To the Editor, Some patients with anaphylaxis experience recurrences even when a trigger is identified in the initial reaction. [1][2][3][4][5][6] However, recurrence has received less attention than other epidemiological parameters associated with this condition. [1][2][3][4][5][6] We carried out a systematic review of the international literature to investigate the frequency, severity, and time to onset of recurrence.Details of the methodology of the review are provided in the additional material.After ruling out 3,527 articles, we eventually selected 35 for quantitative analysis (Figure A1).The 35 studies on recurrence covered 34,864 patients. The median percentage of recurrence was 27% (IQR, 12.8-61.43) (Table A1, A2). The median duration of studies was 5 years (range, 1-13 years).Retrospective and prospective cohorts accounted for only 31.43%(Table 1 and Table A2).Studies from Australia reported the highest rates (up to 57.27 recurrences per 100 person-years) (Figure 1, Table A3), with prevalence values higher than 50% for at least 1 recurrence. 3,4 For both prevalence and incidence, differences between continents were statistically significant (p < .01) and heterogeneity was high (I 2 > 99%).Studies carried out in 2 age groups (under 19 years and all ages) did not reveal differences for incidence or prevalence of recurrence rates (p = .88 and .67, respectively) (Table A3), although differences may be diluted because of the inclusion of children and adolescents in the studies covering all age groups. We found no studies that provided data on all causes of recurrence for the >18-year-old group.Given that the review revealed up to 25 different ways of grouping ages, it was impossible to aggregate them into more homogeneous categories.By principal cause of anaphylaxis, the lowest incidence rates were found for recurrences due to drugs and exercise, although only 1 study 3 addressed both causes. The lowest prevalence rates were for drugs, with the differences also being significant for both prevalence and incidence (p < .01) (Figure 1, Table A3).Other potential explanations for the heterogeneity of the metaanalysis include the incorrect classification of anaphylaxis (underand over-diagnosis) in settings other than allergy departments,

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BACKGROUND: Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE: To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS: A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS: Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION: The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.

Background Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling’s initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. Summary/Key Messages Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.