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Global View on Ant Venom Allergy: from Allergenic Components to Clinical Management. Clin Rev Allergy Immunol 2021; 62:123-144. [PMID: 34075569 DOI: 10.1007/s12016-021-08858-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 12/21/2022]
Abstract
Hymenoptera venom allergy is characterised by systemic anaphylactic reactions that occur in response to stings from members of the Hymenoptera order. Stinging by social Hymenoptera such as ants, honeybees, and vespids is one of the 3 major causes of anaphylaxis; along with food and drug exposure, it accounts for up to 43% of anaphylaxis cases and 20% of anaphylaxis-related fatalities. Despite their recognition as being of considerable public health significance, stinging ant venoms are relatively unexplored in comparison to other animal venoms and may be overlooked as a cause of venom allergy. Indeed, the venoms of stinging ants may be the most common cause of anaphylaxis in ant endemic areas. A better understanding of the natural history of venom allergy caused by stinging ants, their venom components, and the management of ant venom allergy is therefore required. This article provides a global view on allergic reactions to the venoms of stinging ants and the contemporary approach to diagnose and manage ant venom allergy.
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Zahirović A, Luzar J, Molek P, Kruljec N, Lunder M. Bee Venom Immunotherapy: Current Status and Future Directions. Clin Rev Allergy Immunol 2020; 58:326-341. [PMID: 31240545 DOI: 10.1007/s12016-019-08752-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bee venom immunotherapy is the main treatment option for bee sting allergy. Its major limitations are the high percentage of allergic side effects and long duration, which are driving the development of novel therapeutic modalities. Three general approaches have been evaluated including the use of hypoallergenic allergen derivatives, adjunctive therapy, and alternative delivery routes. This article reviews preclinical and clinical evidence on the therapeutic potential of these new therapies. Among hypoallergenic derivatives, hybrid allergens showed a markedly reduced IgE reactivity in mouse models. Whether they will offer therapeutic benefit over extract, it is still not known since clinical trials have not been carried out yet. T cell epitope peptides have proven effective in small clinical trials. Major histocompatibility complex class II restriction was circumvented by using long overlapping or promiscuous T cell epitope peptides. However, the T cell-mediated late-phase adverse events have been reported with both short and longer peptides. Application of mimotopes could potentially overcome both T cell- and IgE-mediated adverse events. During this evolution of vaccine, there has been a gain in safety. The efficacy was further improved with the use of Toll-like receptor-activating adjuvants and delivery systems. In murine models, the association of allergen Api m 1 with cytosine-guanosine rich oligonucleotides stimulated strong T-helper type-1 response, whereas its encapsulation into microbubbles protected mice against allergen challenge. An intralymphatic administration of low-dose vaccine has shown the potential to decrease treatment from 5 years to only 12 weeks. Bigger clinical trials are needed to follow up on these results.
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Affiliation(s)
- Abida Zahirović
- Faculty of Pharmacy, Department of Pharmaceutical Biology, University of Ljubljana, Aškerčeva 7, SI-1000, Ljubljana, Slovenia.
| | - Jernej Luzar
- Faculty of Pharmacy, Department of Pharmaceutical Biology, University of Ljubljana, Aškerčeva 7, SI-1000, Ljubljana, Slovenia
| | - Peter Molek
- Faculty of Pharmacy, Department of Pharmaceutical Biology, University of Ljubljana, Aškerčeva 7, SI-1000, Ljubljana, Slovenia
| | - Nika Kruljec
- Faculty of Pharmacy, Department of Pharmaceutical Biology, University of Ljubljana, Aškerčeva 7, SI-1000, Ljubljana, Slovenia
| | - Mojca Lunder
- Faculty of Pharmacy, Department of Pharmaceutical Biology, University of Ljubljana, Aškerčeva 7, SI-1000, Ljubljana, Slovenia
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De Amicis K, Costa PR, Figo DD, De Lima CMF, Castro FFM, Kalil J, Santos KS, Galvão CES. Immunophenotypical Characterization of a Brazilian POIS (Post-Orgasmic Illness Syndrome) Patient: Adding More Pieces to Puzzle. JOURNAL OF SEX & MARITAL THERAPY 2019; 46:227-233. [PMID: 31612795 DOI: 10.1080/0092623x.2019.1677835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Post-orgasmic illness syndrome (POIS) is a rare condition characterized by post-ejaculatory symptoms. Here is reported the first Brazilian POIS patient. Immunological investigation did not confirm the previous hypothesis of a hypersensitivity reaction. Cell immunophenotyping comparing healthy individuals produced evidence of abnormalities not associated to clinical manifestations. The patient was submitted to specific immunotherapy with transient clinical response and was referred to a psychologist but did not demonstrate clinical improvement of symptoms. Therefore, etiology of POIS remains unclear.
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Affiliation(s)
- Karine De Amicis
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Priscilla Ramos Costa
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniele Danella Figo
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Fabio Fernandes Morato Castro
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Serviço de Imunologia Clinica e Alergia, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
- Institute for Investigation in Immunology (III), INCT, Sao Paulo, Brazil
| | - Jorge Kalil
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Laboratorio de Imunologia, Instituto Do Coraçao, Hospital Das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Institute for Investigation in Immunology (III), INCT, Sao Paulo, Brazil
| | - Keity Souza Santos
- Disciplina de Imunologia Clinica e Alergia, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Laboratorio de Imunologia, Instituto Do Coraçao, Hospital Das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Institute for Investigation in Immunology (III), INCT, Sao Paulo, Brazil
| | - Clovis Eduardo Santos Galvão
- Serviço de Imunologia Clinica e Alergia, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Effects of Different Treatment Options on the Prognosis of Wasp Stings. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791302000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Severe wasp sting injuries often threaten patient's life. We compared the effects of three different therapies on the prognosis of wasp stung patients. Methods We conducted a randomised single-blind controlled trial. Patients stung by wasp were randomly assigned to one of the three treatment groups: group A received symptomatic treatment; those complicated with acute renal failure and haemolysis also received haemoperfusion combined with haemodialysis; for patients with severe haemolytic anaemia, plasmapheresis were applied; for patients with haemodynamic instability, continuous renal replacement therapy was used. Group B received intravenous methylprednisolone injection, 80 mg/d for continuous 3 days in addition to the symptomatic therapy; for patients with haemolysis, methylprednisolone 0.5 g/d was injected intravenously for 3-5 days. For group C, in addition to all treatments administrated to group B patients, subcutaneous injection of 0.5 ml 0.1% epinephrine was given immediately after admission. Primary endpoint was mortality. Major complications (gastrointestinal haemorrhage, toxic encephalopathy, haemolysis, and acute left ventricular failure) and serum enzyme spectrum elevate (alanine aminotransferase [ALT], creatine kinase [CK] isoenzyme and serum creatinine) were secondary endpoints. Results Of 134 patients recruited, 45, 44 and 45 patients were assigned to group A, B or C respectively. Therapy in group C reduced mortality compared with group A and B (respectively 24.4%, 9.09%, 0.00% for group A, B, C respectively; p<0.001); there was no significant effects on major complications among three groups (p >0.1). The incidence of elevated ALT was significantly lower in group B and group C than in group A (p<0.001). The incidence of elevated CK isoenzyme was significantly lower in group C than in group A and group B (p<0.001). Conclusions For patients with concurrent organ impairment by wasp sting, early combination of epinephrine and methylprednisolone with supportive treatment with renal replacement therapy can effectively reduce the incidence of organ damage and mortality.
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Specific immunotherapy for latex allergy. Hippokratia 2017. [DOI: 10.1002/14651858.cd009240.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Dhami S, Zaman H, Varga EM, Sturm GJ, Muraro A, Akdis CA, Antolín-Amérigo D, Bilò MB, Bokanovic D, Calderon MA, Cichocka-Jarosz E, Oude Elberink JNG, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Mosbech H, Ollert M, Pfaar O, Pitsios C, Pravettoni V, Roberts G, Ruëff F, Sin BA, Asaria M, Netuveli G, Sheikh A. Allergen immunotherapy for insect venom allergy: a systematic review and meta-analysis. Allergy 2017; 72:342-365. [PMID: 28120424 DOI: 10.1111/all.13077] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines on Allergen Immunotherapy (AIT) for the management of insect venom allergy. To inform this process, we sought to assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy. METHODS We undertook a systematic review, which involved searching 15 international biomedical databases for published and unpublished evidence. Studies were independently screened and critically appraised using established instruments. Data were descriptively summarized and, where possible, meta-analysed. RESULTS Our searches identified a total of 16 950 potentially eligible studies; of which, 17 satisfied our inclusion criteria. The available evidence was limited both in volume and in quality, but suggested that venom immunotherapy (VIT) could substantially reduce the risk of subsequent severe systemic sting reactions (OR = 0.08, 95% CI 0.03-0.26); meta-analysis showed that it also improved disease-specific quality of life (risk difference = 1.41, 95% CI 1.04-1.79). Adverse effects were experienced in both the build-up and maintenance phases, but most were mild with no fatalities being reported. The very limited evidence found on modelling cost-effectiveness suggested that VIT was likely to be cost-effective in those at high risk of repeated systemic sting reactions and/or impaired quality of life. CONCLUSIONS The limited available evidence suggested that VIT is effective in reducing severe subsequent systemic sting reactions and in improving disease-specific quality of life. VIT proved to be safe and no fatalities were recorded in the studies included in this review. The cost-effectiveness of VIT needs to be established.
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Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - H. Zaman
- School of Pharmacy; University of Bradford; Bradford UK
| | - E.-M. Varga
- Department of Pediatric and Adolescent Medicine; Respiratory and Allergic Disease Division; Medical University of Graz; Graz Austria
| | - G. J. Sturm
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
- Outpatient Allergy Clinic Reumannplatz; Vienna Austria
| | - A. Muraro
- Department of Women and Child Health; Food Allergy Referral Centre Veneto Region; Padua General University Hospital; Padua Italy
| | - C. A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); Switzerland Servicio de Enfermedades del Sistema Inmune-Alergia; University of Zurich; Zurich Switzerland
- Departamento de Medicina y Especialidades Médicas; Hospital Universitario Príncipe de Asturias; Madrid Spain
| | | | - M. B. Bilò
- Allergy Unit; Department of Internal Medicine; University Hospital of Ancona; Ancona Italy
| | - D. Bokanovic
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
| | - M. A. Calderon
- Section of Allergy and Clinical Immunology; Imperial College London; National Heart and Lung Institute; Royal Brompton Hospital; London UK
| | - E. Cichocka-Jarosz
- Department of Pediatrics; Jagiellonian University Medical College; Krakow Poland
| | - J. N. G. Oude Elberink
- Department of Allergology and Internal Medicine; University of Groningen; University Medical Hospital Groningen; Groningen The Netherlands
- Groningen Research Center for Asthma and COPD (GRIAC); Groningen The Netherlands
| | - R. Gawlik
- Department of Internal Medicine, Allergy and Clinical Immunology; Medical University of Silesia; Katowice Poland
| | - T. Jakob
- Department of Dermatology and Allergology; University Medical Center Gießen and Marburg (UKGM); Justus Liebig University Gießen; Gießen Germany
| | - M. Kosnik
- Medical Faculty Ljubljana; University Clinic of Respiratory and Allergic Diseases Golnik; Golnik Slovenia
| | - J. Lange
- Department of Pediatric Pneumonology and Allergy; Medical University of Warsaw; Warsaw Poland
| | - E. Mingomataj
- Department of Allergology and Clinical Immunology; Mother Theresa School of Medicine; Tirana Albania
- Department of Paraclinical Disciplines; Faculty of Technical Medical Sciences; Medicine University of Tirana; Tirana Albania
| | - D. I. Mitsias
- Department of Allergy and Clinical Immunology; 2nd Pediatric Clinic; University of Athens; Athens Greece
| | - H. Mosbech
- Allergy Clinic; Copenhagen University Hospital Gentofte; Gentofte Denmark
| | - M. Ollert
- Department of Infection and Immunity; Luxembourg Institute of Health (LIH); Strassen Luxembourg
| | - O. Pfaar
- Department of Otorhinolaryngology; Head and Neck Surgery; Universitätsmedizin Mannheim; Mannheim Germany
- Medical Faculty Mannheim; Heidelberg University; Heidelberg Germany
- Center for Rhinology Allergology; Wiesbaden Germany
| | - C. Pitsios
- Medical School; University of Cyprus; Nicosia Cyprus
| | - V. Pravettoni
- UOC Clinical Allergy and Immunology; IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; University of Southampton; Southampton UK
| | - F. Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie; Klinikum der Universität München; Munich Germany
| | - B. A. Sin
- Department of Pulmonary Diseases; Division of Immunology and Allergy; Faculty of Medicine; Ankara University; Ankara Turkey
| | - M. Asaria
- Research Fellow Centre for Health Economics; University of York; UK
| | - G. Netuveli
- Institute for Health and Human Development; University of East London; London UK
| | - A. Sheikh
- Allergy and Respiratory Research Group; The University of Edinburgh; Edinburgh UK
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Cichocka-Jarosz E, Stobiecki M, Brzyski P, Rogatko I, Nittner-Marszalska M, Sztefko K, Czarnobilska E, Lis G, Nowak-Węgrzyn A. Simplification of intradermal skin testing in Hymenoptera venom allergic children. Ann Allergy Asthma Immunol 2016; 118:326-332. [PMID: 27986410 DOI: 10.1016/j.anai.2016.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/08/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The direct comparison between children and adults with Hymenoptera venom anaphylaxis (HVA) has never been extensively reported. Severe HVA with IgE-documented mechanism is the recommendation for venom immunotherapy, regardless of age. OBJECTIVE To determine the differences in the basic diagnostic profile between children and adults with severe HVA and its practical implications. METHODS We reviewed the medical records of 91 children and 121 adults. RESULTS Bee venom allergy was exposure dependent, regardless of age (P < .001). Atopy was more common in children (P = .01), whereas cardiovascular comorbidities were present almost exclusively in adults (P = .001). In the bee venom allergic group, specific IgE levels were significantly higher in children (29.5 kUA/L; interquartile range, 11.30-66.30 kUA/L) compared with adults (5.10 kUA/L; interquartile range, 2.03-8.30 kUA/L) (P < .001). Specific IgE levels for culprit insect venom were higher in bee venom allergic children compared with the wasp venom allergic children (P < .001). In adults, intradermal tests revealed higher sensitivity, accompanied by larger area of skin reactions, regardless of type of venom. At concentrations lower than 0.1 μg/mL, 16% of wasp venom allergic children and 39% of bee venom allergic children had positive intradermal test results. The median tryptase level was significantly higher in adults than in children for the entire study group (P = .002), as well as in bee (P = .002) and wasp venom allergic groups (P = .049). CONCLUSION The basic diagnostic profile in severe HVA reactors is age dependent. Lower skin test reactivity to culprit venom in children may have practical application in starting the intradermal test procedure with higher venom concentrations.
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Affiliation(s)
- Ewa Cichocka-Jarosz
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland.
| | | | - Iwona Rogatko
- Department of Clinical Biochemistry, University Children's Hospital, and Faculty of Medicine, Jagiellonian University, Krakow, Poland
| | | | - Krystyna Sztefko
- Department of Clinical Biochemistry, University Children's Hospital, and Faculty of Medicine, Jagiellonian University, Krakow, Poland
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Lis
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Nowak-Węgrzyn
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Jaffe Food Allergy Institute, New York, New York
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Şenel E, Kuyucu M, Süslü I. Honey and bee venom in dermatology: A novel possible alternative or complimentary therapy for psoriasis vulgaris. Anc Sci Life 2014; 33:192-3. [PMID: 25538357 PMCID: PMC4264310 DOI: 10.4103/0257-7941.144626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Engin Şenel
- Department of Dermatology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Mutlu Kuyucu
- Urfa MediGap Hospital, Clinic of Neurology, Urfa, Turkey
| | - Iclal Süslü
- Department of Public Administration, Faculty of Economics, Anadolu University, Eskişehir, Turkey
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Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M, Santos AF, Zolkipli ZQ, Bellou A, Beyer K, Bindslev-Jensen C, Cardona V, Clark AT, Demoly P, Dubois AEJ, DunnGalvin A, Eigenmann P, Halken S, Harada L, Lack G, Jutel M, Niggemann B, Ruëff F, Timmermans F, Vlieg-Boerstra BJ, Werfel T, Dhami S, Panesar S, Akdis CA, Sheikh A. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy 2014; 69:1026-45. [PMID: 24909803 DOI: 10.1111/all.12437] [Citation(s) in RCA: 601] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 01/17/2023]
Abstract
Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.
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Affiliation(s)
- A. Muraro
- Department of Mother and Child Health; Padua General University Hospital; Padua Italy
| | - G. Roberts
- David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Human Development in Health and Clinical and Experimental Sciences Academic Units; University of Southampton Faculty of Medicine; Southampton UK
| | - M. Worm
- Allergy-Center-Charité; Department of Dermatology and Allergy; Charité Universitätsmedizin Berlin; Berlin Germany
| | - M. B. Bilò
- Allergy Unit; Department of Internal Medicine; University Hospital; Ospedali Riuniti; Ancona Italy
| | - K. Brockow
- Department of Dermatology and Allergy, Biederstein; Technische Universität München; Munich Germany
| | | | - A. F. Santos
- Division of Asthma, Allergy & Lung Biology; Department of Pediatric Allergy; King's College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Immunoallergology Department; Coimbra University Hospital; Coimbra Portugal
| | - Z. Q. Zolkipli
- David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Human Development in Health and Clinical and Experimental Sciences Academic Units; University of Southampton Faculty of Medicine; Southampton UK
| | - A. Bellou
- European Society for Emergency Medicine and Emergency Department; Faculty of Medicine; University Hospital; Rennes France
| | - K. Beyer
- Department of Pediatric, Pneumology and Immunology; Charité, Universitatsmedizin Berlin; Berlin Germany
| | - C. Bindslev-Jensen
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense Denmark
| | - V. Cardona
- Allergy Section; Department of Internal Medicine; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - A. T. Clark
- Allergy Section; Department of Medicine; University of Cambridge; Cambridge UK
| | - P. Demoly
- Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - A. E. J. Dubois
- Department of Pediatric Pulmonology and Pediatric Allergy; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
- GRIAC Research Institute; University of Groningen; University Medical Center Groningen; Groningen the Netherlands
| | - A. DunnGalvin
- Department of Paediatrics and Child Health; University College; Cork Ireland
| | - P. Eigenmann
- University Hospitals of Geneva; Geneva Switzerland
| | - S. Halken
- Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense Denmark
| | | | - G. Lack
- Division of Asthma, Allergy & Lung Biology; Department of Pediatric Allergy; King's College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
| | - M. Jutel
- Wroclaw Medical University; Wroclaw Poland
| | | | - F. Ruëff
- Department of Dermatology and Allergology; Ludwig-Maximilians-Universität; München Germany
| | - F. Timmermans
- Nederlands Anafylaxis Netwerk - European Anaphylaxis Taskforce; Dordrecht The Netherlands
| | - B. J. Vlieg-Boerstra
- Department of Pediatric Respiratory Medicine and Allergy; Emma Children's Hospital; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
| | - T. Werfel
- Department of Dermatology and Allergy; Hannover Medical School; Hannover Germany
| | - S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - S. Panesar
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - C. A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Davos Switzerland
| | - A. Sheikh
- Allergy & Respiratory Research Group; Centre for Population Health Sciences; The University of Edinburgh; Edinburgh UK
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Dhami S, Panesar SS, Roberts G, Muraro A, Worm M, Bilò MB, Cardona V, Dubois AEJ, DunnGalvin A, Eigenmann P, Fernandez-Rivas M, Halken S, Lack G, Niggemann B, Rueff F, Santos AF, Vlieg-Boerstra B, Zolkipli ZQ, Sheikh A. Management of anaphylaxis: a systematic review. Allergy 2014; 69:168-75. [PMID: 24251536 DOI: 10.1111/all.12318] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 12/20/2022]
Abstract
To establish the effectiveness of interventions for the acute and long-term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series and - only in relation to adrenaline - case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty-five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1-antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long-term management interventions studied were anaphylaxis management plans and allergen-specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom-triggered anaphylaxis.
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Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - S. S. Panesar
- Allergy & Respiratory Research Group; Centre for Population Health Sciences; The University of Edinburgh; Edinburgh UK
| | - G. Roberts
- David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport Isle of Wight UK
- NIHR Southampton Respiratory Biomedical Research Unit; University of Southampton and University Hospital Southampton NHS Foundation Trust; Southampton UK
- Human Development and Health Academic Unit; Faculty of Medicine; University of Southampton; Southampton UK
| | - A. Muraro
- Padua General University Hospital; Padua Italy
| | - M. Worm
- Allergy-Center-Charité; Department of Dermatology and Allergy; Charité - Universitätsmedizin; Berlin Germany
| | - M. B. Bilò
- University Hospital Ospedali Riuniti; Ancona Italy
| | | | - A. E. J. Dubois
- Department of Paediatrics; Division of Paediatric Pulmonology and Paediatric Allergy, and GRIAC Research Institute University Medical Centre Groningen; University of Groningen; Groningen the Netherlands
| | - A. DunnGalvin
- Department of Paediatrics and Child Health; University College; Cork Ireland
| | | | | | - S. Halken
- Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense Denmark
| | - G. Lack
- Department of Pediatric Allergy; Division of Asthma, Allergy & Lung Biology; King's College London; London
- King's Health Partners; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
| | - B. Niggemann
- Allergy Center Charité; University Hospital Charité; Berlin Germany
| | - F. Rueff
- Department of Dermatology and Allergy; Ludwig-Maximilian University; Munich Germany
| | - A. F. Santos
- Department of Pediatric Allergy; Division of Asthma, Allergy & Lung Biology; King's College London; London
- King's Health Partners; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
- Immunoallergology Department; Coimbra University Hospital; Coimbra Portugal
| | - B. Vlieg-Boerstra
- Department of Pediatric Respiratory Medicine and Allergy; Emma Children's Hospital; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
| | - Z. Q. Zolkipli
- David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport Isle of Wight UK
- NIHR Southampton Respiratory Biomedical Research Unit; University of Southampton and University Hospital Southampton NHS Foundation Trust; Southampton UK
| | - A. Sheikh
- Allergy & Respiratory Research Group; Centre for Population Health Sciences; The University of Edinburgh; Edinburgh UK
- Division of General Internal Medicine and Primary Care; Brigham and Women's Hospital/Harvard Medical School; Boston MA USA
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11
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Xia JB, Xu SS, Yang L, Zhang XW, Zhong WQ, Peng AM. Effects of Different Treatment Options on the Prognosis of Wasp Stings. HONG KONG J EMERG ME 2014. [DOI: 10.1177/102490791402100106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Severe wasp sting injuries often threaten patient's life. We compared the effects of three different therapies on the prognosis of wasp stung patients. Methods We conducted a randomised single-blind controlled trial. Patients stung by wasp were randomly assigned to one of the three treatment groups: group A received symptomatic treatment; those complicated with acute renal failure and haemolysis also received haemoperfusion combined with haemodialysis; for patients with severe haemolytic anaemia, plasmapheresis were applied; for patients with haemodynamic instability, continuous renal replacement therapy was used. Group B received intravenous methylprednisolone injection, 80 mg/d for continuous 3 days in addition to the symptomatic therapy; for patients with haemolysis, methylprednisolone 0.5 g/d was injected intravenously for 3-5 days. For group C, in addition to all treatments administrated to group B patients, subcutaneous injection of 0.5 ml 0.1% epinephrine was given immediately after admission. Primary endpoint was mortality. Major complications (gastrointestinal haemorrhage, toxic encephalopathy, haemolysis, and acute left ventricular failure) and serum enzyme spectrum elevate (alanine aminotransferase [ALT], creatine kinase [CK] isoenzyme and serum creatinine) were secondary endpoints. Results Of 134 patients recruited, 45, 44 and 45 patients were assigned to group A, B or C respectively. Therapy in group C reduced mortality compared with group A and B (respectively 24.4%, 9.09%, 0.00% for group A, B, C respectively; p<0.001); there was no significant effects on major complications among three groups (p >0.1). The incidence of elevated ALT was significantly lower in group B and group C than in group A (p<0.001). The incidence of elevated CK isoenzyme was significantly lower in group C than in group A and group B (p<0.001). Conclusions For patients with concurrent organ impairment by wasp sting, early combination of epinephrine and methylprednisolone with supportive treatment with renal replacement therapy can effectively reduce the incidence of organ damage and mortality. (Hong Kong j.emerg.med. 2013;20:270-275)
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Affiliation(s)
| | - SS Xu
- The Yichang Central People's Hospital, Yichang, Hubei Province, 443003, China
| | - L Yang
- The Yichang Central People's Hospital, Yichang, Hubei Province, 443003, China
| | - XW Zhang
- The Yichang Central People's Hospital, Yichang, Hubei Province, 443003, China
| | - WQ Zhong
- The Yichang Central People's Hospital, Yichang, Hubei Province, 443003, China
| | - AM Peng
- The Yichang Central People's Hospital, Yichang, Hubei Province, 443003, China
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12
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Makatsori M, Pfaar O, Lleonart R, Calderon MA. Recombinant allergen immunotherapy: clinical evidence of efficacy--a review. Curr Allergy Asthma Rep 2013; 13:371-80. [PMID: 23740287 DOI: 10.1007/s11882-013-0359-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Recombinant allergens for immunotherapy aim to overcome the problems of natural extracts as they can be produced in unlimited amounts with exact physiochemical and immunological properties. These can be modified to have more favourable characteristics including reduced IgE reactivity or enhanced immunogenicity. Different types of recombinant allergens have been evaluated in clinical phase II and III trials whilst others are currently under development. In this review, we identified double-blind, placebo-controlled randomised clinical trials assessing the efficacy and safety of various recombinant allergen preparations. The majority of studies have up to now focused on cat, grass, birch, ragweed and bee venom allergens. Some studies have shown some of these preparations to be effective and well tolerated. However, there are still outstanding issues regarding optimum doses, minimising side effects and long-term effects.
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Affiliation(s)
- Melina Makatsori
- Section of Allergy and Clinical Immunology, Imperial College London, NHLI, Royal Brompton Hospital, London SW3 6LY, UK
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13
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Qin YE, Mao JR, Sang YC, Li WX. Clinical efficacy and compliance of sublingual immunotherapy withDermatophagoides farinaedrops in patients with atopic dermatitis. Int J Dermatol 2013; 53:650-5. [PMID: 23968339 DOI: 10.1111/ijd.12302] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yu-E Qin
- International Health Care Center; First Affiliated Hospital; College of Medicine; Zhejiang University; Hang Zhou China
| | - Jing-Ran Mao
- Department of Dermatology; The First Affiliated Hospital; College of Medicine; Zhejiang University; Hang Zhou China
| | - Yue-chan Sang
- Department of Clinical Sciences; Zhejiang Wolwo Bio-Pharmaceutical Co., Ltd.; Shanghai China
| | - Wen-Xiu Li
- Department of Clinical Sciences; Zhejiang Wolwo Bio-Pharmaceutical Co., Ltd.; Shanghai China
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14
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Ruëff F, Przybilla B, Biló MB, Müller U, Scheipl F, Seitz MJ, Aberer W, Bodzenta-Lukaszyk A, Bonifazi F, Campi P, Darsow U, Haeberli G, Hawranek T, Küchenhoff H, Lang R, Quercia O, Reider N, Schmid-Grendelmeier P, Severino M, Sturm GJ, Treudler R, Wüthrich B. Clinical effectiveness of hymenoptera venom immunotherapy: a prospective observational multicenter study of the European academy of allergology and clinical immunology interest group on insect venom hypersensitivity. PLoS One 2013; 8:e63233. [PMID: 23700415 PMCID: PMC3659083 DOI: 10.1371/journal.pone.0063233] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 04/01/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment failure during venom immunotherapy (VIT) may be associated with a variety of risk factors. OBJECTIVE Our aim was to evaluate the association of baseline serum tryptase concentration (BTC) and of other parameters with the frequency of VIT failure during the maintenance phase. METHODS In this observational prospective multicenter study, we followed 357 patients with established honey bee or vespid venom allergy after the maintenance dose of VIT had been reached. In all patients, VIT effectiveness was either verified by sting challenge (n = 154) or patient self-reporting of the outcome of a field sting (n = 203). Data were collected on BTC, age, gender, preventive use of anti-allergic drugs (oral antihistamines and/or corticosteroids) right after a field sting, venom dose, antihypertensive medication, type of venom, side effects during VIT, severity of index sting reaction preceding VIT, and duration of VIT. Relative rates were calculated with generalized additive models. RESULTS 22 patients (6.2%) developed generalized symptoms during sting challenge or after a field sting. A strong association between the frequency of VIT failure and BTC could be excluded. Due to wide confidence bands, however, weaker effects (odds ratios <3) of BTC were still possible, and were also suggested by a selective analysis of patients who had a sting challenge. The most important factor associated with VIT failure was a honey bee venom allergy. Preventive use of anti-allergic drugs may be associated with a higher protection rate. INTERPRETATION It is unlikely that an elevated BTC has a strong negative effect on the rate of treatment failures. The magnitude of the latter, however, may depend on the method of effectiveness assessment. Failure rate is higher in patients suffering from bee venom allergy.
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Affiliation(s)
- Franziska Ruëff
- Department of Dermatology and Allergology, Ludwig-Maximilians-Universität, München, Germany.
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15
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Bilò MB, Antonicelli L, Bonifazi F. Honeybee venom immunotherapy: certainties and pitfalls. Immunotherapy 2013. [PMID: 23194365 DOI: 10.2217/imt.12.113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The honeybee is an interesting insect because of the fundamental agricultural role it plays, together with the composition of its venom, which presents new diagnostic and immunotherapeutic challenges. This article examines various aspects of honeybee venom allergy from epidemiology to diagnosis and treatment, with special emphasis on venom immunotherapy (VIT). Honeybee venom allergy represents a risk factor for severe systemic reaction in challenged allergic patients, for the diminished effectiveness of VIT, for more frequent side effects during VIT and relapse after cessation of treatment. Some strategies are available for reducing the risk of honeybee VIT-induced side effects; however, there is considerable room for further improvement in these all-important areas. At the same time, sensitized and allergic beekeepers represent unique populations for epidemiological, venom allergy immunopathogenesis and VIT mechanism studies.
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Affiliation(s)
- M Beatrice Bilò
- Allergy Unit, Department of Immunology, Allergy & Respiratory Diseases, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy.
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16
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Boyle RJ, Elremeli M, Hockenhull J, Cherry MG, Bulsara MK, Daniels M, Oude Elberink JNG. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev 2012; 10:CD008838. [PMID: 23076950 PMCID: PMC8734599 DOI: 10.1002/14651858.cd008838.pub2] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Venom immunotherapy (VIT) is commonly used for preventing further allergic reactions to insect stings in people who have had a sting reaction. The efficacy and safety of this treatment has not previously been assessed by a high-quality systematic review. OBJECTIVES To assess the effects of immunotherapy using extracted insect venom for preventing further allergic reactions to insect stings in people who have had an allergic reaction to a sting. SEARCH METHODS We searched the following databases up to February 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1806), AMED (from 1985), LILACS (from 1982), the Armed Forces Pest Management Board Literature Retrieval System, and OpenGrey. There were no language or publication status restrictions to our searches. We searched trials databases, abstracts from recent European and North American allergy meetings, and the references of identified review articles in order to identify further relevant trials. SELECTION CRITERIA Randomised controlled trials of venom immunotherapy using standardised venom extract in insect sting allergy. DATA COLLECTION AND ANALYSIS Two authors independently undertook study selection, data extraction, and assessment of risk of bias. We identified adverse events from included controlled trials and from a separate analysis of observational studies identified as part of a National Institute for Health and Clinical Excellence Health Technology Assessment. MAIN RESULTS We identified 6 randomised controlled trials and 1 quasi-randomised controlled trial for inclusion in the review; the total number of participants was 392. The trials had some risk of bias because five of the trials did not blind outcome assessors to treatment allocation. The interventions included ant, bee, and wasp immunotherapy in children or adults with previous systemic or large local reactions to a sting, using sublingual (one trial) or subcutaneous (six trials) VIT. We found that VIT is effective for preventing systemic allergic reaction to an insect sting, which was our primary outcome measure. This applies whether the sting occurs accidentally or is given intentionally as part of a trial procedure.In the trials, 3/113 (2.7%) participants treated with VIT had a subsequent systemic allergic reaction to a sting, compared with 37/93 (39.8%) untreated participants (risk ratio [RR] 0.10, 95% confidence interval [CI] 0.03 to 0.28). The efficacy of VIT was similar across studies; we were unable to identify a patient group or mode of treatment with different efficacy, although these analyses were limited by small numbers. We were unable to confirm whether VIT prevents fatal reactions to insect stings, because of the rarity of this outcome.Venom immunotherapy was also effective for preventing large local reactions to a sting (5 studies; 112 follow-up stings; RR 0.41, 95% CI 0.24 to 0.69) and for improving quality of life (mean difference [MD] in favour of VIT 1.21 points on a 7-point scale, 95% CI 0.75 to 1.67).We found a significant risk of systemic adverse reaction to VIT treatment: 6 trials reported this outcome, in which 14 of 150 (9.3%) participants treated with VIT and 1 of 135 (0.7%) participants treated with placebo or no treatment suffered a systemic reaction to treatment (RR 8.16, 95% CI 1.53 to 43.46; 2 studies contributed to the effect estimate). Our analysis of 11 observational studies found systemic adverse reactions occurred in 131/921 (14.2%) participants treated with bee venom VIT and 8/289 (2.8%) treated with wasp venom VIT. AUTHORS' CONCLUSIONS We found venom immunotherapy using extracted insect venom to be an effective therapy for preventing further allergic reactions to insect stings, which can improve quality of life. The treatment carries a small but significant risk of systemic adverse reaction.
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Affiliation(s)
- Robert J Boyle
- Department of Medicine, Section of Paediatrics, Imperial College London, London, UK.
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17
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Sánchez Caraballo JM, Cardona Villa R. Clinical and immunological changes of immunotherapy in patients with atopic dermatitis: randomized controlled trial. ISRN ALLERGY 2012; 2012:183983. [PMID: 23724240 PMCID: PMC3658480 DOI: 10.5402/2012/183983] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 01/10/2012] [Indexed: 12/03/2022]
Abstract
Background. Immunotherapy has proven to be an useful tool in the management of allergic respiratory diseases; however, little has been studied in atopic dermatitis. Objective. To evaluate the clinical and immunological impact of immunotherapy with mites allergen extracts in atopic dermatitis. Methods. Patients with atopic dermatitis were assigned with computer-generated randomization to either of the following groups: (a) controls received only topical treatment with steroids and/or tacrolimus and (b) actively treated patients received topical treatment plus immunotherapy. Levels of serum total IgE, mites-specific IgE and IgG4 were assessed at study start and after one year of immunotherapy. Results. 31 patients in the active group and 29 in the control group completed the study. Symptoms and medication scores were significantly reduced in the active group after six months. Three patients in the control group showed new sensitizations to mites, while 3 patients in the active group showed neosensitization to shrimp with negative oral food challenge. We observed significant increase of mites-specific IgG4 levels in active group. Conclusion. Specific allergen immunotherapy induced a tolerogenic IgG4 response to mite allergens associated with favorable clinical effects in atopic dermatitis patients.
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Affiliation(s)
- Jorge Mario Sánchez Caraballo
- Group of Clinical and Experimental Allergy, University of Antioquia, Medellin, Colombia ; Foundation for the Development of Medical and Biological Sciences (FUNDEMEB), Cartagena, Colombia ; Institute for Immunological Research, University of Cartagena, Cartagena, Colombia ; IPS Universitaria Sede Ambulatoria, Universidad de Antioquia Carrera 51A No. 62-42, Medellin, Colombia
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Abstract
Meta-analysis is a powerful tool for evaluating the efficacy of a therapeutic intervention, and has clearly demonstrated that specific allergen immunotherapy (SIT) is effective for treating allergic rhinitis and asthma. Future research needs to focus on specifying the most effective forms of SIT for specific populations and allergens, using validated clinical outcomes, studying long-term outcomes (particularly the potential disease-modifying effect of immunotherapy), and assessing outcomes regarding health economics. The safety profile of SIT should be evaluated using international guidelines and terminology, and needs to include high-quality surveillance data.
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Lacerda RA, Nunes BK, Batista ADO, Egry EY, Graziano KU, Angelo M, Merighi MAB, Lopes NA, Fonseca RMGSD, Castilho V. [Evidence-based practices published in Brazil: identification and analysis of their types and methodological approches]. Rev Esc Enferm USP 2011; 45:777-86. [PMID: 21710089 DOI: 10.1590/s0080-62342011000300033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 01/17/2010] [Indexed: 11/22/2022] Open
Abstract
This is an integrative review of Brazilian studies on evidence-based practices (EBP) in health, published in ISI/JCR journals in the last 10 years. The aim was to identify the specialty areas that most accomplished these studies, their foci and methodological approaches. Based on inclusion criteria, 144 studies were selected. The results indicate that most EBP studies addressed childhood and adolescence, infectious diseases, psychiatrics/mental health and surgery. The predominant foci were prevention, treatment/rehabilitation, diagnosis and assessment. The most used methods were systematic review with or without meta-analysis, protocol review or synthesis of available evidence studies, and integrative review. A strong multiprofessional expansion of EBP is found in Brazil, contributing to the search for more selective practices by collecting, recognizing and critically analyzing the produced knowledge. The study also contributes to the analysis itself of ways to do research and new research possibilities.
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