Mild Allergic Reactions Research Articles

Complications of therapeutic apheresis in children

Since the equipment of therapeutic apheresis is prepared for adults, the use of it in children may lead to higher complication risks and there are little data in children undergoing therapeutic apheresis. MethodsIn this study the complications experienced during therapeutic apheresis in children between April 2010 and May 2012 at our center are analyzed retrospectively. There were 14 patients who had undergone a total of 50 sessions of therapeutic apheresis. The ages of patients’ ages ranged from 20months to 16years. The procedures were plasma exchange and leukodepletion. ResultsComplications were observed in four patients. One of them was vascular access complication because of insufficient flow. Urticeria was observed in two patients. Abdominal pain and chilling were other complications. Our patients, who underwent TA, did not experience major complications. Minimal or mild allergic reactions were observed and treated by medications. For extracorporeal volume erythrocyte prime is useful. TA will be performed more successfully with correct planning and close examination of the patient with an experienced team.

Plasma Exchange and Intravenous Immunoglobulin in the Treatment of Antibody-Mediated Rejection After Kidney Transplantation: A Single-Center Historic Cohort Study

BackgroundAntibody-mediated rejection (AMR) of a kidney graft has been increasingly recognized as an important cause of graft failure. Our historic cohort study sought to analyze its treatment and outcomes at our center. MethodsAll patients with AMR between 2005 and 2011 were treated with plasma exchange (PE), intravenous low-dose cytomegalovirus (CMV) hyperimmune globulin, and adjustment of basal immunosuppression. We analyzed data regarding baseline characteristics, rejection treatment with focus on PE, complications, and 1-year outcomes. ResultsTwenty-three AMRs occurred in 23 patients (10 male, 13 female) of mean age 41 ± 16 years, all recipients of deceased-donor kidneys with a median of 3 HLA mismatches. The subjects had a median peak panel-reactive antibodies (PRA) of 7% (interquartile range [IQR] 1%–10%). Basal serum creatinine was 174 ± 84 μmol/L estimated glomerular filtration rate (eGFR) (eGFR 42 ± 22 mL/min/1.73 m2), while 3 patients were dialysis- dependent. Median period between transplantation and rejection was 38 months (IQR 1.5–88.5). Concomitant T-cell–mediated rejection was treated in 78% of cases. Median number of PE procedures per patient was 10 (range, 5–17). Treatment was estimated to be successful in 83%. Donor-specific antibodies documented in 12 patients (52%) disappeared or showed reduced titers in 7/10 patients with repeated measurements. An infection was present during treatment in 7 (30%) patients. Among 237 PE, there was 1 (0.4%) mild allergic reaction to fresh frozen plasma and significant metabolic alkalosis occurred after 7 (3%) procedures. One year after rejection the mean serum creatinine level was 144 ± 52 μmol/L and Kaplan-Meier estimated graft and patient survival rates were 62% and 95%, respectively. ConclusionsIntensive treatment with PE, intravenous immunoglobulin, and adjustment of basal immunosuppression were safe and effective to reverse AMR with improved graft function in the majority of patients. However, AMR was associated with markedly decreased 1-year graft survival and the optimal treatment remains uncertain.

IgE- and IgG mediated severe anaphylactic platelet transfusion reaction in a known case of cerebral malaria

Background:Allergic reactions occur commonly in transfusion practice. However, severe anaphylactic reactions are rare; anti-IgA (IgA: Immunoglobulin A) in IgA-deficient patients is one of the well-illustrated and reported causes for such reactions. However, IgE-mediated hypersensitivity reaction through blood component transfusion may be caused in parasitic hyperimmunization for IgG and IgE antibodies.Case Report:We have evaluated here a severe anaphylactic transfusion reaction retrospectively in an 18year-old male, a known case of cerebral malaria, developed after platelet transfusions. The examination and investigations revealed classical signs and symptoms of anaphylaxis along with a significant rise in the serum IgE antibody level and IgG by hemagglutination method. Initial mild allergic reaction was followed by severe anaphylactic reaction after the second transfusion of platelets.Conclusion:Based on these results, screening of patients and donors with mild allergic reactions to IgE antibodies may help in understanding the pathogenesis as well as in planning for preventive desensitization and measures for safe transfusion.

Adverse Reactions to 6% Hydroxyethyl Starch in the Operating Room

Sir, We are reporting a case of allergic reaction to 6% Hydroxyethyl Starch (HES) in the operating room. A 18-year-old male with intertrochanteric fracture in right femur was referred for pre-anaesthetic check-up for dynamic hip screw fixation. Patient had no history of drug allergies and surgery was planned under American Society of Anaesthesiologists grade I (ASA-I). Successful subarachnoid block was achieved with 0.5% Bupivacaine. Crystalloids like Ringer Lactate, 5% Dextrose in 0.9% Sodium Chloride were used to correct fasting status of patient and also as intraoperative fluid of choice. During surgery, pulse volume was low and blood pressure was 90/60mm Hg. 6% HES was used to correct the blood pressure. 6% HES is highly effective plasma expander, less expensive as compared to others and was available in our operating theatres. After few minutes of colloid transfusion, patient started to develop cough, difficulty in breathing, tachypnoea, tachycardia (120/min), hypotension (80/50mmHg). 6% HES transfusion was stopped and 100% oxygen was delivered to the patient via a face mask. Normal saline bolus was given, followed by intravenous (IV) Chlorpheniramine Maleate, Hydrocortisone, Ephedrine, which made the patient haemodynamically stable after some time. HES is synthetic nonprotein colloid solutions that are modified natural polysaccharides consisting of hydroxyethylated polymers of glucose. They are defined by concentration, molar substitution ratio and average molecular weight [1]. The side effects of HES range from mild allergic reactions to severe anaphylactoid reactions. However, their incidences are lowest as compared to those of other colloids and very few cases have been reported till date [2,3]. We couldn’t perform tests like measurement of serum tryptase, plasma histamine or allergen-specific IgE in our patient. We would like to attribute HES as the cause of allergic reaction, because of the signs and symptoms caused soon after its initiation. Here, we would like to stress on the importance of identification of allergic reactions/anaphylaxis intraoperatively, when a colloid is given to a patient, though it is rare. Diagnosis is difficult in a patient under general anaesthesia, as various types of medications are used. Awareness, aggressive therapy with hydration, vasopressors, antihistamines and steroids result in better outcomes in such patients.

Uso do infliximab na consulta de gastrenterologia pediátrica

IntroductionInfliximab is a monoclonal antibody used in refractory inflammatory bowel disease (IBD). AimTo evaluate the clinical response and adverse effects of infliximab therapy in paediatric IBD patients. MethodsAnalytic, descriptive and cross sectional study of Outpatient Clinic of Pediatric Gastroenterology treated with infliximab. ResultsOf six patients treated with infliximab, five have moderate to severe Crohn's disease and one present Ulcerative Colitis. There was clinical remission in five patients. Resolution in analytical changes was observed after 6 months of therapy. There were two mild allergic reactions and a transient elevation of transaminases. ConclusionsIn accordance with the literature, in our population, infliximab therapy has been well tolerated and effective in disease control.

Oral Acetazolamide after Boston Keratoprosthesis in Stevens Johnson Syndrome

BackgroundStevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare but severe and sometimes fatal condition associated with exposure to medications; sulfamethoxazole is among the most common causes. We sought to address the safety of acetazolamide, a chemically related compound, in patients with prior SJS/TEN and glaucoma. A retrospective case series is described of patients at the Massachusetts Eye and Ear Infirmary who underwent keratoprosthesis surgery for corneal blindness from SJS/TEN, and later required oral acetazolamide for elevated intraocular pressure.FindingsOver the last 10 years, 17 patients with SJS/TEN received a Boston keratoprosthesis. Of these, 11 developed elevated intraocular pressure that required administration of oral acetazolamide. One of 11 developed a mild allergic reaction, but no patient experienced a recurrence of SJS/TEN or any severe adverse reaction.ConclusionAlthough an increase in the rate of recurrent SJS/TEN due to oral acetazolamide would not necessarily be apparent after treating only 11 patients, in our series, acetazolamide administration was well tolerated without serious sequela.

A Comparison of Tryptase Levels in Patients with Septic vs. Cardiogenic Shock

Total but not mature tryptase levels in serum are elevated during mild systemic allergic reactions to insect stings and immunotherapy. The current study aims to determine whether this also is the case in septic and/or myocardial shock.

Aliskiren combined with losartan in immunoglobulin A nephropathy: an open-labeled pilot study

Aliskiren is a relatively new oral direct renin inhibitor (DRI) that has been increasingly used for the treatment of diabetic nephropathy and hypertension. Its potential efficacy in nondiabetic chronic kidney diseases that are driven by renin-angiotensin system activation remains to be explored. From a teaching and regional hospital in Hong Kong between July 2009 and March 2010, patients with biopsy-proven immunoglobulin A nephropathy (IgAN) in whom the ratio of protein to creatinine, as measured in early morning urine samples, remained >113 mg/mmol (1000 mg/g), despite receiving the maximum recommended dose of losartan (100 mg daily) were recruited to receive additional DRI treatment. They were followed prospectively for 12 months with changes in proteinuria as the main outcome measure. Twenty-five consecutive patients were enrolled. Treatment with aliskiren for 12 months reduced the mean urinary protein-to-creatinine ratio by 26.3% (95% confidence interval, 20.1-43.6; P = 0.001 versus baseline), with a reduction of ≥ 50% in 24% of patients. There were significant reductions in plasma renin activity (P < 0.0001) and serum interleukin-6 (P < 0.05) and transforming growth factor-β (P = 0.01) levels, compared with baseline. Two patients (8%) developed mild allergic reactions and six (24%) had transient hyperkalemia (K >5.5 mmol/L) during the study. Aliskiren confers an antiproteinuric effect in IgAN patients with significant residual proteinuria, despite receiving the recommended renoprotective treatment. Further prospective randomized trials are warranted to examine its long-term renoprotective potential. This trial is registered with the ClinicalTrials.gov number NCT00922311.

Exanthema after a stress Tc-99m sestamibi study: continue with a rest sestamibi study?

A mild allergic reaction assumed to be caused by injection of Tc-99m sestamibi for a stress myocardial perfusion imaging (MPI) is presented. We want to discuss the risk involved in completing the MPI with another sestamibi injection, and the precautions and possible treatment in case of a further reaction. A patient experienced a maculo-papular exanthema, i.e. a mild, probably allergic, adverse event (AE) after a stress MPI including administration of a dose of Tc-99m sestamibi. A rest MPI was needed to decide whether coronary bypass surgery should be performed. After prophylactic treatment with antihistamine and corticosteroid, an uneventful rest MPI was performed. International recommendations or guidelines related to treatment of AEs after nuclear medicine studies do not exist. Serious AEs in nuclear medicine are very rare, but anaphylactic reactions have been reported and may be life threatening. If repeated administration of the radio-pharmaceutical must be given, the prophylactic and therapeutic interventions should follow general international guidelines for allergic reactions.

Monitoring strategy as a tool for blood transfusion safety

Transfusion reactions are complications of blood component transfusions and may be a risk to patients. The risks range from mild urticariform reactions to fatal reactions if not recognized and dealt with promptly. Moreover, with the improvement of serological techniques over the last decades, surveillance of acute reactions has become more and more important as this decreases the risk of transmitting infectocontagious diseases.(1,2) Recently, several initiatives to improve transfusion safety have been described and current legislation addresses this question; the emphasis is always on trying to guarantee the safety of patients who might need transfusion support.(3,4) In addition, problems related to the under-notification of complications are being discussed worldwide.(5,6) Hospital Pompeia is a charity foundation with approximately 350 beds and is a referral center for a region of around one million inhabitants - especially in respect to trauma, neurosurgery and oncology. The Hospital takes care of National Health Service patients through its own transfusion agency, with blood components being supplied by the regional blood center in Caxias do Sul. The supply for patients who have health care insurance, as well as private patients, comes from the Caxias do Sul Blood Bank that manages an independent transfusion agency inside the Hospital. Aiming at guaranteeing transfusion safety of patients in the Hospital, a transfusion monitoring program was introduced. In the beginning, the strategy was implemented in respect to the Regional Caxias do Sul Blood Bank and then the same methodology was used in the Hospital's own Blood Bank, thereby standardizing transfusion care. Implementation took place in 2008. The monitoring program, which aims at identifying transfusion reactions, is carried out by the professionals administering transfusions. Monitoring consists of observing the first 15 minutes of all transfusions and evaluating the patients who received plasma or cryoprecipitate at the end of the transfusion. Patients receiving red blood cell concentrates are monitored during the first 15 minutes and then are reevaluated one hour after the start of the transfusion and again at the end (time calculated according to the drip). All patients are asked about signs and symptoms which may be related to transfusion reactions and their vital signs are checked. Whenever a transfusion reaction is identified, the duty physician of the hospital examines the patient. The transfusion teams of both agencies were trained and the data from the first 6 months of 2010 were evaluated. During that period, 4121 transfusions were performed at the hospital ranging from 518 in May to 887 in January with an average of 683 transfusions per month. In these six months, 18 acute transfusion reactions were diagnosed; the most frequent were mild allergic reactions and febrile nonhemolytic reactions. The reaction rate was 4.3 reactions per 1000 transfusions. ANVISA, the Brazilian National Health Surveillance Agency considers an incidence of 3 reactions per 1,000 transfusions to be an under-notification of transfusion reactions. From these data, it is estimated that in the state of Rio Grande do Sul and in Brazil there are under-notifications of 73.4% and 78.2%, respectively. The authors believe that with an incidence of 4.3 reactions per 1000 transfusions the methodology described guarantees transfusion safety, making prompt medical care possible while providing adequate notification to the Health Surveillance Agency in respect to immediate transfusion reactions.(7)

Computed Tomography-Guided Preoperative Radiotracer Localization of Nonpalpable Lung Nodules

We describe preoperative computed tomography (CT)-guided injection of radiotracer technetium (99m) macroaggregates ((99m)Tc-MAA) in challenging small lung nodules, intraoperative localization, and resection. Between November 2007 and February 2010, 44 patients with 47 lung nodules which were detected incidentally or at screening and that were (18)F-fluorodeoxyglucose positron emission tomography ((18)F FDG-PET) positive or increasing in size at subsequent CT scans were candidates for surgical biopsy. Inclusion criteria for preoperative percutaneous CT-guided (low-dose technique) (99m)Tc-MAA localization included having at least one of the following characteristics: nodule size less than 1 cm, subsolid morphology, or distance from the pleura greater than 1 cm. Mean nodule size was 11 mm (range, 5 to 24 mm); 24 nodules were nonsolid, 15 nodules were partially solid, and 8 nodules had a solid morphology. Mean distance from the pleura was 11 mm (range, 0 to 35 mm). Localization complications included 13 minor asymptomatic pneumothoraces, 9 parenchymal hemorrhage suffusions, 1 mild allergic reaction to contrast medium, and 2 patients with chest pain after the procedure. Nine patients had mild extravasation of radiotracer into the pleura. In 2 cases, there was an extravasation of a significant quantity of radiotracer into the pleural cavity. Thoracoscopic biopsy was performed in 30 cases, 2 cases were converted to thoracotomy, and 12 patients underwent intentional thoracotomy. Asymptomatic subjects with suspicious nodules detected by screening or incidental CT are best candidates due to small lesion size and high percentage of nonsolid morphology, making thoracoscopic biopsy potentially difficult. Radiotracer localization is a safe, versatile, simple technique to help perform diagnosis with a minimally invasive approach in nonpalpable lung lesions.

Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy

Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy

Autologous bone marrow-derived mesenchymal stromal cell treatment for refractory luminal Crohn's disease: results of a phase I study

Background and aimMesenchymal stromal cells (MSCs) are pluripotent cells that have immunosuppressive effects both in vitro and in experimental colitis. Promising results of MSC therapy have been obtained in patients...

Transfusion premedication to prevent acute transfusion reactions: a retrospective observational study to assess current practices

The use of premedication to prevent acute transfusion reactions has been estimated to occur in 50% to 80% of transfusions. While this practice has some biologic rationale, few clinical studies have been performed to assess the efficacy of this practice, and the methodologic quality of these studies is variable. The primary objective of this study was to describe current practices regarding transfusion premedication to prevent febrile nonhemolytic transfusion reactions, mild allergic transfusion reactions, and transfusion-associated circulatory overload. We conducted an observational retrospective chart review of a stratified random sample of 324 transfusions that took place over a 6-month period. Data were abstracted from medical records and then scanned into a database for analysis. We calculated inter- and intraobserver agreement on key abstracted data to estimate assessment error. A two-phase adjudication process was used to determine whether or not medications given before the time of each transfusion were intended as premedications. Of the transfusions sampled, 1.6% (95% confidence interval, 0.4-3.9) were associated with premedication medications to prevent an acute transfusion reaction. Inter- and intraobserver reliability in the abstraction of key data points was good. Good agreement in adjudicator classification of outcomes was achieved only when adjudicators were provided with patient source documents. Premedication use was infrequent and much less common than previously reported. Improved methods of capturing transfusion premedication, which likely require prospective assessments, are needed for future research studies.

Crise de tétanie

Background: Medical emergencies in dental offices are considered a problem in most countries owing to dentists’ concerns about emergency preparedness, practical skills, lifesaving equipment and staff availability. The prevalence of medical emergencies in dental offices and dentists’ preparedness have been analysed in several countries but have never been studied in Poland. Aim: To assess the prevalence of medical emergencies in dental offices in Poland, as well as dentists’ preparedness and attitudes towards medical emergencies. Methods: An 18-item questionnaire was completed by 419 dentists. It asked for information on their cardiopulmonary resuscitation training, availability of emergency medical equipment in the dental office, prevalence of medical emergencies and self-assessed competence in various dental office emergencies. Data were analysed using the Statistica 13.3 software package. Variability was measured with standard deviation. Pearson’s linear correlation coefficient was used to determine correlation strength. Results: The most common medical emergencies in Polish dental offices were vasovagal syncope (46.30% of study participants experienced at least one case in the preceding 12 months), orthostatic hypotension (18.85%), hyperventilation crisis (18.61%), mild allergic reactions (16.23%), hypoglycaemia (15.99%) and seizures (11.81%). The prevalence of medical emergency situations requiring an emergency medical service call or medical assistance within the preceding 12 months was 0 for 80.66% of dentists, one for 12.65%, two for 4.53%, three for 1.20%, four for 0.48%, 5–10 for 0.48% and more than 10 for 0%. As many as 41.29% of the participants did not feel competent in managing sudden cardiac arrest, 74.47% in managing hypertensive crisis, 55.61% in managing asthma, 55.13% in managing anaphylactic shock and 52.99% in managing seizures. Conclusion: The prevalence of medical emergencies in dental offices in Poland is comparable with that in other countries. A large number of dentists do not feel competent enough to manage medical emergencies. Better undergraduate and postgraduate training in medical emergencies is recommended, as well as broader availability of emergency medical equipment in the dental office.

An open, multicenter clinical study on cetuximab combined with intensity modulated radiotherapy (IMRT) plus concurrent chemotherapy in nasopharyngeal carcinoma (NPC): Preliminary report.

5577 Background: To evaluate the safety and efficacy of cetuximab combined with IMRT + concurrent cisplatin chemotherapy in patients with loco-regionally advanced NPC in a Chinese multicenter clinical study. Methods: Patients with primary stage III – IVb non- keratinizing NPC were enrolled. The planned dose of IMRT to gross tumor volume (GTV) was 66 - 75.9 Gy in 30-33 fractions. Cisplatin (80mg/m2,q3week [w]) and cetuximab (400mg/m2 one w before radiation, and then 250mg/m2/w) were given concurrently for 6 - 7 weeks. The response rate was evaluated according to RECIST, and adverse events (AEs) were graded according to CTCAE v3.0. Results: From July 2008 to April 2009, 100 patients were enrolled with 74 male and 26 female. Median age was 43 years old. The proportion of patients with stage III, IVa and IVb disease was 71%, 22% and 7%, respectively. Actual median dose to GTV was 69.96 Gy. Median dose of cisplatin was 133.17 mg, median first-dose of cetuximab was 690 mg, and median weekly dose was 410 mg. 99% of all included patients finished the planned treatment. AEs were well tolerated and manageable, mainly consisting of acneiform skin eruptions, dermatitis, mucositis, xerostomia and slight ALT elevations (grade 1 - 2). Only one patient had a mild allergic reaction, happening in the first w of cetuximab therapy. 64% of patients had ≥ grade 2 acneiform eruptions, mainly starting at the third week of cetuximab treatment. From the third week of radiotherapy, 58% and 90% of the patients began to suffer from grade 1 dermatitis and ≥ grade 2 mucositis, respectively, while grade 4 mucositis (spontaneous bleeding) was observed in 2% of the patients. 40% of patients experienced ≥ grade 2 xerostomia. Besides mucositis, no other grade 4 AEs were observed. Bone marrow suppression was mild, and only 8%, 4% and 5% patients had ≥ grade 2 decreased ANC, Plt and Hb, respectively. At the third month after treatment, 1 patient died of dysphagia. Clinical remission rate (CR + PR) was 100%. Conclusions: The combined treatment modality of IMRT + concurrent chemotherapy + cetuximab in loco- regionally advanced NPC was well tolerated, with a very encouraging clinical response rate. No significant financial relationships to disclose.

Posterior Spinal Artery Infarct due to Patent Foramen Ovale

Case report. To report the first case of posterior spinal artery (PSA) infarct due to patent foramen ovale (PFO). Infarct in the territories of PSA are very rare: till now 38 cases are reported in the literature. Moreover only 1 case of spinal cord infarction was attributed to paradoxical embolism through PFO, but in the anterior spinal artery territory. A 60-year-old woman was hospitalized for sudden numbness of the right leg. Neurologic examination revealed right leg mild paresis and loss of proprioception and dysesthesia at T11. Spine-MRI showed T5-T7 posterolateral cord ischemia. Transesophageal echocardiography disclosed a PFO with severe right-left shunt confirmed by transcranial Doppler. During the hospitalization she was treated with oral-500 mg ticlopidine, because of a mild allergic reaction to acetylsalicylic acid. No steroids were administrated. Physiotherapy was performed daily. Motor and urinary symptoms disappeared in 20 days. At 1-month clinical follow-up only suspended dysesthesia on the right side was present. At 3 months follow-up spine-MRI showed no signal abnormalities within the spinal cord but the patient still complained of dysesthesia. The therapy was changed to oral 75 mg clopidogrel, cause of leucopoenia. At 1-year follow-up dysesthesia was still present, but less complaining and no recurrence and adverse effect due to clopidogrel therapy were reported. This report describe a case of acute nontraumatic myelopathy. At 4 days after onset, PSA infarct was diagnosed on the basis of neurologic findings and MR images. After extensive diagnostic work-up, we were able to identify only PFO, so it was the first case of PSA due to probable paradoxical embolism. The patient was treated with antiplatelet therapy with good recovery and no recurrence at 1-year follow-up.

Oral desensitization to milk: how to choose the starting dose!

Mori F, Pucci N, Rossi ME, de Martino M, Azzari C, Novembre E. Oral desensitization to milk: how to choose the starting dose! Pediatr Allergy Immunol 2010: 21: e450–e453. © 2009 John Wiley & Sons A/SA renewed interest in oral desensitization as treatment for food allergy has been observed in the last few years. We studied a novel method based on the end point skin prick test procedure to establish the starting dose for oral desensitization in a group of 30 children higly allergic to milk. The results (in terms of reactions to the first dose administered) were compared with a group of 20 children allergic to milk as well. Such control group started to swallow the same dose of 0.015 mg/ml of milk. None reacted to the first dose when administered according to the end point skin prick test. On the other side, ten out of 20 children (50%) from the control group showed mild allergic reactions to the first dose of milk. In conclusion the end point skin prick test procedure results safe and easy to be performed in each single child in order to find out the starting dose for oral desensitization to milk, also by taking into account the individual variability.

Sixteen Years of Severe Tiger Snake (Notechis) Envenoming in Perth, Western Australia

We aimed to describe the characteristics, clinical course, management and outcome of patients presenting to Perth teaching hospitals after envenoming by Tiger snakes. We undertook a chart review from six Perth teaching hospitals over a 16 year period from 1990 to 2005. Data were collected by a trained investigator using a preformatted data abstraction tool. We included patients bitten in the appropriate geographical area, with defibrination coagulopathy and positive Venom Detection Kit result for Tiger snake or response to specific antivenom. Of 381 charts reviewed, 23 patients were envenomed by a Tiger snake. The mean age was 36 years, 83% were male and all were bitten on a limb. First aid was applied poorly and all patients were symptomatic on presentation. Six patients developed rhabdomyolysis, one renal failure, four clinical bleeding, three neurotoxicity, one non-fatal respiratory arrest and one fatal cardiac arrest. All patients received antivenom, 13 received adrenaline premedication, with two mild allergic reactions developing in non-premedicated patients. The average dose of antivenom was four ampoules. Mean hospital stay was 2.6 days. This is the largest series of Tiger snake envenoming reported in Australia. Only one patient of 23 (4%) died, despite all patients being significantly envenomed. With rapid antivenom treatment and modem emergency and intensive care management, most patients envenomed by Tiger snakes survive.

Adverse reactions after the use of sulphur hexafluoride (SonoVue) echo contrast agent

The aim of the present study was to analyse the adverse effects of SonoVue echo contrast in a consecutive series of 352 cardiac patients during a 4-year period. During 352 consecutive cardiac SonoVue studies, seven patients (2.0%) experienced adverse effects. Four patients (1.1%) had mild allergic reactions causing skin erythema and mild sinus tachycardia, and three patients (0.9%) experienced a severe allergic reaction resulting in (nonfatal) shock. The reported incidence of adverse effects of SonoVue echo contrast in this consecutive series of cardiac patients seems markedly higher than those reported in a company postmarketing analysis.