C. Camargo
Mar 1, 2012
Citations
0
Influential Citations
6
Citations
Journal
The Journal of allergy and clinical immunology
Abstract
Potter Stewart was an Associate Justice of the US Supreme Court who might be best known for a snippet from his opinion in the obscenity case of Jacobellis v Ohio (1964). In that case he acknowledged that ‘‘hard-core pornography’’ was difficult to define but then added that ‘‘I know it when I see it.’’ I heard that quote many times when I began clinical research on food allergy and asked my allergist/immunologist colleagues about their definitions of anaphylaxis. I complained that allergy textbooks offered definitions based on IgE levels, mast cells, and other mechanistic details that I had never seen at the bedside. Unfortunately, the experts provided very different clinical definitions, ranging from ‘‘mild anaphylaxis’’ (simple urticaria) to a requirement for hypotensive shock. On that broad severity spectrum, most emergency physicians were in the latter camp, with a reluctance to consider the diagnosis until there was shock. The International Classification of Diseases, ninth revision, did not help because it forced linkage of anaphylaxis with ‘‘shock’’ (eg, code 995.6 for ‘‘anaphylactic shock due to adverse food reaction’’). In the absence of shock, our emergency department (ED) coders assigned acute allergic reactions as ‘‘allergy, unspecified’’ (code 995.3), regardless of the implicated allergen and number of organ systems involved. Needless to say, these issues make epidemiologic research on anaphylaxis challenging. In response to this ambiguity, Dr Sunday Clark and I created a simple working definition of anaphylaxis that we applied in 2 multicenter ED-based studies: one on food-related allergic reactions and another on stinging insect hypersensitivity. Our studies clearly demonstrated low use of epinephrine treatment among ED patients with multisystem allergic reactions (ie, anaphylaxis), and this finding, although disappointing, was well received by allergists/immunologists, who were eager to correct the problem. The publications were less warmly received by some in the emergencymedicine community, who questioned our ‘‘soft’’ definition and the benefit of using epinephrine in patients who did not have shock, patients who, by their definition, did not have anaphylaxis. To address this frustrating situation, several leaders in the allergy/immunology community began to acknowledge that the