Risk factors and indicators of severe systemic insect sting reactions

Hymenoptera venom allergy ranks among the top three causes of anaphylaxis worldwide, and approximately one-quarter of sting-induced reactions are classified as severe. Fatal sting reactions are exceedingly rare, but certain factors may entail a considerably higher risk. Delayed administration of epinephrine and upright posture are situational risk factors which may determine an unfavorable outcome of the acute anaphylactic episode and should be addressed during individual patient education. Systemic mastocytosis and senior age are major, unmodifiable long-term risk factors and thus reinforce the indication for venom immunotherapy. Vespid venom allergy and male sex likewise augment the risk of severe or even fatal reactions. Further studies are required to assess the impact of specific cardiovascular comorbidities. Available data regarding potential effects of beta-blockers and/or ACE inhibitors in coexisting venom allergy are inconclusive and do not justify recommendations to discontinue guideline-directed antihypertensive treatment. The absence of urticaria/angioedema during sting-induced anaphylaxis is indicative of a severe reaction, serum tryptase elevation, and mast cell clonality. Determination of basal serum tryptase levels is an established diagnostic tool for risk assessment in Hymenoptera venom-allergic patients. Measurement of platelet-activating factor acetylhydrolase activity represents a complementary approach but is not available for routine diagnostic use

Is the proteomic composition of the salivary pellicle dependent on the substrate material?

Purpose: The use of dental restorative materials is a routine task in clinical dentistry. Upon exposure to the oral cavity, continuous adsorption of salivary proteins and other macromolecules to all surfaces occurs, representing the first step in dental biofilm formation. Different physico-chemical properties of substrate materials potentially influence the composition of the initial biofilm, termed pellicle. This study aimed at characterizing and comparing the individual proteomic composition of the 3-min pellicle formed on bovine enamel and six restorative materials. Experimental Design: After chemical elution, pellicle proteins were identified by nano-LC-HR-MS/MS. Proteomic profiles were analyzed in terms of molecular weights, isoelectric points, molecular functions and compared to saliva to reveal substrate material-specific adsorption patterns. Results: A total of 1348 different pellicle proteins were identified, with 187–686 proteins in individual 3-min pellicles. Unexpectedly, this yielded quite similar distribution patterns independent of the substrate materials. Furthermore, overall similar fold changes were obtained for the major part of commonly enriched or depleted proteins in the pellicles. Conclusions and Clinical Relevance: The current results point to a minor role of the substrate material on the proteomic composition of the 3-min pellicle and represent core data for understanding the complex surface interactions in the oral cavity

Correction to: Role of root hair elongation in rhizosheath aggregation and in the carbon flow into the soil

The above article’s initial published version contained an error regarding the co-author Vincent J. M. N. L. Felde’s affiliation. Instead of “Institute of Soil Science and Soil Conservation, Justus Liebig University Giessen, Giessen, Germany”, the right affiliation should have been “Institute of Soil Science, Leibniz University of Hannover, Germany”. The original article has been corrected

Is there a difference between preoperative and intraoperative condylar position?

Ziel dieser Studie war die Evaluation des Einflusses der Generalanästhesie im Rahmen einer Dysgnathieoperation auf die zentrische Kondylenposition mit einem neuen dreidimensionalen Verfahren. Bisherige Untersuchung zur Registrierung der Kondylenposition bei Dysgnathieoperationen und der Notwendigkeit der intraoperativen Positionierung erfolgten bislang auf Basis von Gipsmodellen und linearen Untersuchungen. Vorherige Studien konnten nachweisen, dass eine inkorrekte intraoperative Kondylenpositionierung postoperativ zu Rezidiven, Kondylenresorptionen oder Craniomandibulären Dysfunktionen führen kann. Methodik: Bei 30 Dysgnathiepatienten (16 weiblich, 14 männlich) wurden zu zwei Zeitpunkten, präoperativ im wachen Zustand und intraoperativ im narkosierten und relaxierten Zustand, die zentrische Kondylenposition registriert. Die Registrate wurden digitalisiert und mithilfe einer DVT des gesamten Schädels überlagert, die Gelenkspalte von 120 Kondylen vermessen und die volumetrische Übereinstimmung analysiert. Subgruppenanalysen zwischen skelettaler Klasse II und III, sowie asymmetrischen und symmetrischen Patienten wurden durchgeführt. Ergebnisse: Die linearen Messungen der Gelenkspalte ergaben keine signifikanten Änderungen der Kondylenposition. Erst die Analyse der volumetrischen Übereinstimmung zeigte eine signifikante Stellungsänderung der Kondylen zwischen prä-und intraoperativer Registrierung (p=0,015). Die volumetrische Überlagerung zeigte in 63% der untersuchten Kondylen eine Bewegung nach inferior-posterior.  Die Subgruppenanalysen ergaben keine signifikanten Ergebnisse. Fazit: Auf Basis der Ergebnisse scheint die präoperative Registrierung der Kondylenposition und der Einsatz von Hilfsmitteln zur Positionierung im Rahmen der Operationsplanung zur Prävention von Rezidiven und Vorhersagbarkeit des Therapieerfolges sinnvoll zu sein.Aim: The aim of this study was to evaluate the influence of general anaesthesia during orthodontic surgery on centric condylar relation (CR) using a new three-dimensional method. Previous studies on the registration of condylar position in orthodontic surgery and the necessity of intraoperative positioning have been based on plaster models and linear studies. Previous studies have demonstrated that incorrect intraoperative condylar positioning can lead to postoperative recurrence, condylar resorption or craniomandibular dysfunction. Material/Methods: The CR was recorded at two time points at 30 patients (16 female, 14 male) who underwent orthodontic surgery, preoperatively in the awake state and intraoperatively in the narcosed and relaxed state. The registrations were digitised and superimposed using a DVT of the whole skull, the joint space of 120 condyles was measured and the volumetric congruence was analysed. Subgroup analyses between skeletal class II and III, and asymmetric and symmetric patients were performed. Results: Linear measurements of joint spaces did not demonstrate significant changes in condylar position; only analysis of volumetric congruence showed a significant change in condylar position between pre- and intraoperative registration (p=0.015). The volumetric congruence showed an inferior-posterior movement in 63% of the condyles examined.  The subgroup analyses did not show any significant results. Conclusion: Based on the results, the preoperative registration of the CR and the use of positioning aids in surgical planning seems to be useful for the prevention of recurrences and predictability of therapeutic success.2022-02-0

Risk factors in bee and Vespula venom allergy: state of the art

Background Correct recognition of risk factors enables individualized management and treatment of venom allergic patients. Methods Systematic research and review of current literature regarding the risk of (1) severe sting-induced anaphylaxis, (2) anaphylactic adverse event during venom immunotherapy (VIT), and (3) treatment failure. Results and discussion (1) Mastocytosis is the most important risk factor for severe sting-induced anaphylaxis. Hereditary α‑tryptasemia was recently identified as a genetic predictor of severe reactions. Older age is clearly associated with an increased risk; the respective impact of defined cardiovascular comorbidities has yet to be determined. Recent data do not support an aggravation of venom-induced anaphylaxis by intake of β‑blockers or angiotensin-converting enzyme (ACE) inhibitors. A higher risk in men can be attributed to more intensive exposure to stinging insects. (2) Anaphylactic side effects of VIT are most common during the buildup phase, particularly in the course of (ultra-)rush protocols involving a high number of injections and high cumulative daily doses. They are significantly more frequent during honeybee compared to Vespula VIT. Data supporting a negative effect of mastocytosis on the tolerability of VIT are scarce. Older age and cardiovascular medication are not associated with a higher incidence of VIT-induced anaphylaxis. (3) Relapsing anaphylactic reactions to both field and challenge stings are significantly more common during and after honeybee compared to Vespula VIT. Reports of severe field-sting reactions in mastocytosis patients suggest an increased risk of treatment failure which may be overcome by higher maintenance doses and longer duration of VIT

Single venom-based immunotherapy effectively protects patients with double positive tests to honey bee and Vespula venom

Background Referring to individuals with reactivity to honey bee and Vespula venom in diagnostic tests, the umbrella terms “double sensitization” or “double positivity” cover patients with true clinical double allergy and those allergic to a single venom with asymptomatic sensitization to the other. There is no international consensus on whether immunotherapy regimens should generally include both venoms in double sensitized patients. Objective We investigated the long-term outcome of single venom-based immunotherapy with regard to potential risk factors for treatment failure and specifically compared the risk of relapse in mono sensitized and double sensitized patients. Methods Re-sting data were obtained from 635 patients who had completed at least 3 years of immunotherapy between 1988 and 2008. The adequate venom for immunotherapy was selected using an algorithm based on clinical details and the results of diagnostic tests. Results Of 635 patients, 351 (55.3%) were double sensitized to both venoms. The overall re-exposure rate to Hymenoptera stings during and after immunotherapy was 62.4%; the relapse rate was 7.1% (6.0% in mono sensitized, 7.8% in double sensitized patients). Recurring anaphylaxis was statistically less severe than the index sting reaction (P = 0.004). Double sensitization was not significantly related to relapsing anaphylaxis (P = 0.56), but there was a tendency towards an increased risk of relapse in a subgroup of patients with equal reactivity to both venoms in diagnostic tests (P = 0.15). Conclusions Single venom-based immunotherapy over 3 to 5 years effectively and long-lastingly protects the vast majority of both mono sensitized and double sensitized Hymenoptera venom allergic patients. Double venom immunotherapy is indicated in clinically double allergic patients reporting systemic reactions to stings of both Hymenoptera and in those with equal reactivity to both venoms in diagnostic tests who have not reliably identified the culprit stinging insect

Outcome of a de-labelling algorithm compared with results of penicillin (β-lactam) allergy testing

Background Penicillin allergy labels frequently impede guideline-directed treatment with a penicillin or other β-lactam antibiotics. Despite presumed allergy, targeted questioning may indicate a low probability of sensitization and permit reasonably safe administration of the antibiotic in question. In this study, we evaluated a standardized algorithm aiming to differentiate non-allergic patients from those with true allergic β-lactam hypersensitivity. Methods We retrospectively applied a de-labelling algorithm in 800 consecutive patients with suspected β-lactam hypersensitivity. All had undergone complete allergy work-up permitting to definitely exclude or diagnose β-lactam allergy between 2009 and 2019. Results In 595 (74.4%) out of 800 cases evaluated, β-lactam allergy could be excluded by negative challenge testing. IgE-mediated anaphylaxis was diagnosed in 70 (8.7%) patients, delayed-type hypersensitivity in 135 (16.9%). In 62 (88.6%) anaphylaxis cases, the algorithm correctly advised to use an alternative antibiotic. Accuracy was higher in patients with moderate to severe anaphylaxis (97.7%) compared to those with a history of mild reactions (73.1%). The algorithm correctly identified 122 (90.4%) patients with proven delayed-type hypersensitivity. It permitted de-labelling in 330 (55.5%) out of 595 patients with diagnostic exclusion of penicillin hypersensitivity, but failed to identify the remaining 265 (44.5%) as low-risk cases. Conclusions The algorithm detected 89.8% of cases with penicillin (β-lactam) allergy, sensitivity was optimal for moderate to severe anaphylaxis. Study data justify the implementation of a standardized de-labelling algorithm under close supervision in order to permit guideline-directed treatment and reduce the use of broad-spectrum antibiotics as part of an antibiotic stewardship program