\documentclass[11pt,twoside]{article}\makeatletter

\IfFileExists{xcolor.sty}%
  {\RequirePackage{xcolor}}%
  {\RequirePackage{color}}
\usepackage{colortbl}
\usepackage{wrapfig}
\usepackage{ifxetex}
\ifxetex
  \usepackage{fontspec}
  \usepackage{xunicode}
  \catcode`⃥=\active \def⃥{\textbackslash}
  \catcode`❴=\active \def❴{\{}
  \catcode`❵=\active \def❵{\}}
  \def\textJapanese{\fontspec{Noto Sans CJK JP}}
  \def\textChinese{\fontspec{Noto Sans CJK SC}}
  \def\textKorean{\fontspec{Noto Sans CJK KR}}
  \setmonofont{DejaVu Sans Mono}
  
\else
  \IfFileExists{utf8x.def}%
   {\usepackage[utf8x]{inputenc}
      \PrerenderUnicode{–}
    }%
   {\usepackage[utf8]{inputenc}}
  \usepackage[english]{babel}
  \usepackage[T1]{fontenc}
  \usepackage{float}
  \usepackage[]{ucs}
  \uc@dclc{8421}{default}{\textbackslash }
  \uc@dclc{10100}{default}{\{}
  \uc@dclc{10101}{default}{\}}
  \uc@dclc{8491}{default}{\AA{}}
  \uc@dclc{8239}{default}{\,}
  \uc@dclc{20154}{default}{ }
  \uc@dclc{10148}{default}{>}
  \def\textschwa{\rotatebox{-90}{e}}
  \def\textJapanese{}
  \def\textChinese{}
  \IfFileExists{tipa.sty}{\usepackage{tipa}}{}
\fi
\def\exampleFont{\ttfamily\small}
\DeclareTextSymbol{\textpi}{OML}{25}
\usepackage{relsize}
\RequirePackage{array}
\def\@testpach{\@chclass
 \ifnum \@lastchclass=6 \@ne \@chnum \@ne \else
  \ifnum \@lastchclass=7 5 \else
   \ifnum \@lastchclass=8 \tw@ \else
    \ifnum \@lastchclass=9 \thr@@
   \else \z@
   \ifnum \@lastchclass = 10 \else
   \edef\@nextchar{\expandafter\string\@nextchar}%
   \@chnum
   \if \@nextchar c\z@ \else
    \if \@nextchar l\@ne \else
     \if \@nextchar r\tw@ \else
   \z@ \@chclass
   \if\@nextchar |\@ne \else
    \if \@nextchar !6 \else
     \if \@nextchar @7 \else
      \if \@nextchar (8 \else
       \if \@nextchar )9 \else
  10
  \@chnum
  \if \@nextchar m\thr@@\else
   \if \@nextchar p4 \else
    \if \@nextchar b5 \else
   \z@ \@chclass \z@ \@preamerr \z@ \fi \fi \fi \fi
   \fi \fi  \fi  \fi  \fi  \fi  \fi \fi \fi \fi \fi \fi}
\gdef\arraybackslash{\let\\=\@arraycr}
\def\@textsubscript#1{{\m@th\ensuremath{_{\mbox{\fontsize\sf@size\z@#1}}}}}
\def\Panel#1#2#3#4{\multicolumn{#3}{){\columncolor{#2}}#4}{#1}}
\def\abbr{}
\def\corr{}
\def\expan{}
\def\gap{}
\def\orig{}
\def\reg{}
\def\ref{}
\def\sic{}
\def\persName{}\def\name{}
\def\placeName{}
\def\orgName{}
\def\textcal#1{{\fontspec{Lucida Calligraphy}#1}}
\def\textgothic#1{{\fontspec{Lucida Blackletter}#1}}
\def\textlarge#1{{\large #1}}
\def\textoverbar#1{\ensuremath{\overline{#1}}}
\def\textquoted#1{‘#1’}
\def\textsmall#1{{\small #1}}
\def\textsubscript#1{\@textsubscript{\selectfont#1}}
\def\textxi{\ensuremath{\xi}}
\def\titlem{\itshape}
\newenvironment{biblfree}{}{\ifvmode\par\fi }
\newenvironment{bibl}{}{}
\newenvironment{byline}{\vskip6pt\itshape\fontsize{16pt}{18pt}\selectfont}{\par }
\newenvironment{citbibl}{}{\ifvmode\par\fi }
\newenvironment{docAuthor}{\ifvmode\vskip4pt\fontsize{16pt}{18pt}\selectfont\fi\itshape}{\ifvmode\par\fi }
\newenvironment{docDate}{}{\ifvmode\par\fi }
\newenvironment{docImprint}{\vskip 6pt}{\ifvmode\par\fi }
\newenvironment{docTitle}{\vskip6pt\bfseries\fontsize{22pt}{25pt}\selectfont}{\par }
\newenvironment{msHead}{\vskip 6pt}{\par}
\newenvironment{msItem}{\vskip 6pt}{\par}
\newenvironment{rubric}{}{}
\newenvironment{titlePart}{}{\par }

\newcolumntype{L}[1]{){\raggedright\arraybackslash}p{#1}}
\newcolumntype{C}[1]{){\centering\arraybackslash}p{#1}}
\newcolumntype{R}[1]{){\raggedleft\arraybackslash}p{#1}}
\newcolumntype{P}[1]{){\arraybackslash}p{#1}}
\newcolumntype{B}[1]{){\arraybackslash}b{#1}}
\newcolumntype{M}[1]{){\arraybackslash}m{#1}}
\definecolor{label}{gray}{0.75}
\def\unusedattribute#1{\sout{\textcolor{label}{#1}}}
\DeclareRobustCommand*{\xref}{\hyper@normalise\xref@}
\def\xref@#1#2{\hyper@linkurl{#2}{#1}}
\begingroup
\catcode`\_=\active
\gdef_#1{\ensuremath{\sb{\mathrm{#1}}}}
\endgroup
\mathcode`\_=\string"8000
\catcode`\_=12\relax

\usepackage[a4paper,twoside,lmargin=1in,rmargin=1in,tmargin=1in,bmargin=1in,marginparwidth=0.75in]{geometry}
\usepackage{framed}

\definecolor{shadecolor}{gray}{0.95}
\usepackage{longtable}
\usepackage[normalem]{ulem}
\usepackage{fancyvrb}
\usepackage{fancyhdr}
\usepackage{graphicx}
\usepackage{marginnote}

\renewcommand{\@cite}[1]{#1}


\renewcommand*{\marginfont}{\itshape\footnotesize}

\def\Gin@extensions{.pdf,.png,.jpg,.mps,.tif}

  \pagestyle{fancy}

\usepackage[pdftitle={Anaphylaxis and Epinephrine Auto-Injector use: A Survey of Pediatric Trainees},
 pdfauthor={}]{hyperref}
\hyperbaseurl{}

	 \paperwidth210mm
	 \paperheight297mm
              
\def\@pnumwidth{1.55em}
\def\@tocrmarg {2.55em}
\def\@dotsep{4.5}
\setcounter{tocdepth}{3}
\clubpenalty=8000
\emergencystretch 3em
\hbadness=4000
\hyphenpenalty=400
\pretolerance=750
\tolerance=2000
\vbadness=4000
\widowpenalty=10000

\renewcommand\section{\@startsection {section}{1}{\z@}%
     {-1.75ex \@plus -0.5ex \@minus -.2ex}%
     {0.5ex \@plus .2ex}%
     {\reset@font\Large\bfseries}}
\renewcommand\subsection{\@startsection{subsection}{2}{\z@}%
     {-1.75ex\@plus -0.5ex \@minus- .2ex}%
     {0.5ex \@plus .2ex}%
     {\reset@font\Large}}
\renewcommand\subsubsection{\@startsection{subsubsection}{3}{\z@}%
     {-1.5ex\@plus -0.35ex \@minus -.2ex}%
     {0.5ex \@plus .2ex}%
     {\reset@font\large}}
\renewcommand\paragraph{\@startsection{paragraph}{4}{\z@}%
     {-1ex \@plus-0.35ex \@minus -0.2ex}%
     {0.5ex \@plus .2ex}%
     {\reset@font\normalsize}}
\renewcommand\subparagraph{\@startsection{subparagraph}{5}{\parindent}%
     {1.5ex \@plus1ex \@minus .2ex}%
     {-1em}%
     {\reset@font\normalsize\bfseries}}


\def\l@section#1#2{\addpenalty{\@secpenalty} \addvspace{1.0em plus 1pt}
 \@tempdima 1.5em \begingroup
 \parindent \z@ \rightskip \@pnumwidth 
 \parfillskip -\@pnumwidth 
 \bfseries \leavevmode #1\hfil \hbox to\@pnumwidth{\hss #2}\par
 \endgroup}
\def\l@subsection{\@dottedtocline{2}{1.5em}{2.3em}}
\def\l@subsubsection{\@dottedtocline{3}{3.8em}{3.2em}}
\def\l@paragraph{\@dottedtocline{4}{7.0em}{4.1em}}
\def\l@subparagraph{\@dottedtocline{5}{10em}{5em}}
\@ifundefined{c@section}{\newcounter{section}}{}
\@ifundefined{c@chapter}{\newcounter{chapter}}{}
\newif\if@mainmatter 
\@mainmattertrue
\def\chaptername{Chapter}
\def\frontmatter{%
  \pagenumbering{roman}
  \def\thechapter{\@roman\c@chapter}
  \def\theHchapter{\roman{chapter}}
  \def\thesection{\@roman\c@section}
  \def\theHsection{\roman{section}}
  \def\@chapapp{}%
}
\def\mainmatter{%
  \cleardoublepage
  \def\thechapter{\@arabic\c@chapter}
  \setcounter{chapter}{0}
  \setcounter{section}{0}
  \pagenumbering{arabic}
  \setcounter{secnumdepth}{6}
  \def\@chapapp{\chaptername}%
  \def\theHchapter{\arabic{chapter}}
  \def\thesection{\@arabic\c@section}
  \def\theHsection{\arabic{section}}
}
\def\backmatter{%
  \cleardoublepage
  \setcounter{chapter}{0}
  \setcounter{section}{0}
  \setcounter{secnumdepth}{2}
  \def\@chapapp{\appendixname}%
  \def\thechapter{\@Alph\c@chapter}
  \def\theHchapter{\Alph{chapter}}
  \appendix
}
\newenvironment{bibitemlist}[1]{%
   \list{\@biblabel{\@arabic\c@enumiv}}%
       {\settowidth\labelwidth{\@biblabel{#1}}%
        \leftmargin\labelwidth
        \advance\leftmargin\labelsep
        \@openbib@code
        \usecounter{enumiv}%
        \let\p@enumiv\@empty
        \renewcommand\theenumiv{\@arabic\c@enumiv}%
	}%
  \sloppy
  \clubpenalty4000
  \@clubpenalty \clubpenalty
  \widowpenalty4000%
  \sfcode`\.\@m}%
  {\def\@noitemerr
    {\@latex@warning{Empty `bibitemlist' environment}}%
    \endlist}

\def\tableofcontents{\section*{\contentsname}\@starttoc{toc}}
\parskip0pt
\parindent1em
\def\Panel#1#2#3#4{\multicolumn{#3}{){\columncolor{#2}}#4}{#1}}
\newenvironment{reflist}{%
  \begin{raggedright}\begin{list}{}
  {%
   \setlength{\topsep}{0pt}%
   \setlength{\rightmargin}{0.25in}%
   \setlength{\itemsep}{0pt}%
   \setlength{\itemindent}{0pt}%
   \setlength{\parskip}{0pt}%
   \setlength{\parsep}{2pt}%
   \def\makelabel##1{\itshape ##1}}%
  }
  {\end{list}\end{raggedright}}
\newenvironment{sansreflist}{%
  \begin{raggedright}\begin{list}{}
  {%
   \setlength{\topsep}{0pt}%
   \setlength{\rightmargin}{0.25in}%
   \setlength{\itemindent}{0pt}%
   \setlength{\parskip}{0pt}%
   \setlength{\itemsep}{0pt}%
   \setlength{\parsep}{2pt}%
   \def\makelabel##1{\upshape ##1}}%
  }
  {\end{list}\end{raggedright}}
\newenvironment{specHead}[2]%
 {\vspace{20pt}\hrule\vspace{10pt}%
  \phantomsection\label{#1}\markright{#2}%

  \pdfbookmark[2]{#2}{#1}%
  \hspace{-0.75in}{\bfseries\fontsize{16pt}{18pt}\selectfont#2}%
  }{}
      \def\TheFullDate{2020-01-15 (revised: 15 January 2020)}
\def\TheID{\makeatother }
\def\TheDate{2020-01-15}
\title{Anaphylaxis and Epinephrine Auto-Injector use: A Survey of Pediatric Trainees}
\author{}\makeatletter 
\makeatletter
\newcommand*{\cleartoleftpage}{%
  \clearpage
    \if@twoside
    \ifodd\c@page
      \hbox{}\newpage
      \if@twocolumn
        \hbox{}\newpage
      \fi
    \fi
  \fi
}
\makeatother
\makeatletter
\thispagestyle{empty}
\markright{\@title}\markboth{\@title}{\@author}
\renewcommand\small{\@setfontsize\small{9pt}{11pt}\abovedisplayskip 8.5\p@ plus3\p@ minus4\p@
\belowdisplayskip \abovedisplayskip
\abovedisplayshortskip \z@ plus2\p@
\belowdisplayshortskip 4\p@ plus2\p@ minus2\p@
\def\@listi{\leftmargin\leftmargini
               \topsep 2\p@ plus1\p@ minus1\p@
               \parsep 2\p@ plus\p@ minus\p@
               \itemsep 1pt}
}
\makeatother
\fvset{frame=single,numberblanklines=false,xleftmargin=5mm,xrightmargin=5mm}
\fancyhf{} 
\setlength{\headheight}{14pt}
\fancyhead[LE]{\bfseries\leftmark} 
\fancyhead[RO]{\bfseries\rightmark} 
\fancyfoot[RO]{}
\fancyfoot[CO]{\thepage}
\fancyfoot[LO]{\TheID}
\fancyfoot[LE]{}
\fancyfoot[CE]{\thepage}
\fancyfoot[RE]{\TheID}
\hypersetup{citebordercolor=0.75 0.75 0.75,linkbordercolor=0.75 0.75 0.75,urlbordercolor=0.75 0.75 0.75,bookmarksnumbered=true}
\fancypagestyle{plain}{\fancyhead{}\renewcommand{\headrulewidth}{0pt}}

\date{}
\usepackage{authblk}

\providecommand{\keywords}[1]
{
\footnotesize
  \textbf{\textit{Index terms---}} #1
}

\usepackage{graphicx,xcolor}
\definecolor{GJBlue}{HTML}{273B81}
\definecolor{GJLightBlue}{HTML}{0A9DD9}
\definecolor{GJMediumGrey}{HTML}{6D6E70}
\definecolor{GJLightGrey}{HTML}{929497} 

\renewenvironment{abstract}{%
   \setlength{\parindent}{0pt}\raggedright
   \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}}
   \vskip16pt
   \textcolor{GJBlue}{\large\bfseries\abstractname\space}
}{%   
   \vskip8pt
   \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}}
   \vskip16pt
}

\usepackage[absolute,overlay]{textpos}

\makeatother 
      \usepackage{lineno}
      \linenumbers
      
\begin{document}

             \author[1]{Shaza Mohammed Elhassan MD,  MS}

             \author[2]{Dr. Med Carolin  Beck}

             \author[3]{Ahmed Alhammadi  MD}

             \author[4]{Mehdi Adeli  MD}

\renewcommand\Authands{ and }

\date{\small \em Received: 14 December 2019 Accepted: 2 January 2020 Published: 15 January 2020}

\maketitle


\begin{abstract}
        


Background: Pediatric trainees in many instances are the first medical responders and at the frontline managing children at risk for anaphylaxis in the hospital and at community level. Their fundamental knowledge is crucial in anaphylaxis. This study aimed to assess pediatric trainees' knowledge in acute management of anaphylaxis and looked at knowledge gaps between the different trainees' levels.Method: This study was a two-phase cross-sectional surveybased study of 94 pediatrics trainees in phase one and 84 in phase two at the only tertiary hospital in Doha, Qatar. The primary outcome was trainees' knowledge related to anaphylaxis management and Epinephrine auto-injector (EpiPen®) use.Results: 44 (46%) trainees claimed they had not received training about how to treat anaphylaxis. There was a discrepancy between claimed knowledge of how to treat anaphylaxis 86 (90%) and actual knowledge as none of the trainees' level answered all the questions correctly. Moreover 41 (49%) were unaware that EpiPen® should be administered IM in the lateral part of the thigh and 24 (28%) did not know it should be used in case of anaphylaxis.

\end{abstract}


\keywords{}

\begin{textblock*}{18cm}(1cm,1cm) % {block width} (coords) 
\textcolor{GJBlue}{\LARGE Global Journals \LaTeX\ JournalKaleidoscope\texttrademark}
\end{textblock*}

\begin{textblock*}{18cm}(1.4cm,1.5cm) % {block width} (coords) 
\textcolor{GJBlue}{\footnotesize \\ Artificial Intelligence formulated this projection for compatibility purposes from the original article published at Global Journals. However, this technology is currently in beta. \emph{Therefore, kindly ignore odd layouts, missed formulae, text, tables, or figures.}}
\end{textblock*}


\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
naphylaxis is a life-threatening event, which requires urgent and prompt medical attention. Its exact incidence in pediatric is unknown, because few epidemiologic studies to date have examined the incidence of anaphylaxis in the general pediatric population.1 Available UK estimates suggest that approximately 1 in 1333 of the population of England has experienced anaphylaxis at some point in their lives.2 Lifetime prevalence based on international studies is estimated at 0.05-2\%.3 This translates to a major impact on quality of life and healthcare costs. \hyperref[b4]{4} Increase in diagnosis of anaphylaxis and hospitalizations were reported from multiple countries. 5-8 Pediatric trainees are at the frontline managing children at risk for anaphylaxis in the hospital and at community level. In many instances, they are the first medical responders. Their fundamental knowledge is crucial in all sorts of emergencies including anaphylaxis. Clinical diagnosis of anaphylaxis is based on consideration of the patient's presenting symptoms and signs and on ruling out other sudden-onset multisystem diseases.1 9 10 Epinephrine is the first-line and lifesaving medication of choice in anaphylaxis. Its use is recommended in guidelines issued by the World Allergy Organization.  {\ref 1 9} Epinephrine should be injected by the intramuscular route in the mid-anterolateral thigh as soon as anaphylaxis is diagnosed or strongly suspected, in a dose of 0.01 mg/kg of a 1:1,000 (1 mg/mL) solution, to a maximum dose of 0.3 mg in children and the patient should be placed on the back with the lower extremities elevated. Intravenous epinephrine is potentially hazardous and should be avoided except in an intensive care setting. \hyperref[b0]{1} These guidelines advise that epinephrine via the intramuscular route should be given by first medical responders. 11 Early administration of epinephrine effectively reduces morbidity and mortality in human anaphylaxis, whereas delayed administration of epinephrine is associated with increased mortality because epinephrine becomes progressively less effective in reversing anaphylaxis with the passage of time.12 13 cardiovascular side effects and overdoses were significantly more likely with intravenous epinephrine compared to intramuscular administration. \hyperref[b14]{14} Plumb and colleagues found that junior doctors today seem to be no better at correctly identifying the clinical need for, and correct dose and route for administration of, adrenaline than their predecessors a decade earlier. \hyperref[b15]{15} Deaths have been reported from the inappropriate use of epinephrine in the context of allergic reaction. \hyperref[b16]{16}  The primary objective of our study was to evaluate the level of knowledge regarding anaphylaxis and its management in our pediatric training program. The secondary objective was to compare knowledge between the most junior and most senior residents for any observed knowledge gap. Understanding key knowledge gaps and their underlying reasons are vital to optimizing the training at medical school and/or during the training program, thus ensuring that a fatal outcome to a reversible condition is avoided. This furthermore will give the chance to implement training interventions at the right time points of pediatric training. 
\section[{II. Methods a) Study Design}]{II. Methods a) Study Design}\par
This study was a two-phase cross-sectional study where verbal consent was taken from the trainees after explaining the objectives of the study. Questionnaires with pre-determined multiple-choice questions and one open ended question were handed out to the trainees. Phases one and two were 1 month apart. The reason for the two-phase study was to reinforce the accuracy of the responses. The study was approved by the IRB and Hamad Medical Corporation Hospital Committee. 
\section[{b) Setting}]{b) Setting}\par
The study was conducted at Hamad Medical Center (HMC), the only tertiary hospital in the state of Qatar. In phase one, the participants were approached after the morning report and asked to fill a questionnaire. They were divided into six groups according to their training level. Each questionnaire took about 3 minutes to complete. Phase two questionnaire was started 1 month after completed Phase one. The surveys were collected immediately after they were completed. 12 trainees were reached via WhatsApp® only. Their responses were received electronically. Each round of surveys took around 7 days to complete 
\section[{c) Participants}]{c) Participants}\par
Our six trainee groups included interns, who rotate in all specialties one year prior to residency program, and pediatric residents divided into postgraduate year 1 (PGY1), post-graduate year 2 (PGY2), post-graduate year 3 (PGY3), post-graduate year 4 (PGY4), and pediatric fellows from all pediatric subspecialties. The study was done between February and March 2015. 
\section[{d) Selection criteria}]{d) Selection criteria}\par
We selected all trainees in the pediatric department including interns, residents and fellows. We only excluded those who were not willing to participate. 
\section[{Sample Size}]{Sample Size}\par
The questionnaires were distributed to 96 trainees. For sample size refer to Figure  {\ref 1}. Participants were informed verbally about the questionnaire and paper surveys were distributed to the trainees for both phases one and two. Survey administered questions were in English language. The interview questions were created based on previous studies and the clinical expertise of the investigator group.\par
A total number of 12 questions was given to the trainees (Table1). In each phase one and two, there were two demographic questions plus four knowledge related questions.  
\section[{g) Data sources/measurement}]{g) Data sources/measurement}\par
This study aimed to assess pediatric trainees' knowledge in acute management of anaphylaxis as primary objective. Secondary objective was to assess possible knowledge gaps between the different trainees' levels, to evaluate whether the educational deficiencies are found at medical school or postgraduate training, so targeted training can be implemented accordingly. Statistical Analysis Descriptive statistics were used to summarize the demographics and level of training of the participants. We assessed knowledge related responses amongst trainees using frequencies along with percentages (univariate analysis). To compare knowledge between the most junior and most senior trainees, we used the fisher exact test (multivariate analysis).\par
A two-sided P value <0.05 was considered statistically significant. Surveys with missed data were not included in the analysis. All statistical analyses were performed using statistical package SPSS, version 19.0 (IBM Corporation, Armonk, NY).\par
A total of 98 trainees were approached for both phases one and two, from whom we analysed 94 (96\% response rate) for phase one and 84 surveys (86\% response rate) in phase two (Figure  {\ref 1}). Most participants were females and pediatric fellows in both parts as seen in table \hyperref[tab_3]{3}.  \hyperref[tab_4]{4} shows knowledge related responses for all participants. Of notice 44 (46\%) of the trainees responded they received no training about how to treat anaphylaxis. While 86 (89\%) claimed they know how to treat anaphylaxis, 41 (49\%) trainees were unaware that epinephrine should be administered in the lateral part of the thigh by intramuscular route and 24 (28\%) trainees did not know that the EpiPen® is used in case of anaphylaxis.\par
In table \hyperref[tab_5]{5} we compared the knowledge related responses between the most junior and most senior trainees in the residency program, to explore whether the training programs were well equipped with the necessary tools to provide trainees with the necessary knowledge and skills to treat anaphylaxis Comparing the most junior and most senior trainees, there was no statistical difference in knowledge related responses except that all 9 (100\%) senior residents claimed to know how to treat anaphylaxis compared to only 14 (74\%) of junior residents (p-value 0.01).  As summarized in figure 2, pediatric fellows (12 fellows or 30\%) and PGY1 (10 residents or 25\%) were more likely to report that they did not receive training compared to other categories. There are notable findings from our study. Despite the vital importance of knowing the emergency treatment of anaphylaxis, of significance is the observation that none of the trainees' categories answered all the questions correctly. Surprisingly significant number of the total trainees 44 (46\%) claimed they did not receive any training about how to treat anaphylaxis. Almost half of the trainees 41 (49\%) were not aware that the EpiPen® should be administered in the lateral part of the thigh by intramuscular route. Moreover, 24 (28\%) of trainees did not know that EpiPen® is used in case of anaphylaxis. Our study showed that 13 (15\%) have never heard about epinephrine auto-injectors from which the most junior trainees represent about half.\par
These worrisome results indicate that both medical schools and training programs need to consider restructuring their existing educational agenda to better address low prevalence high consequence conditions like anaphylaxis and other emergencies. There is an urgent need for improving training in the recent international consensus.20 There was an obvious discrepancy between claimed and actual knowledge in our study. While 86 (89\%) of the trainees claimed they knew how to manage anaphylaxis, when they were asked more detailed questions, half of them were unaware that epinephrine should be administered in the lateral part of the thigh by intramuscular route and one third did not know that the EpiPen® is used in case of anaphylaxis.\par
Studies suggested that doctors claim to know how to treat anaphylaxis but this is often not translated into practice.19 Unlike our findings, a large survey based study of doctors and nurses in a Singapore hospital indicated not only good recognition of anaphylaxis but also a trend to over-diagnose this condition.21 A systematic review study showed that participants reported high levels of confidence in diagnosing or managing anaphylaxis at baseline and follow-up despite their limited clinical experience.22 Physicians' overestimation of their own competence may compromise the safety and clinical outcomes of patients. It may be advantageous to help trainees at all levels to become more cognizant of this disconnect. \hyperref[b23]{23} The incorporation of continuous medical education to practice skills is essential to maintain knowledge and competency.  {\ref 24 25} Though most participants knew that epinephrine is the drug of choice for treating anaphylaxis, few interns thought wrongly that antihistamine is the drug to use for treating anaphylaxis. Our study showed that 13 (15\%) have never heard about epinephrine auto-injectors from which the interns and PGY1 represent about half. This might indicate gaps in the educational programs at medical schools. We anticipate that trainees' performance will continue to decline in the absence of educational reinforcement. When we compared the knowledgerelated responses of the most junior and most senior trainees, we found no statistical difference between the two categories in most of the core areas. Similar to our study, a survey-based study in adult medicine by Droste et al, which compared two district hospitals with different levels of trainees showed that there was a lack of knowledge in a significant number of senior and junior doctors regarding the dose, route, and concentration of epinephrine with no much difference among trainee levels.27 Another study by Drupad HS et al of 265 subjects in which a pretested structured questionnaire was used showed no significant difference between senior and junior doctors.28 Trainees of all grades who may be the first responders at a scene of anaphylaxis should solidify their knowledge about emergencies and should be well prepared if anaphylaxis ensued. Innovative educational interventions are essential to improve and maintain trainees' knowledge and clinical competency.\par
Although prompt treatment with epinephrine is critically important for survival in anaphylaxis, we continue to have gaps in the critical knowledge of the frontline trainees regarding anaphylaxis management. Knowledge about epinephrine injection site, mode of administration and the lack of overall training of anaphylaxis treatment were the most concerning findings.\par
Continuing medical education, coupled with training opportunities to apply knowledge and practice skills, is needed to improve trainees' knowledge. 
\section[{Limitations}]{Limitations}\par
Our study was based on self-reports. Our institution is the only tertiary center in the area and is comprised of pediatric trainees from all over the world. 
\section[{Strengths}]{Strengths}\par
Our training program enrols medical school graduates from multiple different countries, which makes our findings more generalizable and consists of a large number of 98 trainees within a single institution. We handed out surveys are 2 time points to ascertain our findings and included comprehensive questions on anaphylaxis knowledge and treatment/ EpiPen® use, both of which are important to successfully recognize and treat such condition. We had a high response rates using both paper and electronic version of the questionnaire.\par
What is known about the subject? 1. Pediatric trainees are at the frontline managing children with anaphylaxis inthe hospital and at community level. Their fundamental knowledge of anaphylaxis treatment is crucial. 2. Studies showed that poor knowledge of anaphylaxis management impairs patients' quality of life, and leads to increased healthcare costs and preventable deaths. \begin{figure}[htbp]
\noindent\textbf{12}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 : 2}\end{figure}
    \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.6509009009009008\textwidth}P{0.07657657657657657\textwidth}P{0.038288288288288286\textwidth}P{0.015315315315315315\textwidth}P{0.06891891891891892\textwidth}}
Doctors,\tabcellsep especially\tabcellsep those\tabcellsep in\tabcellsep emergency\\
\multicolumn{5}{l}{departments need to be skilled and confident in the}\\
\multicolumn{2}{l}{care of these patients."19}\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.2677946324387398\textwidth}P{0.10810968494749125\textwidth}P{0.1368728121353559\textwidth}P{0.08728121353558926\textwidth}P{0.10116686114352393\textwidth}P{0.04661610268378063\textwidth}P{0.04463243873978996\textwidth}P{0.041656942823803965\textwidth}P{0.01586931155192532\textwidth}}
What's your Gender\tabcellsep Male\tabcellsep Female\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
What's your\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Level of\tabcellsep Intern\tabcellsep PGY-1\tabcellsep PGY-2\tabcellsep PGY-3\tabcellsep PGY-4\tabcellsep Fellow\tabcellsep \tabcellsep \\
training?\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Question 1 Do you know how to treat Anaphylactic shock due to Food Allergy?\tabcellsep 1.1 Yes, and I got training about it.\tabcellsep 1.2 Yes, but I did not get training about it\tabcellsep 1.3 Maybe, I forgot how to treat despite my training\tabcellsep 1.4 No, and I did not get any training.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Question 2\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
What is the lifesaving drug in this\tabcellsep 2.1 Antihistamine\tabcellsep 2.2 Methylpre dnisolone\tabcellsep 2.3 Terbutaline\tabcellsep 2.4 Norepine phrine\tabcellsep 2.5 Epinep hrine\tabcellsep 2.6 IV fluids\tabcellsep 2.7 oxygen\tabcellsep \\
case?\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Question 3\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep 3.7\tabcellsep \\
Which route would you use to administer\tabcellsep 3.1 Oral\tabcellsep 3.2 Nebulizer or inhaler\tabcellsep 3.3 IV\tabcellsep 3.4 SC\tabcellsep 3.5 IM\tabcellsep 3.6 Rectal\tabcellsep Via continuous mask\tabcellsep 3.8 In the heart\\
the treatment?\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep inhalation\tabcellsep \\
Question 4 What dose would you give?\tabcellsep 4.1 0.001mg/kg from 1:1,1000 solution\tabcellsep 4.2 solution 0.01mg/kg from 1:1,1000\tabcellsep 4.3 1mg/kg\tabcellsep 4.4 solution 2mg in 2ml nebulizer\tabcellsep 4.5 1 liter / minute\tabcellsep 4.6 I don't know\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.38389529724933447\textwidth}P{0.05279503105590062\textwidth}P{0.06335403726708075\textwidth}P{0.09880212954747115\textwidth}P{0.10860692102928127\textwidth}P{0.022626441881100266\textwidth}P{0.027151730257320317\textwidth}P{0.030922803904170362\textwidth}P{0.061845607808340725\textwidth}}
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Year 2020\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Volume XX Issue I Version I\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep D D D D ) F\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (\\
What's your Gender What's your Level of training Question 5 Have you heard of Epinephrine Autoinjector / Epipen? Question 6 (which case)? -> Advised to stop here if answer "no" Question 7 Please write down which case it is used for Do you know when to use it\tabcellsep Male Intern 5.1 Yes 6.1 Yes 7.1 No answer\tabcellsep \multicolumn{2}{l}{Female PGY-1 5.2 No 6.2 No 7.2 Correct answer (anaphylaxis)}\tabcellsep PGY-2 5.3 I can't remember 7.3 Other answer (wrong)\tabcellsep PGY-3\tabcellsep PGY-4\tabcellsep Fellow\tabcellsep Global Journal of Medical Research\\
Question 8 Where would you give it?\tabcellsep 8.1 lateral part upper arm SC\tabcellsep \multicolumn{2}{l}{8.2 lateral part thigh IM}\tabcellsep 8.3 frontal part upper arm IM\tabcellsep 8.4 frontal part thigh SC\tabcellsep 8.5 lateral part thigh IM or SC\tabcellsep 8.6 no answer\\
f) Variables\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{Three variable themes were included in the}\tabcellsep \multicolumn{5}{l}{3. Epinephrine auto-injector (EpiPen®) knowledge-}\\
questionnaire:\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{related questions. Outcomes}\tabcellsep \\
\multicolumn{3}{l}{1. Demographic data i.e. gender and training level,}\tabcellsep \multicolumn{4}{l}{The outcomes of importance were:}\tabcellsep \\
\multicolumn{3}{l}{2. Anaphylaxis-related questions i.e., lifesaving}\tabcellsep \multicolumn{5}{l}{1. Knowledge related to anaphylaxis management and}\\
\multicolumn{3}{l}{medications, route of administration and dosage,}\tabcellsep \tabcellsep \multicolumn{4}{l}{EpiPen® use among pediatric trainees;}\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep © 2020 Global Journals\end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.3768041237113402\textwidth}P{0.2424398625429553\textwidth}P{0.23075601374570445\textwidth}}
Variable\tabcellsep Part 1 N=94\tabcellsep Part 2 N=84\\
Gender\tabcellsep \tabcellsep \\
a. Male\tabcellsep 40 (41.5\%)\tabcellsep 39 (46\%)\\
b. Female\tabcellsep 56 (58.5\%)\tabcellsep 45 (54\%)\\
Training level\tabcellsep \tabcellsep \\
a. Interns\tabcellsep 7 (7\%)\tabcellsep 4 (5\%)\\
b. Pgy1\tabcellsep 20 (21\%)\tabcellsep 15 (18\%)\\
c. Pgy2\tabcellsep 19 (20\%)\tabcellsep 17 (20\%)\\
d. Pgy3\tabcellsep 11 (12\%)\tabcellsep 10 (12\%)\\
e. Pgy4\tabcellsep 9 (9\%)\tabcellsep 7 (8\%)\\
f. Pediatric fellows\tabcellsep 30 (31\%)\tabcellsep 31 (37\%)\\
Knowledge related responses\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.07762119503945886\textwidth}P{0.6363021420518602\textwidth}P{0.13607666290868095\textwidth}}
\tabcellsep \tabcellsep III. Results\\
Year 2020\tabcellsep \tabcellsep \\
Volume XX Issue I Version I\tabcellsep \tabcellsep \\
D D D D ) F\tabcellsep \tabcellsep \\
(\tabcellsep \tabcellsep \\
Medical Research\tabcellsep Knowledge related responses Q1. Do you know how to treat Anaphylaxis? Did you receive any training about it? a. Yes and I got training about it. b. Yes, but I did not get training about it. c. May be, I forget how to treat despite my training. d. No, and I did not get any training.\tabcellsep Trainees N (\%) 46 (48) 40 (42) 4 (4) 4 (4)\\
Global Journal of\tabcellsep Q2. What is the lifesaving drug in this case? a. Antihistamine b. Norepinephrine c. Epinephrine Q3. Which route would you use to administer the treatment? a. I.V b. S.C c. I.M\tabcellsep 3 (3) 2 (2) 89 (92) 6 (6) 12 (13) 76 (80)\\
\tabcellsep Q4. What dose would you give?\tabcellsep \\
\tabcellsep A. 0.001mg/kg from 1:1000 solution\tabcellsep 4 (4)\\
\tabcellsep B. 0.01mg/kg from 1:1000 solution\tabcellsep 77 (80)\\
\tabcellsep C. 1mg/kg\tabcellsep 4 (4)\\
\tabcellsep D. 2mg in 2ml nebulizer solution\tabcellsep 1 (1)\\
\tabcellsep F. Not sure\tabcellsep 8 (8)\\
\tabcellsep Q5. Have you heard about the EpiPen®?\tabcellsep \\
\tabcellsep A. Yes\tabcellsep 71 (85)\\
\tabcellsep B. No\tabcellsep 11 (13)\\
\tabcellsep C. Not sure\tabcellsep 2 (2)\end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.6118079096045198\textwidth}P{0.09124293785310734\textwidth}P{0.08163841807909604\textwidth}P{0.06531073446327684\textwidth}}
Correct responses to knowledge questions Questionnaire Part 1\tabcellsep PGY1 N=19 (\%)\tabcellsep PGY4 N=9 (\%)\tabcellsep P value (fischer exact test)\\
Q1. Do you know how to treat anaphylactic shock due to food allergy? Yes, and I got training about it.\tabcellsep 4 (21)\tabcellsep 7 (78)\tabcellsep 0.01\\
Yes, but I didn't get training about it.\tabcellsep 10 (53)\tabcellsep 2 (22)\tabcellsep 0.27\\
Maybe/No.\tabcellsep 5 (26)\tabcellsep 0\tabcellsep 0.24\\
Q2. What is the lifesaving drug in this case? Epinephrine\tabcellsep 18 (95)\tabcellsep 9 (100)\tabcellsep 0.9\\
Q3. Which route would you use to administer the treatment? I.M\tabcellsep 19 (100)\tabcellsep 8 (89)\tabcellsep 0.6\\
Q4. What dose would you give? 0.01mg/kg from 1:1000 solution\tabcellsep 15 (79)\tabcellsep 9 (100)\tabcellsep 0.3\\
Correct response to knowledge questions Questionnaire Part 2\tabcellsep PGY1 N=15(\%)\tabcellsep PGY4 N=7(\%)\tabcellsep P value\\
Q5. Have you heard about EpiPen®? Yes\tabcellsep 11 (73)\tabcellsep 7 (100)\tabcellsep 0.3\\
Q6. Do you know when to use it? Yes\tabcellsep 10 (67)\tabcellsep 7 (100)\tabcellsep 0.2\\
Q7. Please write down which case it is used for? Anaphylaxis\tabcellsep 10 (67)\tabcellsep 7 (100)\tabcellsep 0.2\\
Q8. Where would you give it? Lateral part of the thigh\tabcellsep 7 (47)\tabcellsep 5 (71)\tabcellsep 0.5\end{longtable} \par
 
\caption{\label{tab_5}Table 5 :}\end{figure}
 			\footnote{© 2020 Global Journals} 			\footnote{Anaphylaxis and Epinephrine Auto-Injector use: A Survey of Pediatric Trainees© 2020 Global Journals} 		 		\backmatter   			 
\subsection[{Acknowledgements}]{Acknowledgements}\par
We thank Dr. Karima Becetti for her valuable review and feedback. We also thank Dr. Prem Chandra from Hamad Medical Corporation research center for support in the statistical analysis. 
\subsection[{Disclosure Statement}]{Disclosure Statement}\par
The authors declare no conflict of interests.\par
Authors Contribution MA (Principal investigator) conceptualized the study, CB collected the data analyzed, drafted and edited the manuscript. SME analysed data and wrote the manuscript. AA presented the data in the PAAM conference. All authors read and approved the final manuscript. 			  			  				\begin{bibitemlist}{1}
\bibitem[Lieberman et al.]{b2}\label{b2} 	 		\textit{},  		 			P Lieberman 		,  		 			C A Camargo 		,  		 			K Bohlke 		.  		89 p. .  	 
\bibitem[]{b5}\label{b5} 	 		\textit{},  		 \xref{http://dx.doi.org/10.1016/j.jaci.2014.06.018}{10.1016/j.jaci.2014.06.018}.  		134 p. .  	 	 (published Online First: 2014/08/07) 
\bibitem[]{b10}\label{b10} 	 		\textit{},  		 \xref{http://dx.doi.org/10.1016/j.jaci.2013.10.029}{10.1016/j.jaci.2013.10.029}.  		133 p. .  	 	 (published Online First: 2013/12/14) 
\bibitem[ ()]{b18}\label{b18} 	 		\textit{},  		 \xref{http://dx.doi.org/10.1111/j.1365-2044.2012.07159.x}{10.1111/j.1365-2044.2012.07159.x}.  		2016. 67 p. .  	 	 (published Online First: 2012/05/18] 18. NICE-Guideline. Anaphylaxis) 
\bibitem[Jongco et al. ()]{b22}\label{b22} 	 		‘A Simple Allergist-Led Intervention Improves Resident Training in Anaphylaxis’.  		 			A M Jongco 		,  		 			S Bina 		,  		 			R J Sporter 		.  		 \xref{http://dx.doi.org/10.1155/2016/9040319}{10.1155/2016/9040319}.  	 	 		\textit{J Allergy (Cairo)}  		2016. 2016. p. 9040319.  	 	 (published Online First: 2016/02/21) 
\bibitem[Davis et al. ()]{b21}\label{b21} 	 		‘Accuracy of physician self-assessment compared with observed measures of competence: a systematic review’.  		 			D A Davis 		,  		 			P E Mazmanian 		,  		 			M Fordis 		.  		 \xref{http://dx.doi.org/10.1001/jama.296.9.1094}{10.1001/jama.296.9.1094}.  	 	 		\textit{JAMA}  		2006. 296  (9)  p. .  	 
\bibitem[Torey and Fitzharris ()]{b19}\label{b19} 	 		‘Adrenaline in anaphylaxis: overtreatment in theory, under treatment in reality’.  		 			P Torey 		,  		 			P Fitzharris 		.  		 \xref{http://dx.doi.org/10.1136/postgradmedj-2014-133185}{10.1136/postgradmedj-2014-133185}.  	 	 		\textit{Postgrad Med J}  		2015. 1071. 91 p. .  	 
\bibitem[Gibbison et al. ()]{b17}\label{b17} 	 		‘Anaphylaxis admissions to UK critical care units between’.  		 			B Gibbison 		,  		 			A Sheikh 		,  		 			P Mcshane 		.  	 	 		\textit{Anaesthesia}  		2005 and 2009. 2012.  	 
\bibitem[Gopalakrishnan and Alexander ()]{b25}\label{b25} 	 		‘Anaphylaxis-Junior doctors' knowledge of guidelines’.  		 			S Gopalakrishnan 		,  		 			R Alexander 		.  		 doi: 10.1016/j. resuscitation. 2008.11.004.  	 	 		\textit{Resuscitation}  		2009. 80  (3)  p. .  	 	 (published Online First: 2008/12/31) 
\bibitem[Droste and Narayan ()]{b26}\label{b26} 	 		‘Anaphylaxis: lack of hospital doctors' knowledge of adrenaline (epinephrine) administration in adults could endanger patients' safety’.  		 			J Droste 		,  		 			N Narayan 		.  	 	 		\textit{Eur Ann Allergy Clin Immunol}  		2012. 44  (3)  p. .  	 
\bibitem[Ma et al. ()]{b9}\label{b9} 	 		‘Case fatality and population mortality associated with anaphylaxis in the United States’.  		 			L Ma 		,  		 			T M Danoff 		,  		 			L Borish 		.  	 	 		\textit{J Allergy Clin Immunol}  		2014.  	 
\bibitem[Plumb et al. ()]{b15}\label{b15} 	 		‘Correct recognition and management of anaphylaxis: not much change over a decade’.  		 			B Plumb 		,  		 			P Bright 		,  		 			M M Gompels 		.  	 	 		\textit{Postgrad Med J}  		2015.  	 
\bibitem[Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group Ann Allergy Asthma Immunol ()]{b3}\label{b3} 	 		‘Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group’.  		 \xref{http://dx.doi.org/10.1016/S1081-1206(10)61086-1}{10.1016/S1081-1206(10)61086-1}.  	 	 		\textit{Ann Allergy Asthma Immunol}  		2006. 97  (5)  p. .  	 
\bibitem[Campbell et al. ()]{b14}\label{b14} 	 		‘Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine’.  		 			R L Campbell 		,  		 			M F Bellolio 		,  		 			B D Knutson 		.  		 \xref{http://dx.doi.org/10.1016/j.jaip.2014.06.007}{10.1016/j.jaip.2014.06.007}.  	 	 		\textit{J Allergy Clin Immunol Pract}  		2015. 3  (1)  p. .  	 	 (published Online First: 2014/08/29) 
\bibitem[Simons et al. ()]{b12}\label{b12} 	 		‘Fatal and near-fatal anaphylactic reactions to food in children and adolescents’.  		 			F E Simons 		,  		 			L R Ardusso 		,  		 			M B Bilò 		.  		 \xref{http://dx.doi.org/10.1016/j.jaci.2005.12.130311.11}{10.1016/j.jaci.2005.12.130311.11}.  		 doi: 10.1016/j.jaci.2011.01.038 12. 12.  	 	 		\textit{J Allergy Clin Immunol}  		2011. 1992. 117  (2)  p. .  	 	 (N Engl J Med) 
\bibitem[Pumphrey and Gowland ()]{b13}\label{b13} 	 		‘Further fatal allergic reactions to food in the United Kingdom’.  		 			R S Pumphrey 		,  		 			M H Gowland 		.  		 \xref{http://dx.doi.org/10.1056/NEJM19920806327060313.13}{10.1056/NEJM19920806327060313.13}.  		 doi: 10.1016/j.jaci.2007.01.021.  	 	 		\textit{J Allergy Clin Immunol}  		19992006. 2007. 327  (6)  p. .  	 	 (published Online First: 2007/03/08) 
\bibitem[Kennedy et al. ()]{b24}\label{b24} 	 		‘High-fidelity hybrid simulation of allergic emergencies demonstrates improved preparedness for office emergencies in pediatric allergy clinics’.  		 			J L Kennedy 		,  		 			S M Jones 		,  		 			N Porter 		.  		 \xref{http://dx.doi.org/10.1016/j.jaip.2013.07.006}{10.1016/j.jaip.2013.07.006}.  	 	 		\textit{J Allergy Clin Immunol Pract}  		2013. 1  (6)  p. .  	 	 (published Online First: 2013/09/21) 
\bibitem[Turner et al. ()]{b8}\label{b8} 	 		‘Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012’.  		 			P J Turner 		,  		 			M H Gowland 		,  		 			V Sharma 		.  		 doi: 10.1016/ j.jaci.2014.10.021.  	 	 		\textit{J Allergy Clin Immunol}  		2015. 135  (4)  p. .  	 	 (published Online First) 
\bibitem[Nocerino et al. ()]{b6}\label{b6} 	 		‘Increasing rate of hospitalizations for food-induced anaphylaxis in Italian children: An analysis of the Italian Ministry of Health database’.  		 			R Nocerino 		,  		 			L Leone 		,  		 			L Cosenza 		.  	 	 		\textit{J Allergy Clin Immunol}  		2015.  	 
\bibitem[Simons et al. ()]{b20}\label{b20} 	 		‘Knowledge of anaphylaxis among Emergency Department staff’.  		 			F E Simons 		,  		 			L R Ardusso 		,  		 			M B Bilò 		.  		 \xref{http://dx.doi.org/10.1186/1939-4551-7-9}{10.1186/1939-4551-7-9}.  		 doi: 10.5415/apallergy.2014.4.3.164.  	 	 		\textit{World Allergy Organ J}  		2014. 2014. 7  (1)  p. .  	 	 (Asia Pac Allergy. published Online First: 2014/07/29) 
\bibitem[Drupad and Nagabushan ()]{b27}\label{b27} 	 		‘Level of knowledge about anaphylaxis and its management among health care providers’.  		 			H S Drupad 		,  		 			H Nagabushan 		.  		 \xref{http://dx.doi.org/10.4103/0972-5229.160288}{10.4103/0972-5229.160288}.  	 	 		\textit{Indian J Crit Care Med}  		2015. 19  (7)  p. .  	 
\bibitem[Hernandez-Trujillo and Simons ()]{b23}\label{b23} 	 		‘Prospective evaluation of an anaphylaxis education minihandout: the AAAAI Anaphylaxis Wallet Card’.  		 			V Hernandez-Trujillo 		,  		 			F E Simons 		.  		 \xref{http://dx.doi.org/10.1016/j.jaip.2012.11.004}{10.1016/j.jaip.2012.11.004}.  	 	 		\textit{J Allergy Clin Immunol Pract}  		2013. 1  (2)  p. .  	 	 (published Online First: 2013/01/26) 
\bibitem[Simons et al. ()]{b11}\label{b11} 	 		‘Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium’.  		 			F E Simons 		,  		 			M Ebisawa 		,  		 			M Sanchez-Borges 		.  		 \xref{http://dx.doi.org/10.1186/s40413015-0080-1}{10.1186/s40413015-0080-1}.  		 2015/10/28] 10. 10.  	 	 		\textit{J Allergy Clin Immunol}  		2015. 2006. 8  (1)  p. 32.  	 	 (World Allergy Organ J) 
\bibitem[Stewart and Ewan ()]{b1}\label{b1} 	 		‘The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department’.  		 			A G Stewart 		,  		 			P W Ewan 		.  	 	 		\textit{QJM}  		1996.  	 
\bibitem[Mullins et al. ()]{b7}\label{b7} 	 		‘Time trends in Australian hospital anaphylaxis admissions in 1998’.  		 			R J Mullins 		,  		 			K B Dear 		,  		 			M L Tang 		.  		 \xref{http://dx.doi.org/10.1016/j.jaci.2015.05.009}{10.1016/j.jaci.2015.05.009}.  	 	 		\textit{J Allergy Clin Immunol}  		1999 to 2011-2012. 2015. 136  (2)  p. .  	 	 (published Online First: 2015/07/14) 
\bibitem[Rudders et al. ()]{b4}\label{b4} 	 		‘Trends in hospitalizations for food-induced anaphylaxis in US children’.  		 			S A Rudders 		,  		 			S A Arias 		,  		 			C A Camargo 		.  	 	 		\textit{J Allergy Clin Immunol}  		2000-2009. 2014.  	 
\bibitem[Tanno et al. ()]{b16}\label{b16} 	 		‘Under notification of anaphylaxis deaths in Brazil due to difficult coding under the ICD-10’.  		 			L K Tanno 		,  		 			F Ganem 		,  		 			P Demoly 		.  		 \xref{http://dx.doi.org/10.1111/j.1398-9995.2012.02829.x}{10.1111/j.1398-9995.2012.02829.x}.  	 	 		\textit{Allergy}  		2012. 67  (6)  p. .  	 	 (published Online First: 2012/04/23) 
\bibitem[Simons et al. ()]{b0}\label{b0} 	 		‘Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis’.  		 			F E Simons 		,  		 			L R Ardusso 		,  		 			M B Bilò 		.  		 \xref{http://dx.doi.org/10.1097/ACI.0b013e328355b7e4}{10.1097/ACI.0b013e328355b7e4}.  	 	 		\textit{CurrOpin Allergy Clin Immunol}  		2012. 2012. 12  (4)  p. .  	 
\end{bibitemlist}
 			 		 	 
\end{document}
