The Resuscitation Council UK has updated its Guideline for healthcare providers on the Emergency treatment of anaphylaxis. As part of this process, an evidence review was undertaken by the Guideline Working Group, using an internationally-accepted approach for adoption, adaptation, and de novo guideline development based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework, referred to as GRADE-ADOLOPMENT. A number of significant changes have been made, which will be reflected in the updated Guideline.These include: emphasis on repeating intramuscular adrenaline doses after 5 min if symptoms of anaphylaxis do not resolve; corticosteroids (e.g. hydrocortisone) no longer being routinely recommended for the emergency treatment of anaphylaxis; interventions for reactions which are refractory to initial treatment with adrenaline; a recommendation against the use of antihistamines for the acute management of anaphylaxis; and guidance relating to the duration of observation following anaphylaxis, and timing of discharge.

There is no established definition for refractory anaphylaxis. The European Anaphylaxis Registry use a definition of "anaphylaxis which, despite treatment with at least two doses of minimum 300 μg adrenaline, does not achieve normalization" of symptoms. 1 A US-based panel recently proposed a reaction which "must be treated with 3+ appropriate doses of epinephrine (or initiation of an intravenous epinephrine infusion)" 2 -a definition which does not specifically refer to treatment response, although this is implied. The Resuscitation Council UK (RCUK) recently updated its guideline on the emergency treatment of anaphylaxis, defining refractory anaphylaxis as a reaction "requiring ongoing treatment despite two (appropriate) doses of intramuscular adrenaline" and proposes an algorithm to facilitate management (Figure 1). 3Refractory anaphylaxis is rare: the European Registry reported a rate of 0.37% of all anaphylaxis cases reported in the registry, with

There are approximately 20-30 deaths reported each year due to anaphylaxis in the UK, but this may be a significant underestimate; approximately 10 anaphylaxis deaths each year are due to foods, and another 10 due to perioperative anaphylaxis. 6 The most common triggers are food, drugs and venom. 4 Food is the most common trigger in young people: teenagers and adults up to the age of 30 years appear to be at greatest risk of fatal food-induced reactions. 4,5 In contrast, the rate of druginduced anaphylaxis is highest in the elderly, probably due to the combination of comorbidities (such as cardiovascular disease) and polypharmacy (including beta-blockers and angiotensinconverting-enzyme (ACE) inhibitors). 4,7 The diagnosis is supported if there is exposure to a known trigger, however, in up to 30% of cases, there may be no obvious trigger ('idiopathic' or 'spontaneous' anaphylaxis). The characteristics of anaphylaxis to the most common causes are shown in Table 1. 1,8 Anaphylaxis is a clinical diagnosis that lies along a spectrum of severity of allergic symptoms (Fig 1 ), and no symptom is entirely specific for the diagnosis.

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The aim of this project was to provide a community-based group intervention incorporating both practical and psychological coping techniques for managing these 'what if' worries that patients can often experience after cancer treatment has completed. Method and Materials: The FCR intervention was co-facilitated by a Clinical Psychologist and a Therapeutic Radiographer as a 6 week programme in both hospital and community-based settings, ensuring optimal access. The programme design was adapted from the Conquer Fear intervention (7) to accommodate a group setting with the incorporation of practical and educational information around breast cancer recurrence. 16 group programme cycles were delivered between February 2017 and March 2019. Participants completed the following evaluation measures before, after and 12 weeks upon completion of the intervention: Quality of life. (Functional Assessment of Cancer Therapy e Breast Cancer, FACT-B) Psychological flexibility (CompACT) Anxiety (GAD-7) Mood e (PHQ-9) We aimed to improve patients' ability to manage their anxiety through the delivery of bespoke practical and psychological coping techniques to assist with living with uncertainty following their breast cancer diagnosis. Results: Seventy-nine individuals completed the group programme during the two year pilot project over 16 group cycles. Quantitative and qualitative analysis indicate a reduction in fears of cancer recurrence; anxiety with an increase in quality of life, mood and psychological flexibility. Conclusion and Discussion: This approach provided a new service of supported self-management to address the needs of those patients who continue to experience significant anxiety related to fears of recurrence following their completion of breast cancer treatment. Overall, group participants described benefitting from the programme in helping them adjust emotionally after their active cancer treatment finished.