Near-fatal Events Research Articles

Vascular complications in patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors

Background: Patients with chronic myeloid leukemia (CML) now have an improved life expectancy similar to that of the general population due to the introduction of tyrosine kinase inhibitors (TKIs). However, many patients experience mild to severe adverse events while undergoing TKI treatment. This review aimed to discuss the adverse events of TKIs, including myocardial infarction and hypertension, and comprehensively analyze strategies for minimizing vascular complications.Current Concepts: Near-fatal cardiovascular events (CVEs) are common among patients receiving nilotinib and ponatinib. However, those receiving other TKIs, such as imatinib and dasatinib, rarely experience CVEs. Among these CVEs, vascular complications, including peripheral arterial occlusion, venous occlusion, and hypertension, are exacerbated in patients with pre-existing vascular risk factors and prolonged TKI use. Therefore, it is crucial to assess predisposing factors to vascular complications and select the optimal TKI to minimize serious CVEs before initiating therapy. Additionally, patients should be closely monitored for vascular complications during nilotinib and ponatinib treatment.Discussion and Conclusion: Despite advancements in therapeutic approaches and research on CML leading to the development of target-specific TKIs aiming to minimize side effects, newer generations are not entirely devoid of adverse events. Hence, it is important for patients and physicians to be knowledgeable about these medications to effectively monitor for side effects, particularly those that are life-threatening, such as vascular toxicity. It is now more important than ever to carefully observe symptoms and perform adequate testing to identify at-risk individuals early and avoid preventable adverse events.

Obesity is a risk factor for worse asthma exacerbation outcomes in the United States

Obesity is an important risk factor for the development of asthma and increased asthma morbidity. Large epidemiological studies addressing the impact of obesity on near-fatal asthma events are lacking. Here we determine if obesity is a risk factor for worse outcomes in asthma patients with an exacerbation.

Three near fatal or fatal complications during implantation of tunnelled hemodialysis catheters : Learning from experts.

Tunnelled hemodialysis catheters are well accepted and widely used devices to provide vascular access for dialysis in patients when an arteriovenous shunt is not feasible or dysfunctional. In the literature complications after implantation are well documented but fatal or near-fatal events during implantation are seldom reported. In this article 3 such cases from asingle tertiary center over aperiod of more than 10 years are presented and discussed. The (near) fatal complications occurred despite experienced surgeons and the use of ultrasound and fluoroscopy during implantation. Although the incidence is estimated to be much less than 1% at this centre, implantation of atunnelled hemodialysis catheter is demanding, athorough evaluation of vascular structures in advance is mandatory and experiencend professionals with high index of suspicion are essential. Performing the procedure with the patient under conscious sedation has benefits compared to general anesthesia. If the patient indicates atypical pain, the procedure should be stopped immediately and re-evaluated for any cause. If aperforation with relevant vascular damage is suspected, we recommend leaving the dilator/introducer/catheter in place to reduce major hemorrhage until the vascular or cardiothoracic surgeon can fix the problem.

Complications of operative hysteroscopy: an anaesthetist's perspective

Operative hysteroscopy has revolutionised the management of gynaecological diseases. There were 71,000 hysteroscopies performed in England in 2019–2020, of which almost half were therapeutic. They are minimally invasive, cost and time effective and can spare patients major surgery. They are seen as low-risk procedures often performed in patients who are otherwise fit (ASA Grade 1 or 2), but complications in operative hysteroscopy can be immediate, severe and life-threatening. Over the past decade, multiple near-fatal and fatal events have been reported.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal.

PurposeAcute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.MethodsWe conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.ResultsThe AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43–4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11–3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362–6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.ConclusionThe current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

Major Earthquake Experience and Presently-Gratifying Expenditures

Major natural disasters are often life-changing events, capable of potentially altering the economic behavior of those who experience it first-hand. We investigate the impact of experiencing a major earthquake on individuals’ investment and consumption expenditure shares using the major earthquakes in China from 1920 to 2008. We focus on the hypothesis that first-hand experience with a major earthquake influences consumption towards presently gratifying items and experiences. A theoretical framework is provided in which the attraction of current consumption is heightened by direct experience with previous near-fatal events. We compare the expenditure patterns of individuals who began residing in earthquake-stricken areas in China directly before a major earthquake with those who began their residence in the area directly afterwards. Numerous robustness checks and placebo tests in the context of China’s institutional migration regulations, are conducted to provide confidence in the identification approach. On average, individuals who experienced a major earthquake early in life tend to invest less in human capital, while spending more on entertainment, conspicuous consumption, health enhancements and convenience services during their subsequent years as household heads. Our study makes progress in understanding the factors which explain long term behavioral heterogeneity in spending and investment tendencies.

Induction of homeostatic biological parameters in reward deficiency as a function of an iron-free multi-nutrient complex: Promoting hemoglobinization, aerobic metabolism, viral immuno-competence, and neuroinflammatory regulation.

Background:A common neurological condition worldwide is Reward Deficiency Syndrome (RDS) leading to both substance and non-substance addictive behaviors, that must be combatted by integrating both central nervous system and peripheral nervous system biological approaches. Integrity of hemoglobin is a crucial determining factor for the overall health functions. Nutrient repletion therapy should be a fundamental strategy to restore the healthy properties of blood. A unique patent-pending iron-free VMP35 formulation was engineered by our laboratory to restore iron-dependent hemoglobin in anemic cells using a proprietary Prodosome® absorption technology. This formulation, containing an array of nano-emulsified botanical ingredients rich in bioflavonoids, strengthens the structural integrity of connective tissues, and potentiates immune competence, cellular aerobic metabolism, and enhances efficient regulation of inflammatory events. We discuss the intricate aspects of strong vs. fragile immunity and consequential inflammatory responses to convey a deeper understanding of the varied and overly complex sequela of immunological behaviors and events. The effect of the VMP35 is mediated through highly absorbable nutritional/nutrigenomic repletion enabling improvements in the systemic set of functional behaviors. In fact, the iron-free VMP35 facilitates a “Systems Biology Approach” which restores hemoglobin status, reverses anaerobic hypoxia, improves competent immune responsivity, and regulates appropriate and controlled activation of general and neuro-inflammatory sequela. Under these pathogenic circumstances, iron-deficiency anemia has been misconceptualized, and a new nosological term, Chronic Anemia Syndrome, is proposed. The comparative therapeutic rationale of Reductionist vs. Systems Biology approaches is also explained in detail.Methods:The efficacy of the novel therapeutic iron-free VMP35 liquid nutraceutical is detailed in restoring iron-dependent hemoglobin to RBCs and boosting cellular morphology, viability, and immune competence, thereby reducing the need for prolonging inflammatory sequela.Results:This was demonstrated in a previous IRB approved multi-subject human study. In addition, two recent case studies report dramatic restorative benefits of nutrient repletion therapy of the VMP35 on subjects having experienced near-fatal events, which confirmed the findings explained in this manuscript.Conclusions:This novel iron-free VMP35 modulates an array of homeostatic biological parameters such as enhanced hemoglobinization, aerobic metabolism, viral immuno-competence, and inflammatory regulation. Further research, examining mechanistic and beneficial effects in athletic performance, is in progress. Importantly, during these troubled immune challenging times, modulating an array of homeostatic immunological and inflammatory dysfunctions are tantamount to improved population outcomes.Trial registration:The Clinical investigation in a total of 38 subjects was conducted under an Institutional Review Board (IRB) from the Path Foundation in New York, NY (#13-009 April 25, 2013). The two case studies were done at Lancaster General Hospital, Lancaster, PA, and Jefferson University Hospital, Philadelphia, PA, USA. Both studies were retrospectively registered.

Tolerability of a comprehensive cardiorespiratory monitoring protocol in an epilepsy monitoring unit

BackgroundRecent reports of fatal or near-fatal events in epilepsy monitoring units (EMUs) and an increasing awareness of the effects of seizures on breathing have stimulated interest in cardiorespiratory monitoring for patients undergoing video-electroencephalography (EEG) recording. Patient and provider acceptance of these extra recording devices has not previously been studied and may represent a barrier to widespread adoption. MethodsWe queried EMU subjects regarding their experiences with a monitoring protocol that included the continuous measurement of oral/nasal airflow, respiratory effort (chest and abdominal respiratory inductance plethysmography), oxygen saturation, and transcutaneous CO2. Surveys were returned by 71.4% (100/140) of eligible subjects. ResultsOverall, 73% of participants reported being moderately to highly satisfied with the monitoring, and 82% reported moderate to strong agreement that advance knowledge of the monitoring would not have changed their decision to proceed with the video-EEG study. Except for nasal airflow, none of the additional monitoring devices caused more discomfort than EEG electrodes. ConclusionPatient acceptance of an EMU comprehensive cardiorespiratory monitoring protocol is high. The information obtained from “multimodality recording” should help clinicians and investigators understand the effect of seizures on both cardiac and respiratory physiology, may enhance safety in the EMU, and may aid in the identification of biomarkers for sudden unexpected death in epilepsy (SUDEP).

A Focus on Pharmacological Management of Catecholaminergic Polymorphic Ventricular Tachycardia.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a channelopathy characterized by adrenergic mediated ventricular arrhythmia. Untreated CPVT is a malignant syndrome with more than 50% of arrhythmic events and up to 25% of fatal or near-fatal cardiac events at 8 years follow-up. Prevention of sudden cardiac death starts with exclusion of competitive sports. Beta blockers (BB) are the cornerstone pharmacological therapy for the prevention of cardiac event in CPVT patients. Dose of BB should be highly tolerable, preferably nadolol. Efficiency of BB is undeniable but uncompleted. Therefore, on top of BB, one can propose the use of Calcium channel blockers or Class 1c antiarrythmic drugs. Indeed Flecainide allows reducing exercise- induced premature ventricular contraction and ventricular arrhythmia. Pharmacological management should be a stepwise approach with BB as the first line of choice. At each step of therapeutic changes, heart rhythm during exercise should be monitored by Holter monitoring and exercise testing. If the pharmacological management fails, left cardiac sympathetic denervation or implantation of cardioverter defibrillator should be considered.

Occupational Asthma, Not a Trivial Disorder and a Source of Fatal and Near-Fatal Events

Purpose of review Asthma is one of our society’s heaviest health burdens, which is estimated to be responsible for 250,000 deaths every year. Whenever severe asthma with fatal or near-fatal events is described, occupational asthma is not specifically mentioned, but its importance should not be underestimated.

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Nationwide experience of catecholaminergic polymorphic ventricular tachycardia caused by RyR2 mutations

ObjectiveThe aim of this study was to characterise disease penetrance, course of disease and use of antiarrhythmic medication and implantable cardioverter-defibrillator (ICD) therapy in a Danish nationwide cohort of patients...

Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease.

BackgroundLittle is known about patients who frequently visit the emergency department (ED) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to quantify the proportion and characteristics of patients with frequent ED visits for AECOPD and associated healthcare utilization.MethodsWe conducted a retrospective cohort study of adults aged ≥40 years with at least one ED visit for AECOPD between 2010 and 2011, derived from population-based all-payer data of State ED and Inpatient Databases for two large and diverse states: California and Florida. Outcome measures were frequency of ED visits for AECOPD, 30-day ED revisits, subsequent hospitalizations, near-fatal events (AECOPD involving mechanical ventilation), and charges for both ED and inpatient services (available only for Florida) during the year after the first ED visit.ResultsThe analytic cohort comprised 98,280 unique patients with 154,736 ED visits for AECOPD. During the 1-year period, 29.4% (95% CI, 29.1%-29.7%) of the patients had two or more (frequent) visits, accounting for 55.2% (95% CI, 54.9%-55.4%) of all ED visits for AECOPD. In the multivariable model, significant predictors of frequent ED visits were age 55–74 years (vs. 40–54 years), male sex, non-Hispanic white or black race, Medicaid insurance (vs. private), and lower median household income (all P < 0.001). At the visit-level, 12.3% of ED visits for AECOPD were 30-day revisit events (95% CI, 12.1%-12.4%). Additionally, 62.8% of ED visits for AECOPD (95% CI, 62.6%-63.0%) resulted in a hospitalization; patients with frequent ED visits comprised 55.5% (95% CI, 55.2%-55.8%) of all hospitalizations. Furthermore, 7.3% (95% CI, 7.3%-7.5%) of ED visits for AECOPD led to a near-fatal event; patients with frequent ED visits accounted for 64.4% (95% CI, 63.5%-65.3%) of all near-fatal events. Total charges for AECOPD were $1.94 billion (95% CI, $1.90-1.97 billion) in Florida; patients with frequent ED visits accounted for $1.07 billion (95% CI, $1.04-1.09 billion).ConclusionsIn this large cohort study, we found that 29% had frequent ED visits for AECOPD and that lower socioeconomic status was significantly associated with a higher frequency of ED visits. Individuals with frequent ED visits for AECOPD accounted for a substantial amount of healthcare utilization and financial burden.

Epidemiology of Emergency Department Visits for Opioid Overdose: A Population-Based Study

ObjectivesTo evaluate the rate of emergency department (ED) visits for opioid overdose and to examine whether frequent ED visits for opioid overdose are associated with more hospitalizations, near-fatal events, and health care spending. Patients and MethodsRetrospective cohort study of adults with at least 1 ED visit for opioid overdose between January 1, 2010, and December 31, 2011, derived from population-based data of State Emergency Department Databases and State Inpatient Databases for 2 large and diverse states: California and Florida. Main outcome measures were hospitalizations for opioid overdose, near-fatal events (overdose involving mechanical ventilation), and hospital charges during the year after the first ED visit. ResultsThe analytic cohort comprised 19,831 unique patients with 21,609 ED visits for opioid overdose. During a 1-year period, 7% (95% CI, 7%-7%; n=1389 patients) of the patients had frequent (2 or more) ED visits, accounting for 15% (95% CI, 14%-15%; n=3167) of all opioid overdose ED visits. Middle age, male sex, public insurance, lower household income, and comorbidities (such as chronic pulmonary disease and neurological diseases) were associated with frequent ED visits (all P<.01). Overall, 53% (95% CI, 52%-54%; n=11,412) of the ED visits for opioid overdose resulted in hospitalizations; patients with frequent ED visits for opioid overdose had a higher likelihood of hospitalization (adjusted odds ratio, 3.98; 95% CI, 3.38-4.69). In addition, 10.0% (95% CI, 10%-10%; n=2161) of the ED visits led to near-fatal events; patients with frequent ED visits had a higher likelihood of a near-fatal event (adjusted odds ratio, 2.27; 95% CI, 1.96-2.66). Total charges in Florida were $208 million (95% CI, $200-$219 million). ConclusionIn this population-based cohort, we found that frequent ED visits for opioid overdose were associated with a higher likelihood of future hospitalizations and near-fatal events.

P74 ‐ Brittle asthma: a clinical phenotype of severe asthma

The term Brittle Asthma was generally used to describe those patients with sudden, severe attacks, usually out of the blue. Recently the following classification was suggested: type 1 characterized by a maintained wide PEF variability despite medical therapy, and type 2 characterized by sudden acute attacks on a background of apparently normal airway function. Patients who develop sudden-onset near-fatal asthma seem to have massive allergen exposure and emotional distress. Diminished perception of dyspnea and reduced compliance with anti-inflammatory therapy have been associated with fatal or near-fatal events. We are presenting two case reports of two patients admitted to emergency service due to severe asthma attacks. The first, 31 year-old patient with clinical history: allergic rhinoconjunctivitis since the age of 16 and untreated atopic asthma since the age of 20. At the moment of hospitalization he was without conscience, with tachypnea, cyanosis and the following vital signs: temperature 37.4°C, blood pressure 90/60 mmHg, pulse rate 140 bpm. The second, 40 year-old patient, was admitted with cyanosis, breathless and agitated with the following vital signs: temperature 37°C, blood pressure 70/40 mmHg, pulse rate 130 bpm. ABG yielded the following: PO2 87.8 mmHg, PCO2 70.9 mmHg, pH 7.14, BE 8.4. His clinical history was: allergic asthma and rhinoconjunctivitis since the childhood, reappearance of asthma at the age of 22, and frequent avoidance of steroid therapy. At the thoracic examination diffuse inspiratory and expiratory wheezes with prolonged expiratoy phase were present. Chest radiography and EKG were normal. Laboratory: blood count, renal, liver functions were normal. They were successfully resuscitated and recovered completely after aggressive treatment. We considered our patients as type 2 brittle asthma. Poor adherence with steroid treatment, ignoring the symptoms of airways obstruction, and emotional distress are offending factors for these near fatal attacks. Patients with brittle asthma are difficult to manage. They have to be monitored firmly and treat the acute attacks with self-administered subcutaneous adrenaline.

Loss of asthma control after cessation of omalizumab treatment: real life data

IntroductionMany clinical and observational studies have demonstrated effectiveness of omalizumab (OMA) in the treatment of severe asthma, but the optimal duration of the therapy remains unknown.AimThe article presents the authors’ clinical experience on OMA cessation in routine practice.Material and methodsDue to new reimbursement criteria, OMA therapy has been interrupted in 11 subjects (6 women/5 men). The mean age of patients was 50.73 ±14.16 years, the mean time of severe asthma duration was 13.54 ±6.05 years. All of them had an excellent/good response to OMA. The duration of OMA therapy was 67.73 ±11.64 months.ResultsNine out of 11 patients had severe asthma exacerbation within the first 5 months after the OMA withdrawal. The mean time to the first severe exacerbation was 7.56 ±2.67 weeks. Between the time of OMA cessation and the time of reassessment, the mean score of Asthma Control Questionnaire increased from 2.58 ±0.71 to 3.63 ±1.26 points and the mean score of Asthma Quality of Life Questionnaire decreased from 4.3 ±1.91 to 3.18 ±1.17 points. The mean oral corticosteroids (OCS) dose increased from 4.61 ±3.0 mg/day to 33.33 ±13.12 mg/day. The number of exacerbations within the last 12 months increased from 1.6 ±0.67 to 5.2 ±1.4, and the number of hospitalizations or emergency room (ER) attendence increased from 0.11 ±0.31 to 1.56 ±1.26.ConclusionsThese data indicate that the withdrawal of OMA therapy after the successful long-term therapy may cause severe asthma exacerbations. Therefore, the decision regarding cessation of OMA treatment should be undertaken individually after careful weighing benefits and risks, especially in patients with a long history of severe asthma, treated with high doses of OCS before OMA introduction, near-fatal asthma events and/or aggravation of asthma during previous episodes of interruptions in OMA treatment.

Cardiac Arrest and Neuromuscular Blockade Reversal Agents in the Transplanted Heart

CASES OF CARDIAC ARREST after the administration of a neuromuscular reversal agent have been reported in the literature. However, no clear explanation of these near-fatal events has been formulated. In the authors' institution, 2 additional cases of cardiac arrest have been experienced. Therefore, this study reviewed the characteristics of all available patients and, in conjunction with the latest studies on heart transplant patients, speculated on the possible causes of these events.

Age-related differences in clinical outcomes for acute asthma in the United States, 2006-2008

Little is known about the effect of age on acute asthma outcomes. We sought to investigate age-related differences in the emergency department (ED) presentation and clinical outcomes for patients with acute asthma. We analyzed the 2006-2008 Nationwide Emergency Department Sample, the largest, all-payer, US ED and inpatient database. ED visits for acute asthma were identified with a principal diagnosis of International Classification of Disease, ninth revision, Clinical Modification code 493.xx. Patients were divided into 3 age groups: children (<18 years), younger adults (18-54 years), and older adults (≥55 years). The outcome measures were in-hospital all-cause mortality, near-fatal asthma-related events (noninvasive or mechanical ventilation), hospital charges, admission rates, and hospital length of stay. There were an estimated 1,813,000 visits annually for acute asthma from approximately 4,700 EDs. The estimated overall annual number of in-hospital asthma-related deaths was 1,144 (0.06%); 101 died in the ED, and 1,043 died as inpatients. By age group, there were 37 asthma-related deaths per year in children, 204 in younger adults, and 903 in older adults. Compared with younger adults, older adults had higher mortality, had higher rates of near-fatal asthma-related events, had higher hospital charges, were more likely to be hospitalized, and had a longer hospital length of stay (P< .001 for all). After adjusting for comorbidities, older asthmatic patients had a 5-fold increased risk of overall mortality (adjusted odds ratio, 5.2; 95% CI, 4.0-6.9), compared with younger adults. Older adults with acute asthma have a substantial burden of morbidity and mortality. With the US population aging, there is an urgent need for targeted interventions for this high-risk population.

Therapeutic approach for patients with catecholaminergic polymorphic ventricular tachycardia: state of the art and future developments

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia syndrome characterized by bidirectional or polymorphic ventricular arrhythmias under conditions of increased sympathetic activity in young patients with structurally normal hearts. Patients with CPVT are at high risk of developing life-threatening ventricular arrhythmias when untreated. A wide variety of arrhythmic event rates on conventional therapy, with β-blockers as the cornerstone, has been reported. Here, we systematically review all available studies describing the efficacy of β-blocker therapy for prevention of arrhythmic events in CPVT. Because of heterogeneity between the studies, a random-effects meta-analysis model was used to assess the efficacy of β-blocker therapy in preventing any arrhythmic event [syncope, aborted cardiac arrest (ACA), and sudden cardiac death (SCD)], near-fatal arrhythmic events (ACA and SCD), and fatal arrhythmic events. Eleven studies including 403 patients, of whom 354 (88%) had a β-blocker prescribed, were identified. Mean follow-up ranged from 20 months to 8 years. Estimated 8-year arrhythmic, near-fatal, and fatal event rates were 37.2% [95% confidence interval (CI): 16.6-57.7], 15.3% (95% CI: 7.4-23.3), and 6.4% (95% CI: 3.2-9.6), respectively. In addition, we review the recent developments in alternate chronic treatment options for CPVT patients, including calcium channel blockers, flecainide, left cardiac sympathetic denervation, and implantable cardioverter defibrillators. A new treatment strategy is proposed, including a stepwise addition of the alternate treatment options to β-blockers in patients who do not respond sufficiently to this first-line therapy. Finally, future developments in chronic treatment options and acute treatment options of ventricular arrhythmias are discussed.

Insect Allergy

Anaphylaxis is a life-threatening allergic condition. The 3 most common triggers for anaphylaxis are food, medications, and insects. All of these triggers are the sources of considerable morbidity and mortality, but of the 3, only insect allergy is treatable through means other than trigger avoidance. Because ≥ 40 deaths per year are attributed to insect stings, it is critical that healthcare providers and the public understand the proper diagnosis as well as the long-term treatment of this potentially life-threatening allergy. Unlike food and medication allergy, which are managed primarily by allergen avoidance, Hymenoptera allergy is managed prospectively using venom immunotherapy; this results in a protective level of up to 98%. Insects of the order Hymenoptera include bees, wasps, hornets, yellowjackets, and ants. They are responsible for the majority of the fatal and near-fatal sting events. Understanding the biology and habitat of the various Hymenoptera species is helpful in recommending insect-avoidance strategies. The diagnosis of insect allergy relies on a history of a systemic allergic reaction with appropriate testing for venom-specific immunoglobulin E. If the history of a systemic reaction to an insect sting and the presence of venom specific immunoglobulin E is confirmed, venom immunotherapy is indicated. The proper and primary means of treating acute anaphylaxis is immediate epinephrine-and studies suggest that it is underutilized in the acute setting. However, it is venom immunotherapy, a disease-modifying therapy, that provides the affected individual with the most effective protection against future sting reactions. Long-term management of insect allergy and anaphylaxis includes appropriate referral to an allergist familiar with insect allergy and, if indicated, venom immunotherapy.