine, in Rochester, Minnesota.
Dr. Decker noted the lack of studies on anaphylaxis that address patients' knowledge about their disease. He pointed to education as a key factor in preventing delays in patients' arrival at the emergency department and in their use of SIE. Information for the current study was obtained from a questionnaire given while patients were at the emergency department and from telephone follow-up.
The study population consisted of 42 patients (26 female) arriving at the emergency department with symptoms of anaphylaxis. Ages ranged from 13 to 52 years (median, 30 years). Slightly more than half of those surveyed (22 individuals) reported a delay in coming to the emergency department, with 15 saying they expected the symptoms to go away. However, the severity of an anaphylactic reaction is impossible to anticipate, and treatment could come too late, Dr. Decker said in his talk. "Mild reactions in the past can lead to severe reactions in the future," he reminded the audience.
Causes of anaphylactic reactions in the study population included foods, insects, medications, other allergens, or "unknown," with time to symptom onset ranging from 6 to 39 minutes (median, 15 minutes). Nearly all patients (95.2%) used some medication before obtaining medical care, including antihistamines (19 patients), albuterol inhalers (4 patients), and nebulizer (1 patient).
Dr. Decker's report focused on 19 patients with SIE prescriptions. Of the 14 patients who had SIE with them at the time of the anaphylactic reaction, only 7 used it.
"The most common cause anecdotally [for not using SIE] appears to be that patients want to see if they get better before they give themselves a shot of epinephrine," Dr. Decker told Medscape Allergy Clinical Immunology. "Or they believe that if they give themselves a shot then they have to come to the hospital, so they're reluctant to give themselves the shot. This is not what we want."
The questionnaire asked patients their reasons for not using SIE: 3 patients did not consider their symptoms serious enough; 1 was unable to find their SIE; 1 felt it was unsafe to use; 1 was unsure when SIE use was indicated; and 1 had SIE that was past its expiration date.
Asked by Medscape Allergy Clinical Immunology whether using SIE increased the need for patients to go to the hospital, Dr. Decker indicated this was not the case. "The most important indication of going to the hospital is the severity of the reaction. You have to activate [SIE] early because the [patient] can't tell yet if [their reaction] is going to be dangerous or not. So by getting themselves to the hospital or having prehospital providers come to them, it's like insurance. If it gets desperate, then the experts are there. If they wait, there may not be time.?.?.?. The few fatal cases of anaphylaxis that we see are often in people who waited; then it gets so severe that they call for help but it's too late. That's the danger with waiting," Dr. Decker emphasized.
In very rare cases, epinephrine's effect on heart rate can trigger myocardial infarction. When these cases are examined, as they have been by other researchers, nearly all are inadvertent overdoses of epinephrine. "It's almost impossible to do that with an EpiPen or SIE because they're the appropriate dose," noted Dr. Decker. Patients are a little afraid of the epinephrine, probably too much so. "It should just be given and then they should come to the hospital," he said.
Session comoderator Dana V. Wallace, MD, a private practitioner in Fort Lauderdale, Florida, assistant clinical professor at Nova Southeastern University, and president-elect of the American College of Allergy, Asthma Immunology, identified another patient concern about SIE: "When I ask why patients don't take the epinephrine, they say 'Because I didn't want to go to the emergency room.' In the United States, not everyone is covered for the expensive ambulance ride, so they don't want to pay for it," Dr. Wallace said.
"We have to emphasize that the worst of all possible errors is not to give it and not go to the emergency room," Dr. Wallace told Medscape Allergy Clinical Immunology. "So at least if they know to take it, please do administer it, even if for some poor reason they choose not to go to the emergency room." She also noted that some people are afraid to self-inject or afraid to inject their child.
"There was one very nice study where an allergist took a group of healthy young patients, adolescents and adults, and asked them to self-administer [SIE] in a controlled environment in his office, when they were not having anaphylaxis. It seemed that they and their families all walked away much happier because they knew they could do it and that it wasn't going to cause a horrible side effect," said Dr. Wallace. "I think at times maybe that's the message for healthy people we should try," she concluded.
Dr. Decker reports receiving funding from the not-for-profit Food, Allergy, and Anaphylaxis Network. Dr. Wallace reports being on the speakers' bureau for Schering-Plough, Aventis, Pfizer, and Merck, and is on the advisory board for AstraZeneca.
World Allergy Organization XXI World Allergy Congress (WAC): Abstract?434. Presented December?7, 2009.