Background Epinephrine is a lifesaving medication in the treatment of anaphylaxis. Epinephrine auto-injectors are the preferred method of epinephrine administration, but are not universally available or affordable. Little is known about the effects on epinephrine when it is drawn up in advance and stored as prefilled syringes. Objective To study the stability and sterility of epinephrine when stored in syringes. Methods We searched Embase, Medline, and Web of Science in June 2016 for all studies of epinephrine stored in syringes in concentrations between 0.1 and 1 mg/mL that measured epinephrine stability and/or sterility over time, regardless of date published or language. Results Three studies were included, one testing two concentrations of epinephrine. Only one study tested epinephrine 1 mg/mL, the concentration clinically relevant for intramuscular use during anaphylaxis. Neither this study nor the one study testing 0.7 mg/mL epinephrine found significant degradation after 56 and 90 days, respectively. One of the two studies testing epinephrine at a concentration of 0.1 mg/mL found significant degradation by 14 days; the other found no degradation up to 168 days. Two studies tested for bacterial growth, with none detected after 28 and 90 days, respectively. One study tested for fungal growth, with none detected after 90 days. Conclusions Limited evidence suggests that syringes filled with 1 mg/mL epinephrine are stable and sterile for 90 days. More research is needed testing the duration of stability and sterility of prefilled syringes with the 1 mg/mL concentration most commonly used in anaphylaxis, testing more extensively in different storage conditions and across a wider range of marketed syringe brands.
The results of the survey showed there is an insufficiency of knowledge and understanding among medical staff concerning the principles, clinical applications and limitations of pulse oximetry. More emphasis needs to be placed on teaching these principles to ensure quality care for patients.
Temperature excursions in real-world conditions may be less detrimental than previously suggested. Freezing and limited heat excursions did not result in epinephrine degradation. Refrigeration of epinephrine appears to reduce degradation. However, the effect of extreme temperatures, particularly freezing, on autoinjectors is not sufficiently well established. More research in needed at clinically relevant high temperatures, with limited exposure to heat, and involving autoinjector devices.
Peanut oral immunotherapy (PN-OIT) is associated with increases in serum peanut-specific IgG4. Recent studies suggest that eosinophilic esophagitis (EoE), a potential complication of PN-OIT, is associated with marked tissue deposition of IgG4. We sought to examine the IgG4 and eosinophil responses to PN-OIT in gastrointestinal biopsies. METHODS: We performed serial esophagogastroduodenoscopies (EGD) in adults undergoing PN-OIT. Biopsies were obtained from the esophagus, stomach, and duodenum at baseline, 1, and 2yrs. Immunohistochemical staining for IgG4 and eosinophil peroxidase (EPX) were performed. Deposition of IgG4/mm 2 and EPX/mm 2 in serial hpf were quantified using automated image analysis. RESULTS: EGD's were performed at baseline (n 5 21), 1yr (n 5 10) and 2yrs (n 5 5) during PN-OIT. At baseline, 48% of subjects had gastrointestinal eosinophilia (esophagus > _15 eos/hpf; stomach > _30 eos/ hpf; and duodenum (> _52 eos/hpf). EPX/mm 2 correlated strongly with eos/ hpf in all biopsies (r 5 0.89, p < 0.0001) and with IgG4/mm 2 at baseline (r 5 0.38, p 5 0.004), 1yr (r 5 0.36, p 5 0.05) and 2yrs (r 5 0.72, p 5 0.003). Importantly 4/8 subjects with <15 eos/hpf at baseline developed esophageal eosinophilia; one met clinicopathologic criteria for EoE and 2 had histologic resolution by 2yrs. This trial is ongoing and only the subject with OIT-induced EoE has withdrawn. CONCLUSIONS: This is the first study examining tissue IgG4 deposition in serial gastrointestinal biopsies (including baseline) during PN-OIT. Similar to EoE, PN-OIT subjects demonstrate esophageal IgG4 deposition correlating with eosinophilic inflammation. Further studies are needed to clarify the relationship between IgG4, EoE, and PN-OIT.
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