Talk:Anaphylaxis/GA1

GA Review
The edit link for this section can be used to add comments to the review.''

Reviewer: Axl (talk · contribs) 20:47, 1 December 2011 (UTC)

Okay, I'll review it. Axl ¤  [Talk]  20:47, 1 December 2011 (UTC)
 * Thanks -- Doc James (talk · contribs · email) 20:01, 7 December 2011 (UTC)

From "Signs and symptoms": "Anaphylaxis typically presents with many different symptoms over minutes or hours." Harrison's Principles states "The life-threatening anaphylactic response of a sensitized human appears within minutes after administration of specific antigen". Do Oswalt and Simons really indicate onset over hours? If so, is this truly "rapid in onset"? Axl ¤  [Talk]  21:06, 1 December 2011 (UTC)
 * Quote is "Clinically, anaphylaxis is considered likely to be present if any one of three criteria is satisfied within minutes to hours" And from the second review in 2009 "Anaphylaxis triggered by red meat thatoccurs 4 to 6 hours after ingestion is due to the oligosaccharide galactose a-1,3 galactose rather than to a protein." I have found a free pdf for the 2009 review-- Doc James (talk · contribs · email) 20:01, 7 December 2011 (UTC)
 * Okay, thanks. Axl  ¤  [Talk]  11:47, 8 December 2011 (UTC)

From "Signs and symptoms": "Respiratory symptoms may also be present, including shortness of breath, wheezes or stridor, and low oxygen." Low oxygen is not a symptom. (Technically, stridor isn't a symptom either. Wheezing is sometimes a symptom in the acute setting, but more usually a sign.) Axl  ¤  [Talk]  20:50, 1 December 2011 (UTC)
 * Sure I was hoping to get away with one or the other since they are similar. Will say symptoms and signs. Doc James (talk · contribs · email) 20:06, 7 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  11:58, 8 December 2011 (UTC)

From "Signs and symptoms": "Due to the presence of histamine-releasing cells in the heart, coronary artery spasm may occur with subsequent myocardial infarction or dysrhythmia even in the absence of epinephrine use." Is it reasonable to remove the qualifier "even in the absence of epinephrine use"? Axl ¤  [Talk]  20:53, 1 December 2011 (UTC)
 * This is important from an ER perspective. MI is typically blamed on Epi. We could move it to the treatment section? Doc James (talk · contribs · email) 20:09, 7 December 2011 (UTC)
 * A general reader wouldn't necessarily have known that MI in this context is typically blamed on epinephrine use. (Actually I didn't know; I inferred it from the sentence.) Perhaps remove the "epinephrine" comment from the "Signs and symptoms" section and add it to the "Management" section? Perhaps say that epinephrine increases the risk of MI? Axl  ¤  [Talk]  14:44, 8 December 2011 (UTC)
 * Moved with new ref.-- Doc James (talk · contribs · email) 06:30, 9 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  12:16, 9 December 2011 (UTC)

From "Signs and symptoms": "A Bezold–Jarisch reflex has been described in 10% of cases, with slow heart rate in association with low blood pressure." Anaphylaxis typically causes tachycardia, doesn't it? It's worth mentioning this before the Bezold–Jarisch reflex. Also, it is worth mentioning "distributive shock" somewhere. Axl ¤  [Talk]  21:14, 1 December 2011 (UTC)
 * Done-- Doc James (talk · contribs · email) 07:49, 9 December 2011 (UTC)
 * Thanks for mentioning fast heart rate. I don't see distributive shock mentioned anywhere though. Axl  ¤  [Talk]  13:28, 9 December 2011 (UTC)
 * Mention shock here Anaphylaxis can cause shock by cardiogenic mechanisms aswell thus I do not feel mentioning that exact subtype adds anything. -- Doc James  (talk · contribs · email) 06:19, 15 December 2011 (UTC)
 * I am surprised that you consider the Bezold–Jarisch reflex to be more relevant than distributive shock. Anaphylaxis is one of the classic causes of distributive shock. The main benefits of epinephrine are vasoconstriction (to increase systemic vascular resistance), relax bronchial smooth muscle, and reduce vascular permeability. Cardiac output plays a minor role. Axl  ¤  [Talk]  21:17, 15 December 2011 (UTC)
 * Okay added. Doc James (talk · contribs · email) 03:55, 16 December 2011 (UTC)
 * Thank you. Axl  ¤  [Talk]  11:29, 16 December 2011 (UTC)

From "Causes", subsection "Medication": "The most common ones include antibiotics (β-lactam antibiotics in particular), aspirin, ibuprofen, and other analgesics." I presume that these are the commonest because they are so commonly prescribed/dispensed? Axl ¤  [Talk]  21:21, 1 December 2011 (UTC)
 * Partly and partly because they are more allergenic. Doc James (talk · contribs · email) 07:49, 9 December 2011 (UTC)
 * Could you include that in the article (with a reference)? Axl  ¤  [Talk]  13:57, 9 December 2011 (UTC)
 * Have added it here -- Doc James (talk · contribs · email) 06:19, 15 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  14:17, 15 December 2011 (UTC)

From "Causes", subsection "Medication": "Chemotherapy agents and herbal preparations have also been implicated." Why are chemotherapy agents specifically called out? Axl ¤  [Talk]  22:06, 1 December 2011 (UTC)
 * Diferent agents have different rates of anaphylaxis associated with them. These are sort of mid risk. Doc James (talk · contribs · email) 08:14, 9 December 2011 (UTC)
 * Okay. I still don't understand why chemotherapy agents have been specifically called out. Axl  ¤  [Talk]  19:27, 9 December 2011 (UTC)
 * The ref does not say why they where singled out. Probably that they are more common than some other types but this is not said directly.-- Doc James (talk · contribs · email) 06:19, 15 December 2011 (UTC)
 * Would you consider removing "chemotherapy agents" from the article? Axl  ¤  [Talk]  21:21, 15 December 2011 (UTC)
 * I have found a book that states "chemotherapy agents are especially implicated" along with a few others I have listed. Doc James (talk · contribs · email) 04:17, 16 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  11:54, 16 December 2011 (UTC)

From "Causes", subsection "Medication": "Some medications (vancomycin, morphine, x-ray contrast among others) cause anaphylaxis by directly triggering mast cell degranulation." Is this truly anaphylaxis (allergy-mediated) or anaphylactoid? Axl ¤  [Talk]  22:02, 1 December 2011 (UTC)
 * Again, in the "Pathophysiology" section, are non-immunological mechanisms truly "allergic"? Axl  ¤  [Talk]  22:56, 1 December 2011 (UTC)
 * The WHO does not use the term anaphylactoid and includes what was previously this group into anaphylaxis. This distinction is discussed some under diagnosis. Doc James (talk · contribs · email) 08:14, 9 December 2011 (UTC)
 * Okay, that's fine. Axl  ¤  [Talk]  19:36, 9 December 2011 (UTC)

Split 1
From "Causes", subsection "Venom": "Venom from stinging or biting insects such as ... Hemiptera (kissing bugs) may induce anaphylaxis in susceptible people." "Kissing bugs" apparently refer to "Triatominae", a subfamily of Hemiptera. Axl ¤  [Talk]  22:33, 1 December 2011 (UTC)
 * Change it to Triatominae? Doc James (talk · contribs · email) 08:14, 9 December 2011 (UTC)
 * The source (Simons) states: "Hemiptera [kissing bugs]". Simons references Peng ("Immune responses to mosquito saliva in 14 individuals with acute systemic allergic reactions to mosquito bites") and Freeman ("Clinical practice. Hypersensitivity to Hymenoptera stings").
 * This reference clearly and reliably links triatominae with anaphylactic reactions. Axl  ¤  [Talk]  20:05, 9 December 2011 (UTC)
 * The ref says "Kissing bugs belong to the family Reduviidae, subfamily Triatominae in the order Hemiptera, and are referred to as triatomines." Not sure what you are suggesting? Doc James  (talk · contribs · email) 06:24, 15 December 2011 (UTC)
 * I am suggesting that Klotz should used as the reference for "kissing bugs"/triatominae, not Simons. Axl  ¤  [Talk]  13:49, 15 December 2011 (UTC)
 * Added Klotz however it is not a review Doc James  (talk · contribs · email) 04:17, 16 December 2011 (UTC)
 * Well, that's debatable. Klotz does include several illustrative example cases. Also, PubMed does not flag it as a review. On the other hand, over half of the article summarizes the available information in the literature. Anyway, thank you for adding it as a reference. Axl  ¤  [Talk]  12:11, 16 December 2011 (UTC)

From "Causes", subsection "Venom": "Previous systemic reactions to stings is a risk factor for future anaphylaxis." What is a "systemic reaction" in this context? Axl ¤  [Talk]  22:35, 1 December 2011 (UTC)
 * Anything more than a local reaction. Doc James (talk · contribs · email) 08:16, 9 December 2011 (UTC)
 * lol Then what is a local reaction? The term "systemic reaction" needs clarification in the article. Axl  ¤  [Talk]  20:09, 9 December 2011 (UTC)
 * How is "systemic reactions, which are anything more than a local reaction around the site of the sting" reffed to  Doc James  (talk · contribs · email) 06:35, 15 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  14:02, 15 December 2011 (UTC)

In "Pathophysiology", I am wary of the weight being given to the IgE-independent immunological mechanism, given that it has not been established in humans. Perhaps it should be given just a single sentence at the end of the "Immunologic" subsection? Axl ¤  [Talk]  23:41, 1 December 2011 (UTC)
 * Thanks for the review. I am a little under the weather right now. Hopefully will be better and able to address this in a few days... Doc James  (talk · contribs · email) 01:26, 4 December 2011 (UTC)
 * I hope that you're feeling better soon. There is no rush with this article. I am about half-way through the review. I should be able to finish it in the next couple of days. Axl  ¤  [Talk]  02:00, 4 December 2011 (UTC)
 * Shortened. -- Doc James (talk · contribs · email) 04:25, 16 December 2011 (UTC)
 * I have re-written the subsection. Axl  ¤  [Talk]  12:56, 16 December 2011 (UTC)

From "Pathophysiology", subsection "Non-immunologic": "These include agents such as ... temperature." Hot or cold temperature? Axl ¤  [Talk]  12:51, 4 December 2011 (UTC)
 * Either / or. Doc James (talk · contribs · email) 08:16, 9 December 2011 (UTC)
 * Can you add this information to the article, please? Axl  ¤  [Talk]  01:27, 11 December 2011 (UTC)
 * Yes have here "temperature (either hot or cold)" Doc James  (talk · contribs · email) 06:37, 15 December 2011 (UTC)
 * Er, where? Axl  ¤  [Talk]  21:27, 15 December 2011 (UTC)
 * Thought you where referring to the causes section here [ http://en.wikipedia.org/wiki/Anaphylaxis#Causes]. Have mentioned in both places.-- Doc James (talk · contribs · email) 04:25, 16 December 2011 (UTC)
 * Thanks. Axl  ¤  [Talk]  19:27, 24 December 2011 (UTC)

From "Diagnosis": "During an attack, blood tests for tryptase or histamine (released from mast cells) might be useful in diagnosing anaphylaxis due to insect stings or medications, but are of limited utility if the cause is food or the person has a normal blood pressure." Can this long sentence be split? Axl ¤  [Talk]  13:14, 4 December 2011 (UTC)
 * Sure-- Doc James (talk · contribs · email) 04:25, 16 December 2011 (UTC)
 * Thanks. I have adjusted the text. Axl  ¤  [Talk]  19:31, 24 December 2011 (UTC)

From "Prevention": "Oral immunotherapy may be effective at desensitizing some people to certain food including mild." "Milk"? Axl ¤  [Talk]  16:29, 5 December 2011 (UTC)
 * Thanks. -- Doc James (talk · contribs · email) 08:39, 9 December 2011 (UTC)

"Management", subsection "Epinephrine" contains extended details of doses and administration. WP:MEDMOS recommends "Do not include dose, titration or pricing information except when they are extensively discussed by secondary sources, or necessary for the discussion in the article. Wikipedia is not an instruction manual or textbook and should not include instructions, advice (legal, medical or otherwise) or "how-to"s." Axl ¤  [Talk]  16:46, 5 December 2011 (UTC)
 * Yes I know. It is tough as this is extensively covered in secondary sources. Have removed the exact dosing. Doc James (talk · contribs · email) 08:17, 9 December 2011 (UTC)
 * Thanks. I have removed the concentrations from the article. Axl  ¤  [Talk]  01:31, 11 December 2011 (UTC)

The "Prognosis" section needs to be expanded. Axl ¤  [Talk]  21:10, 5 December 2011 (UTC)
 * Have combined into epidemiology as their is not sufficient content. Doc James (talk · contribs · email) 20:30, 9 December 2011 (UTC)
 * Moving the text into "Epidemiology" isn't the solution. The "Prognosis" information needs to be expanded. Axl  ¤  [Talk]  01:33, 11 December 2011 (UTC)
 * Managed to dig some stuff up from textbooks and expanded :-) Doc James  (talk · contribs · email) 05:00, 16 December 2011 (UTC)
 * Thanks. That looks a bit better. (I have adjusted the text.) Axl  ¤  [Talk]  12:23, 27 December 2011 (UTC)

From "Epidemiology": "Lifetime prevalence of anaphylaxis is estimated at between 0.05–2% globally or 4 to 50 per 100,000 persons per year. Rates appear to be increasing: prevalence in the 1980s was approximately 20 per 100,000 per year, while in the 1990s it was 50 per 100,000 per year." There is confusion between "prevalence" and "incidence" here. Axl ¤  [Talk]  21:23, 5 December 2011 (UTC)
 * Thanks Doc James  (talk · contribs · email) 08:41, 9 December 2011 (UTC)
 * I have adjusted the syntax. Axl  ¤  [Talk]  16:05, 11 December 2011 (UTC)


 * If I can chip in with an outside comment: my impression is that I've more frequently encountered the term "anaphylactic shock" than "anaphylaxis" per se -- it might be good if the article dealt explicitly with that term, especially since it redirects here. Looie496 (talk) 17:20, 5 December 2011 (UTC)
 * Yes anaphylactic shock specifically refers to anaphylacis with a BP 30% less usual. Will add. Doc James (talk · contribs · email) 08:26, 9 December 2011 (UTC)

Review article pending publication
I am wanting to combine the NICE guideline into this article as it is coming out this month. Hopefully can use it to clarify the last couple of remaining comments. Doc James (talk · contribs · email) 08:43, 9 December 2011 (UTC)
 * Review is out. It does not really add anything. Any further comments? Doc James (talk · contribs · email) 10:25, 22 December 2011 (UTC)

Opinion
Wondering if I could get peoples opinion on "with 2–20% of cases resulting in death.[8]" This seems high to me, but that is what the ref says... Doc James (talk · contribs · email) 04:48, 16 December 2011 (UTC)
 * Found another ref which says 0.7% -- Doc James (talk · contribs · email) 05:03, 16 December 2011 (UTC)

Diagnosis in a table
What do people think of this change? Doc James (talk · contribs · email) 17:17, 9 December 2011 (UTC)
 * It's more confusing. Does diagnosis require involvement of the skin/mucosa and respiratory difficulty/low blood pressure and two or more of the specific symptoms and low blood pressure after exposure to a known allergen? (I know the answer, but the format was less confusing before.) Axl  ¤  [Talk]  17:53, 9 December 2011 (UTC)
 * Have adjusted the table and readded the other format... -- Doc James (talk · contribs · email) 18:10, 9 December 2011 (UTC)
 * Now the information is duplicated. I don't think that table format adds anything; it should be deleted. Axl  ¤  [Talk]  01:23, 11 December 2011 (UTC)
 * Sure removed. -- Doc James (talk · contribs · email) 06:37, 15 December 2011 (UTC)

Summary

 * 1) The article is clear and well-written.
 * 2) The text is accurate, with appropriate reliable references.
 * 3) The article covers the topic thoroughly, without excessive detail.
 * 4) The article presents information with a neutral viewpoint.
 * 5) The article is stable; there is no edit war.
 * 6) The pictures are all free images from Wikimedia Commons. They are appropriately used in this article to complement the text.

I am awarding GA status. My thanks and congratulations to Doc James.

For future improvement, several subsections would benefit from expansion. Also, many of the reference titles have two full stops (periods), which should be fixed.

Axl ¤  [Talk]  12:50, 27 December 2011 (UTC)