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Talk:Allergy Intolerance UseCase Storyboards May23

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I have some comments! -- Larry.

The introductory paragraphs under "Scope and Use Cases" gives me an impression that "adverse reaction" is a type of "allergies". May be this is a reflection of my lack of understanding of the sentence structure. But this is the impression I infer from the following text:

"Within the context of allergies, an 'adverse reaction' is a harmful or undesirable response after administration of an agent/substance. _Intolerance_ is a condition where the patient has been noted to have an adverse reaction and a judgment is made that the reaction was caused by a given substance. Administration of substances (in the form of ingestion, inhalation, injection, or direct contact) may result in adverse reactions which may be severe or mild, occur after variable lengths of time, and the relationship between exposure and the adverse reaction may be uncertain. Additionally, the noted exposure may be (usually is) to a mixture of complex substances. Additionally, many substances cross react, so that it may be a class of medications that cause problems. Therefore the assignment of causality of the actual relationship between the offending substance and the reaction is generally always uncertain to some degree."

"Adverse Reaction" should be the top level concept. It covers "immune response-induced" adverse reactions and "non-immune response" adverse reactions ( I think it is useful to give an overview of the "Adverse Reaction" hierarchy, and then focus on the discussion on "allergy" and "intolerance".

"Adverse Reaction" definition (NEHTA) - a harmful or undersirable response to an agent/substance. An adverse reaction includes allergies, intolerance and (non immune induced) sensitivity. An adverse reaction does not include poisoning, medical errors or mishaps that may occur during medical or surgical care, as these are generally classified as adverse event.

Adverse reaction heirarchy:

                                      ADVERSE REACTION
                    |                                               |
    Allergy (immune response-induced)               Non immune response induced
      - IgE-mediated                                  - pharmacologic side effects
      - cytotoxic                                     - drug toxicity
      - immune complex                                - drug-drug interactions
      - delayed, cell-mediated                        - pseudoallergies
      - other immune mechanism                        - idosyncratic reactions
                                                      - intolerance



Hi Stephen,

Sorry for the delay in answering this.

I did consider your comments carefully, but I don't think the hierarchy above works because in both the Allergy and Adverse Reaction are observations which are temporally unrelated, and looking at different types of things.

In the case of an adverse reaction, this is generally *the result* of an allergy or non-immune response induced condition. The condition persists despite the fact that the adverse reaction is gone. So when we say the allergy is an "observation" we really mean that it is a observation by the clinician that he things the clinical condition still exists in the patient. It's as if he could peak inside the body and physically observe this, but in fact he is actually making a complex judgment based on lots of other evidence and experience.

The reaction is a bit more easy to understand, it's he physically sees the rash and notes that in the computer. He then uses the observation of the rash as evidence in his judgment that there is an allergy, but only as evidence. There must be temporal exposure to a substance, the rash must be consistent in appearance, and other potential causes must be ruled out before he can state that the allergy/intolerance exists.

Larry 08:50, 14 September 2007 (CDT)