Venom allergy treatment practices in Poland in comparison to guidelines : next edition of the national audit

Introduction: Venom immunotherapy treatment (VIT) is the only causal treatment of hymenoptera venom anaphylaxis, which aims to provide long-lasting immunoprotection against severe reactions to subsequent stings. Aim: To reassess the compliance of VIT procedures in the Polish allergy centres with the European guidelines. Material and methods: A structured questionnaire survey conducted in all 33 VIT-centres. The response rate was 94%. Results: The ultrarush initial protocol was the most common protocol (71%, n = 22), usually lasting for 3.5 h (50%, n = 7). The most frequent (36%, n = 11) time interval from the initial to the first maintenance dose (MD) was 14 days, ranging from 7 to 35 days. All centres used an MD of 100 \mug. The most frequent time interval between subsequent MDs was 4 weeks (58%, n = 18). Five years' of VIT was declared by 71% (n = 22). Before the termination of treatment, more than half of the centres (58%, n = 18) performed sIgE and almost half (42%, n = 13) performed skin tests. To confirm VIT efficacy, few centres (26%, n = 8) conducted the sting challenge. About half of centres provided the patients with an adrenalin auto-injector both at the time of initial diagnostics and at the end of treatment. More than half (55%, n = 17) used antihistamines in all patients. Almost half (45%, n = 14) declared to stop treatment with \beta-blockers and almost one fourth (23%, n = 7) discontinued angiotensin-converting-enzyme inhibitors. Conclusions: In the most important procedures, there is a very high compliance with the guidelines. In the areas where the guidelines are not precise, we observed a large spread of results

The long-term variability of FeNO in pregnant asthmatic women with controlled asthma

 INTRODUCTION: Fractional exhaled nitric oxide (FeNO) is considered as a useful, noninvasive marker of airway inflammation in asthma and allergic rhinitis. It has also been suggested that anti-inflammatory treatment guided by monitoring of exhaled NO could improve overall asthma control. However, long-term intra-subject variability of this parameter as well as the rate of its change, which can be clinically significant, have not been established yet. The aim of our study was to assess the long-term variability of FeNO in pregnant asthmatic women with controlled asthma.MATERIAL AND METHODS: Pregnant, non-smoking women with asthma were recruited between 3 and 6 months of gestation. Exhaled nitric oxide (FeNO) spirometric parameters were measured, and the asthma control test (ACT) was completed during monthly visits up to delivery. The data of 26 subjects with well-controlled asthma during pregnancy (ACT values within the range 20–25, normal spirometric parameters, stable treatment) were analysed. The variability of FeNO values was assessed using the variation coefficient CV (standard deviation x 100%/arithmetic mean).RESULTS: The median level of FeNO coefficient of variation (CV) was: 33.8% (range 11.3 to 121.9) in all subjects with well-controlled asthma during pregnancy. There were no statistically significant differences in FeNO variability between groups of patients who had at least one measurement of FeNO higher than 50ppb (39%; 11.8–121.9%) and those with all FeNO values below 50ppb (29.9%; 11.3–71.8%), as well as between atopic (35.7%; 11.8–121.9%) and nonatopic (24.2%; 11.3–71.8%) pregnant asthmatics (p = 0.95 and 0.11, respectively).CONCLUSIONS: High long-term variability of fractional exhaled nitric oxide values revealed in pregnant women with well-controlled asthma indicates that changes in this parameter should be interpreted with caution while being used for asthma treatment monitoring.  WSTĘP: Pomiar stężenia tlenku azotu w wydychanym powietrzu (FeNO) jest uważany za dobry i nieinwazyjny marker zapalenia dróg oddechowych w astmie i alergicznym nieżycie nosa. Istnieją także sugestie, że dobierając dawkę kortykosteroidów na podstawie stężenia FeNO, można poprawić stopień kontroli astmy. Jednak dotychczas nie oszacowano wiarygodnie długoterminowej wewnątrzosobniczej zmienności FeNO oraz nie ustalono eksperymentalnie, jaka zmiana tego parametru powinna być uważana za klinicznie znamienną.Celem pracy była ocena długoterminowej zmienności FeNO w grupie kobiet ciężarnych z astmą kontrolowaną.MATERIAŁ I METODY: Do badania kwalifikowano ciężarne w 2.–6. miesiącu ciąży, w wieku 19–36 lat, niepalące papierosów, chorujące na astmą oskrzelową. Co 4 tygodnie do daty porodu wykonywano badanie spirometryczne, oznaczano stężenie tlenku azotu FeNO i ACT (test kontroli astmy). Do analizy zakwalifikowano 26 kobiet leczonych stałą dawką kortykosteroidówwziewnych, u których nie obserwowano istotnego pogorszenia samopoczucia (ACT 20–25 pkt) lub upośledzenia parametrów spirometrycznych podczas całego okresu obserwacji. Zmienność parametru FeNO oceniono za pomocą współczynnika zmienności (odchylenie standardowe x 100%/średnia).WYNIKI: U wszystkich badanych chorych wykazano dużą zmienność wartości stężenia tlenku azotu: (mediana 33,8%; min. 11,3%; maks. 121,9%). Porównano zmienność FeNO w grupie ciężarnych, które miały przynajmniej jeden pomiar FeNO powyżej 50 ppb (39,2%; 11,8–121,9%) ze zmiennością FeNO w grupie kobiet, u których wartości FeNO nie przekroczyły progu 50 ppb (29,9%; 11,3–71,8%). Nie stwierdzono różnicy istotnej statystycznie w żadnej z badanych populacji (p = 0,95). Porównując również współczynnik zmienności w grupie chorych na astmę IgE-zależną i IgE-niezależną, nie wykazano istotnych różnic (odpowiednio 35,7%; 11,8–121,9% i 24,2%; 11,3–71,8; p = 0,11).WNIOSKI: Pomiary FeNO charakteryzują się dużą zmiennością w czasie u ciężarnych chorych z kontrolowaną astmą, co wskazuje, że zmiany stężenia tlenku azotu w wydychanym powietrzu powinny być ostrożnie interpretowane.

SLIT in respiratory allergy – status quo 2017

The article presents the utilization of SLIT in the immunotherapy of respiratory allergies based on: (1) EAACI 2017 guidelines formulated using AGREE II (Appraisal of Guidelines for Research and Evaluation), dedicated to the assessment of the efficacy of allergen immunotherapy in the treatment of allergic rhinitis and bronchial asthma, (2) current AAAAI recommendations concerning SLIT, (3) systematic reviews and meta-analyses by Dhami et al., published in 2017. Drawing on these sources, the following issues have been dealt with: current recommendations and contra-recommendations for SLIT in respiratory allergies, short- and long-term efficacy of SLIT, recommendations regarding the use of specific forms of SLIT application, wiz. aqueous solutions and sublingual tablets, recommendations regarding different SLIT protocols and safety of this form of therapy. Additionally, expert opinions on the uses of SLIT in the case of polyvalent allergy and sensitization. Adherence in SLIT has been highlighted based on the most recent “real life” Breath study.Artykuł przedstawia miejsce SLIT w immunoterapii alergii układu oddechowego w oparciu o (1) wytyczne EAACI z 2017 roku opracowane z wykorzystaniem instrumentu AGREE II (Appraisal of Guidelines for Research and Evaluation), a dedykowane ocenie efektywności immunoterapii alergenowej w leczeniu alergicznego nieżytu nosa i astmy alergicznej, (2) wytyczne AAAAI dotyczące SLIT oraz (3) w oparciu o wyniki opublikowanych w roku 2017 przeglądów systematycznych i metaanaliz autorstwa Dhami i wsp. W kontekście powyższych dokumentów przedstawiono: aktualne wskazania i przeciwskazania do SLIT w alergiach układu oddechowego, ocenę skuteczności krótko- i długoterminowej SLIT, rekomendacje dotyczące stosowania poszczególnych form SLIT tj. roztworów wodnych i tabletek podjęzykowych, rekomendacje dotyczące poszczególnych protokołów SLIT oraz problem bezpieczeństwa SLIT. Przedstawiono również opinie ekspertów na temat stosowania SLIT w przypadkach uczulenia i alergii poliwalentnej. Problem adherencji do SLIT zilustrowano wynikami najnowszego badania typu „real life” – badania „Breath”

Ischemic stroke as a rare complication of wasp venom allergy: two clinical scenarios

Neurological complications after a single Hymenoptera insect sting are very rare. The authors of this paper describe two instances of cerebral ischemic stroke that occurred immediately after a wasp sting. Two distinct pathomechanisms involved in the cases are put forward. When diagnosing such cases, it is vital to rule out the possibility of an immunoglobulin E (IgE)-dependent reaction of hypersensitivity. However, if sIgE antibodies against wasp venom extract and/or its allergenic components are detected, after hospitalization the patient should be qualified for venom immunotherapy, which is the only efficient method of protection from severe allergic reactions caused by an insect sting. Although the incidence of ischemic stroke in patients stung by insects is very low, it is important to be aware of this complication. This will allow rapid implementation of appropriate diagnostics and treatment. The optimal stroke treatment (thrombolysis or mechanical thrombectomy) in these rare cases has not yet been established

Influenza and Other Prophylactic Vaccination Coverage in Polish Adult Patients Undergoing Allergen Immunotherapy—A Survey Study among Patients and Physicians

Vaccines against infectious diseases may raise safety concerns in patients undergoing allergen immunotherapy (AIT). The objective of our study was to investigate influenza vaccine and other selected prophylactic vaccines coverage in patients treated with AIT and the attitude of physicians towards vaccinations in this group of patients. We conducted a questionnaire-based study among patients undergoing AIT and physicians. The patients’ survey evaluated influenza and other prophylactic vaccines coverage. The physicians’ survey assessed their experience and opinions on prophylactic vaccinations during AIT. In total, 176 patients (aged 18–79 years) and 120 doctors filled the questionnaires. Patients were assigned to two groups—inhaled allergens group (n = 101) and insect venoms group (n = 68). The number of patients who received any dose (36% and 45%, p = 0.26), as well as two or more doses (17% and 22%, p = 0.43) of influenza vaccine was comparable between two groups. However, in both groups there was a significant (p p = 0.004). The groups did not differ in the pneumococcal and tick-borne encephalitis vaccination coverage. A majority of doctors believe that prophylactic vaccinations in patients undergoing AIT are safe and effective (96% and 94%, respectively); however, as many as 87% of them identify with the need to create clear recommendations regarding vaccinating patients undergoing AIT. Prophylactic vaccine coverage is not satisfactory among Polish adult patients undergoing AIT. Polish doctors are convinced of the validity of prophylactic vaccinations during AIT

Influenza and Other Prophylactic Vaccination Coverage in Polish Adult Patients Undergoing Allergen Immunotherapy—A Survey Study among Patients and Physicians

Vaccines against infectious diseases may raise safety concerns in patients undergoing allergen immunotherapy (AIT). The objective of our study was to investigate influenza vaccine and other selected prophylactic vaccines coverage in patients treated with AIT and the attitude of physicians towards vaccinations in this group of patients. We conducted a questionnaire-based study among patients undergoing AIT and physicians. The patients’ survey evaluated influenza and other prophylactic vaccines coverage. The physicians’ survey assessed their experience and opinions on prophylactic vaccinations during AIT. In total, 176 patients (aged 18–79 years) and 120 doctors filled the questionnaires. Patients were assigned to two groups—inhaled allergens group (n = 101) and insect venoms group (n = 68). The number of patients who received any dose (36% and 45%, p = 0.26), as well as two or more doses (17% and 22%, p = 0.43) of influenza vaccine was comparable between two groups. However, in both groups there was a significant (p < 0.0001) decrease in influenza vaccine uptake after the beginning of AIT. Patients from the inhaled allergens group declared a higher tetanus vaccine rate (41% vs. 19%, p = 0.004). The groups did not differ in the pneumococcal and tick-borne encephalitis vaccination coverage. A majority of doctors believe that prophylactic vaccinations in patients undergoing AIT are safe and effective (96% and 94%, respectively); however, as many as 87% of them identify with the need to create clear recommendations regarding vaccinating patients undergoing AIT. Prophylactic vaccine coverage is not satisfactory among Polish adult patients undergoing AIT. Polish doctors are convinced of the validity of prophylactic vaccinations during AIT

Current practices in diagnosis of Hymenoptera venom allergy in Poland

INTRODUCTION: Hymenoptera venom allergy (HVA) is associated with a high risk of anaphylaxis. Effective treatment of HVA patients requires allergologists’ familiarity with the latest HVA recommendations. AIM: Evaluation of current practices in HVA diagnosis in Poland. MATERIAL AND METHODS: A survey questionnaire was conducted in 32 HVA centres in Poland. RESULTS: The response rate was 97%. There were 1829 patients evaluated due to HVA in 2015. Sixty six percent (n = 21) of the centres used skin prick tests, out which 90% (n = 19) used 100 µg/ml of the venom extract as the highest concentration. All the centres performed intradermal tests (IDT) and serum specific IgE (sIgE), an initial diagnostic tool in 91% (n = 29). The highest venom concentration in IDT was 1 µg/ml in 75% (n = 24), 0.1 µg/ml in 16% (n = 5), 0.01 µg/ml in 3% (n = 1) and 10 µg/ml in 6% (n = 2). Baseline serum tryptase was assessed in 84% of the centres (n = 27), out of which 53% (n = 17) tested all their patients, whereas 31% (n = 10) checked only those with life-threatening reactions. In case of negative IDT/sIgE, 59% of the centres (n = 19) performed components evaluation, while 19% (n = 6) did the basophil activation test. In case of no identification of the culprit insect and sensitization to both venoms, VIT employed venom with higher sIgE. CONCLUSIONS: Most allergology centres in Poland follow HVA guidelines. We identified two inaccuracies in their HVA management including non-adequate venom concentration in IDT and a false belief in correspondence between sIgE concentration and severity of allergic reactions