Article

Congruence of the current practices in Hymenoptera venom allergic patients in Poland with EAACI guidelines

Department of Pediatrics, Polish-American Children's Hospital, Jagiellonian University Medical College, Krakow, Poland.
Archives of medical science : AMS 10/2011; 7(5):832-9. DOI: 10.5114/aoms.2011.25558
Source: PubMed
ABSTRACT
Venom immunotherapy (VIT) practice is the definitive treatment for patients with potentially fatal allergic reactions to Hymenoptera stings. The aim is assesing compliance of VIT practice in Poland with the current European Academy of Allergy and Clinical Immunology (EAACI) guidance.
A multicentre study was carried out using a structured questionnaire which was sent by post to all VIT practitioners in Poland. Some questionnaire items were altered, in comparison to original version by adding additional answer options or alowing multiple answer option. The response rate was 100%. The obtained results were compared with the published EAACI guidelines.
Twenty-six Polish centres took part in the survey. SSIgE and skin prick tests (SPT) are together used as the first line of investigation, whereas confirmatory intradermal tests (IDT) are applied in half of centres. Only a few centres measure baseline serum tryptase levels. The ultra-rush protocol is preferred. Antihistamine pre-medication is routinely practiced. A target dose equal to 100 µg is used in most centres. A 6-week interval between booster doses is the most frequent. Five years is considered as an optimal VIT duration. Before the VIT completion, SSIgE is evaluated in fifty percent of centres, whereas sting challenge is considered by half of responders.
There are some differences between current practice in Poland and the EAACI recommendations, indicating areas requiring better compliance. Comparision between Poland and the United Kingdom revealed that health service organization and health care funding may play a major role in the provision of allergy services. This may affect the extent to which international guidance may be applied in individual countries. It is worth considering conducting the same survey in other European countries.

Full-text

Available from: Grzegorz Lis
Congruence of the current practices in Hymenoptera
venom allergic patients in Poland with EAACI guidelines
Ewa Cichocka-Jarosz
1
, Lavanya Diwakar
2
, Piotr Brzyski
3
, Beata Tobiasz-Adamczyk
3
, Grzegorz Lis
1
,
Jacek J. Pietrzyk
1
A b s t r a c t
IInnttrroodduuccttiioonn::
Venom immunotherapy (VIT) practice is the definitive treatment
for patients with potentially fatal allergic reactions to Hymenoptera stings. The
aim is assesing compliance of VIT practice in Poland with the current European
Academy of Allergy and Clinical Immunology (EAACI) guidance.
MMaatteerriiaall aanndd mmeetthhooddss::
A multicentre study was carried out using a structured
questionnaire which was sent by post to all VIT practitioners in Poland. Some
questionnaire items were altered, in comparison to original version by adding
additional answer options or alowing multiple answer option. The response rate
was 100%. The obtained results were compared with the published EAACI
guidelines.
RReessuullttss::
Twenty-six Polish centres took part in the survey. SSIgE and skin prick
tests (SPT) are together used as the first line of investigation, whereas
confirmatory intradermal tests (IDT) are applied in half of centres. Only a few
centres measure baseline serum tryptase levels. The ultra-rush protocol is
preferred. Antihistamine pre-medication is routinely practiced. A target dose
equal to 100 µg is used in most centres. A 6-week interval between booster
doses is the most frequent. Five years is considered as an optimal VIT duration.
Before the VIT completion, SSIgE is evaluated in fifty percent of centres, whereas
sting challenge is considered by half of responders.
CCoonncclluussiioonnss::
There are some differences between current practice in Poland and
the EAACI recommendations, indicating areas requiring better compliance.
Comparision between Poland and the United Kingdom revealed that health
service organization and health care funding may play a major role in the
provision of allergy services. This may affect the extent to which international
guidance may be applied in individual countries. It is worth considering
conducting the same survey in other European countries.
KKeeyy wwoorrddss::
current practice, serum-specific IgE, skin tests, venom immunotherapy.
Introduction
European Academy of Allergy and Clinical Immunology (EAACI)
recommendations summarize the results of studies evaluating the efficacy
CCoorrrreessppoonnddiinngg aauutthhoorr::
Ewa Cichocka-Jarosz MD, PhD
Department of Pediatrics
Polish-American
Children’s Hospital
Jagiellonian University
Medical College
265 Wielicka, 30-663 Krakow
Poland
Phone: 48 12 658 20 11,
ext. 1655
Fax: 48 12 658 44 46
E-mail: mijarosz@cyfronet.pl
Clinical research
1
Department of Pediatrics, Polish-American Children’s Hospital, Jagiellonian University
Medical College, Krakow, Poland
2
Department of Allergy and Immunology, Heartlands Hospital, Birmingham, United
Kingdom
3
Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine,
Jagiellonian University Medical College, Krakow, Poland
SSuubbmmiitttteedd::
4 September 2010
AAcccceepptteedd::
26 October 2010
Arch Med Sci 2011; 7, 5: 832-839
DOI: 10.5114/aoms.2011.25558
Copyright © 2011 Termedia & Banach
Page 1
Arch Med Sci 5, October / 2011 833
and safety of venom allergy diagnosis and
management [1, 2] (Table I). The adoption of these
recommendations is dependent upon education,
health system organization and cultural aspects
unique to the country. Allergy to insect venom is
a serious, potentially life-threatening condition.
Venom immunotherapy (VIT) is the only treatment
that has proven effective at decreasing the
incidence and seriousness of subsequent sting
reactions in affected individuals [1, 2]. Accordingly,
patients who have experienced a systemic reaction
to insect sting should be referred to an allergist-
immunologist for diagnosis. The VIT is obligatorily
indicated in patients with a history of a life-
threatening (cardiac or respiratorygrade 3 and
4 according to Muellers classification) syste-
mic reaction to Hymenoptera stings and demon -
strable serum-specific IgE (SSIgE) antibodies to
Hymenoptera venom [1-3]. In the case of IgE-
mediated grade 2 and grade 1 reaction, additional
risk factors such as high exposure, or decreased
quality of life arising from anxiety, are taken into
consideration while establishing the indications for
VIT [2, 4]. There are some differences between the
European and US approach to venom allergic
patients. In the US, VIT introduction is more
common in mild skin reactions, and trials of
treatment in large local reactions are becoming
increasingly popular [5]. Guidelines are of increasing
importance in clinical practice. If corresponding
recommendations are not followed, the quality of
medical care will suffer. Ignoring recommendations
from guidelines may also have legal consequences.
Therefore the gap that exists between both national
and international recommendations and clinical
practice must be taken seriously. There are also
Polish national guidelines concerning management
of venom allergic patients, which strictly follow
EAACI recommendations according to points from
2 to 6 and points from 18 to 24 presented in Table I,
and do not refer to the other ones [6]. The first
comprehensive audit of current practices in
management of Hymenoptera venom allergic
patients among the European Union countries was
done in the United Kingdom [7].
The aim of our study was to estimate what level
of congruence with EAACI guidelines is presented
by current practice in management of Hymenoptera
venom allergic patients in Poland.
Material and methods
In Poland, diagnostic investigation and
management of venom allergic patients are
exclusively conducted in 26 (18 for adults, 8 for
children) university or large public health centres.
A list of these centres is available on the Polish
Allergology Society website (www.pta.pl). A pre -
viously published questionnaire was translated from
NNoo** TTooppiicc
2. First line of investigation:
SPT
RAST
4. Highest venom concentration used in SPT [µg/ml]:
100
5. IDT confirmatory in diagnosis
6. Highest venom concentration used in IDT [µg/ml]:
1.0
7. Treatment strategy in case of severe reaction and
uncertain culprit insect:
Both venoms
Discharge with Epipen
8. Baseline plasma tryptase in patients with history
of severe SR
10. Strategy in systemic reaction with non-detectable
venom sIgE and normal baseline serum tryptase:
Discharge with Epipen
Follow up in 3 months
11. Strategy in systemic reaction with non-detectable
venom sIgE, elevated baseline serum tryptase:
Discharge with Epipen
Follow up in 3 months
16. Antihistamines in premedication of VIT:
Troublesome local reactions
17. Grade 2-4 in Mueller's scale side effects during VIT:
Accelerated regimen
18. Maximum time interval between the maintenance
doses [weeks]:
4 within first year of treatment
6 within 2-5 years of treatment
8 over 5 years of treatment
19. Routine target maintenance dose [µg/ml]:
100
20. IgG
4
evaluation during or at the end of VIT:
Not advisable
21. Optimal VIT duration [years]:
3-5
22. Sting challenge considered at the end of VIT:
Advisable
23. sIgE evaluation at the end of VIT:
Advisable
24. Specific IgE detectable at the end of 3-5 years VIT
period as indicator for VIT prolongation:
Advisable
In grade 4 reactions only
*Number in left column refers to number of item in the questionnaire
TTaabbllee II..
EAACI guidelines concerning diagnostic and
therapeutic procedures towards venom allergic
patients
M
anagement of venom allergic patients in Poland
Page 2
834 Arch Med Sci 5, October / 2011
English into Polish [6]. The translation process was
done independently by two Polish native speakers
with professional skills in English. Differences
between the two versions were identified and
eliminated during a consensus meeting. Then the
questionnaire was retranslated and compared to
the original version. Some adaptations, reflecting
local differences in VIT practice, were required in
the Polish version of the questionnaire as follows:
A) question 2, the choice of both methods (RAST
and SPT) performed simultaneously as a first line
of investigation was allowed; B) questions 3 and
12, the choice of other SPT extracts/treatment
extracts, respectively, was added; C) questions 10,
11, 13 and 16, due to characteristics of VIT practices
in Poland, were treated as multiple answer
questions as opposed to multiple choice ones in the
UK; D) question 14, information about previous
experience with the accelerated protocol was
reported as separated options; E) question 24,
the answer option other” was added. The
questionnaire was sent to all centres by post.
Answers were obtained from senior doctors directly
responsible for management of venom allergic
patients. The congruence of current practice with
EAACI recommendations was expressed as the
percentage of centres strictly following the
recommended procedures.
Results
The audit response rate was 100% (in a few
cases, a reminder by phone was necessary).
DDiiaaggnnoossttiicc tteessttss
As the first line of investigation, almost two
thirds of Polish centres performed skin prick tests
(SPT) with concentration 100 µg/ml. Serum-specific
IgE (SSIgE) application was common. Intradermal
tests (IDT) with venom concentration equal to
1.0 µg/ml as a confirmatory procedure were
performed in over one half of Polish centres.
VVIITT PPRROOTTOOCCOOLL ((iinncclluuddiinngg ddoossaaggee,,
aannttiihhiissttaammiinneess,, dduurraattiioonn))
The most common protocol of VIT incremental
dose in Poland was ultra rush. Almost all the
centres used the maintenance dose equal to
100 µg. One half of the centres practised a 6-week
interval between the maintenance doses. Three to
five years was the most frequent VIT duration,
despite the severity of past sting reaction. In Polish
practice, almost three fourths of the centres used
premedication with antihistamines in all the treated
patients. One third of the centres performed
acceleration of the schedule and increasing the
maintenance dose from 100 µg to 200 µg in case
of grade 2-4 side effects during VIT.
MMaannaaggeemmeenntt ooff nnoonn--eevviiddeenntt ccaasseess
Thirty-five percent of centres respected the
strategy of providing self-injectable epinephrine
upon discharge and performing follow-up in 6-12
months in a patient with SR, non-detectable SSIgE
and normal baseline serum tryptase, while the
same strategy was employed by only 27% of
centres in patients with the same history and
negative sIgE, but elevated baseline serum tryptase.
AAddddiittiioonnaall tteessttss ((ttrryyppttaassee,, IIggGG
4
4
,, SSSSIIggEE bbeeffoorree
ssttooppppiinngg tthheerraappyy,, ssttiinngg cchhaalllleennggee))
Baseline serum tryptase at the beginning of
treatment only in case of severe systemic reactions
was performed in 40% of the centres where the
estimation of this marker is available, which
constitutes less than 20% of centres in Poland. At
the end of VIT, almost one half of centres evaluated
SSIgE; similarly, almost one half of them considered
sting challenge. Specific IgG
4
level both before
treatment and before stopping VIT was rarely
practised.
Discussion
The results obtained in this questionnaire survey
allowed for description of current practice in
management of the whole population of insect
venom allergic patients (both adults and children)
in Poland. We realize that the option of a self-
completed questionnaire-based study limits the
validity of obtained results. However, for objectivity
of the data, answers to the questions were
exclusively obtained from senior doctors directly
responsible for management of venom allergic
patients. They were all informed about the research
purpose of the survey. On the other hand, we
followed the same way of data collecting as in
a British study, so comparisons to those data could
be performed [7]. Previously only preliminary
results of a multicentre (8 centres) study dedicated
to current practices in Poland in management of
venom allergic children were published [8]. The
EAACI recommendations are strictly the same for
adults and children, so only showing the current
practices in all Polish allergy centres will reflect
how the Polish health system allows for
congruence of the current practices with the
guidelines. It also indicates the topics which should
be urgently improved. The total analysis is
additionally justified, as centres for children closely
cooperate with centres for adults, transferring
patients at the age over 18 years for continuation
of treatment. Finally, total results will be more
representative for Poland against the European
background, allowing them to be compared with
British study results [7]. It may also encourage
E
wa Cichocka-Jarosz, Lavanya Diwakar, Piotr Brzyski, Beata Tobiasz-Adamczyk, Grzegorz Lis, Jacek J. Pietrzyk
Page 3
Arch Med Sci 5, October / 2011 835
authors from other European countries to conduct
similar studies, enabling further comparison
(a panEuropean view).
CCoommppaarriissoonn ooff ccuurrrreenntt pprraaccttiiccee iinn PPoollaanndd wwiitthh
EEAAAACCII rreeccoommmmeennddaattiioonnss
There are some discrepancies between the
current practice in Poland and the EAACI
recommendations [1, 2]. The results of our study
are shown in Table II.
DDiiaaggnnoossttiicc tteessttss
Using both tests (SPT and SSIgE) together as the
first line of investigation in Poland expresses their
good availability and allows diagnostic duration to
be shortened. It should be strongly emphasized that
venom skin testing requires highly experienced staff
to achieve highly repeatable results [9]. In patients
with a negative SPT, it is therefore recommended
to confirm this result in IDT. Positive results of IDT
with venom concentration of 1 µg/ml confirm
venom sensitization, while negative results exclude
it. For this reason, some centres do not perform SPT.
In our experience, positive results of SPT in children
occur very seldom. A high percentage of centres
evaluating SSIgE express good accessibility of the
test, though its sensitivity is somewhat lower than
that of IDT [10]. For providing the highest available
sensitivity, the newer, third generation methods
(ImmunoCAP, Immulite) are the most recom -
mended [11, 12]. Both are in use in Poland.
A “negative” result of skin testing could be due to
insufficient sensitivity of tests or too long interval
from the sting-induced reaction [12]. In patients
with a history of severe SR reaction, confirmation
of IgE-mediated reaction is important and allows
for VIT commencement as a treatment of choice.
VVIITT PPRROOTTOOCCOOLL
The maintenance dose equal to 100 µg was
almost fully respected in Poland. Different
schedules of treatment concerning the up-dosing
phase required to reach the maintenance dose may
last several weeks to months (conventional,
clustered), a few days or even hours (rush or ultra
rush protocol, respectively) [2, 13]. The accelerated
protocols predominate in Poland. The most popular
aqueous venom extracts in Poland are Venomenhal
(HALAllergy) and Pharmalgen (ALKAbello). Only
a few centres use depot venom extract Alutard
(ALKAbello). A 4-week interval between main -
tenance doses during the first year, 6 weeks within
2-5 years and 8 weeks over 5 years of VIT are
recommended [2], though in the case of depot
extracts, the interval from the beginning of
maintenance doses might be up to 8 weeks. In the
case of grade 2-4 side effects during VIT, a high
percentage of Polish centres accelerate the schedule
and increase the maintenance dose from 100 µg to
200 µg. In-patient management of these cases
makes this procedure possible in Poland. According
to our clinical observations, VIT-treated children well
tolerating venom doses are protected at the early
stage of treatment, which is consistent with the
other data [14]. In Poland, pre-treatment with
antihistamines was applied to all patients, probably
as a result of well-known data of Polish origin on
their advantageous effect on the immune response
during VIT [15-17]. More clinical data supporting the
use of antihistamine pre-treatment in all VIT
patients are needed.
In the case of managing a patient with an
unclear background of systemic reaction to sting,
the original British questionnaire-reported time of
a follow-up examination after 6-12 months is not
in line with the EAACI recommendation of a follow-
up visit 3 months after the event.
NNoonn--eevviiddeenntt ccaasseess
The important topic of safety indicates the low
number of Polish centres providing self-injectable
epinephrine upon discharge to patients after SR,
with non-detectable SSIgE and uncertain insect
stinging, normal or elevated baseline serum
tryptase. It is a matter of question whether the
emergency department (ED) staff supplies these
patients with emergency kits immediately after
severe SR, before referring them to a specialist
[2], which is strongly recommended [18-20].
Epipen, Anapen and Fastject are well-known self-
injectable epinephrine specimens. Additionally,
a low-cost product of Polish origin is also available
on the market. Findings that only about one-third
of patients received a prescription for self-
injectable epinephrine indicate an urgent need
for education [20, 21]. Also, providing self-
injectable epinephrine immediately after reaction
(ED) is recommended in the case of patients with
SR and both honeybee and wasp venom positivity
or an uncertain culprit insect. True double
positivity to venoms creates a problem in the
selection of venom for immunotherapy. True
double positivity should be distinguished from
the presence of cross reacting carbohydrate
determinants of venoms [22]. When true double
sensitivity has been confirmed, application of VIT
with both venoms by a specialist is recom -
mended. In the case of patients with a history of
SR and undetectable IgE and normal baseline
tryptase, follow-up within 3 months is recom -
mended. It is justified in the case of severe SR, as
negative skin tests after a recent sting anaphylaxis
can occur during the refractory period of “anergy”
for the first weeks after the event [1, 23].
M
anagement of venom allergic patients in Poland
Page 4
836 Arch Med Sci 5, October / 2011
NNoo QQuueessttiioonn nn ((%%))
2. First line of investigation
#
:
SPT 00
RAST 8 31
SPT + RAST 18 69
3. Skin prick extract manufacturer:
ALK Pharmalgen 4 15
ALK commercial skin testing extract 00
HalAllergy 15 58
Venomil 14
Alutard ALK 14
ALK + HALAllergy 5 19
Other 00
4. Highest venom concentration used
in SPT [µg/ml]:
10 28
100 22 84
200 28
300 00
5. IDT confirmatory in diagnosis 23 88
6. Highest venom concentration used
in IDT [µg/ml]:
0.01 28
0.1 5 19
1.0 18 69
10 14
7. Treatment strategy in case of severe
reaction and uncertain culprit insect:
Both venoms 7 27
Venom of higher IgE level 7 27
Discharge with Epipen 14
Other 11 42
8. Baseline plasma tryptase in patients 10 39
with history of SR
9. Check tryptase in:
Systemic severe reaction 4 40
&
All systemic reactions, irrespectively 6 60
&
of their severity
10. Strategy in systemic reaction with
non-detectable venom sIgE
and normal baseline serum tryptase
#
:
Discharge with advice 6 23
Discharge with Epipen 15 58
Follow up in 6-12 months 20 77
Commence immunotherapy 00
NNoo QQuueessttiioonn nn ((%%))
11. Strategy in systemic reaction with
non-detectable venom sIgE, elevated
baseline serum tryptase
#
:
Discharge with advice 00
Discharge with Epipen 11 42
Follow up in 6-12 months 18 69
Commence immunotherapy 14
12. Immunotherapy extract manufacturer:
ALK (Pharmalgen/Alutard) 5 19
HALAllergy 11 42
Both 6 24
Other 4 15
13. VIT protocol commonly applied
#
:
Conventional 4 15
Clustered 6 23
Rush 5 19
Ultra rush 15 58
14. Accelerated protocols ever applied
#
:
Rush 14 54
Ultra rush 16 62
16. Antihistamines in premedication of VIT:
Troublesome local reactions 12 46
Systemic reactions 7 27
Asthma or cardiorespiratory problems 28
All patients 19 73
Other 00
17. Grade 2-4 in Mueller's scale side effects
during VIT:
Discontinue treatment 3 12
Accelerated regimen 8 31
Persist with VIT as usual 28
Other 13 50
18. Maximum time interval between
maintenance doses [weeks]:
428
6 13 50
828
12 00
Other 9 34
19. Routine target maintenance dose [µg/ml]:
100 24 92
150 00
200 28
TTaabbllee IIII..
Characteristics of current diagnostic and therapeutic practice in patients with Hymenoptera venom allergy
in Poland based on questionnaire study
E
wa Cichocka-Jarosz, Lavanya Diwakar, Piotr Brzyski, Beata Tobiasz-Adamczyk, Grzegorz Lis, Jacek J. Pietrzyk
Page 5
Arch Med Sci 5, October / 2011 837
TTaabbllee IIII..
cont.
AAddddiittiioonnaall tteessttss
Baseline serum tryptase level expresses the
whole body mast cell load and is a predictor of
severe SR [24, 25]. It is recommended to be
determined in all patients with such a history,
though the frequency of its clinical application is
still too low [1, 21]. In treated patients, VIT leads
to a variety of specific immunological changes still
being determined. It is unknown, however, which
parameter shifts might indicate therapeutic
success [26, 27]. The level of specific IgG
4
primarily reflects exposure, and is not recom -
mended in routine assessment [28]. Provocation
with sting challenge is indicated in individual
patients on a maintenance dose of VIT to identify
those who are not yet protected [29, 30]. Sting
challenge before the end of VIT was considered
in Poland, though formulation “considered” should
not be understood as equal to "per for med".
The results of specific IgE in monitoring the end
of treatment often influenced the decision of VIT
prolongation in Poland. The SSIgE evaluation at the
end of VIT, though widely used in Poland, is helpful
for making the decision on VIT cessation in the case
of both skin and SSIgE negative results. Otherwise,
the decision should be made individually. The VIT
prolongation is justified in the case of a life-
threatening reaction in the past and SSIgE still
detectable at the end of 3-5 years of treatment,
which is a rather common practice in Poland.
CCoommppaarriissoonn ooff ccuurrrreenntt pprraaccttiiccee bbeettwweeeenn
PPoollaanndd aanndd tthhee UUnniitteedd KKiinnggddoomm
Since almost the same questionnaire was used
in both Poland and the United Kingdom, we were
able to make a comparison of VIT practice between
these two regions.
The majority of differences in current practice
seem to mirror the distinct organization of the
national health system and economic aspects. In
Poland, both the diagnosis and therapy in venom
allergic patients are in-patient procedures, contrary
to out-patient management in the United Kingdom.
The inpatient-based service in Poland goes together
with safety concerns (ICU accessibility) and may
result in a higher percentage of centres performing
IDT, accelerated regimes of regular treatment,
accelerated treatment in case of systemic (grade
2-4) side effects during VIT introduction, considering
sting challenge before the end of VIT, and longer
duration of treatment [31]. In Poland, VIT procedures
are usually performed either in university hospital
units or large public health centres. It might be
a matter of financial background that availability
of evaluation baseline serum tryptase in Poland is
much poorer, though if available, its clinical
application is proper and concerns all patients with
severe SR [1, 2]. In contrast, the outpatient-based
service in the United Kingdom may imply a lower
number of centres performing intradermal tests,
considering insect-sting challenge before end of
VIT, an almost exclusive use of the conventional
schedule, as well as a shorter time of treatment. In
both countries, the frequency of prescribing
epinephrine for self-intervention was too low and
this should be improved.
The presented study, based on an original
unique British paper, allows us to estimate the
congruence of a highly specialist procedure in
Poland with EAACI guidelines and indicates the
differences between two European countries. It
was possible thanks to the application of the same
tool and it might identify the necessary research
fields, as well as indicating the topics requiring
better education, and perhaps raise the question
whether international guidelines might be
#
Answer options altered in comparison to the original version, n – number of centres which reported chosen category,
&
ratio of centres in relation to number of centres where estimation of serum tryptase was available
NNoo QQuueessttiioonn nn ((%%))
20. IgG
4
evaluation during or at the 28
end of VIT:
21. Optimal VIT duration [years]:
2 00
314
5 19 73
>5 4 15
Other 28
22. Sting challenge considered at the 12 46
end of VIT
NNoo QQuueessttiioonn nn ((%%))
23. sIgE evaluation at the end of VIT 12 46
24. Specific IgE detectable at the end
of 3-5 years VIT period as indicator
for VIT prolongation:
Yes 5 19
In grade 4 reactions only 8 31
No 13 50
Other 00
M
anagement of venom allergic patients in Poland
Page 6
838 Arch Med Sci 5, October / 2011
respected in different countries to the same
extent. It would be interesting to compare data
from other European countries and, in the case of
insufficient acceptance of guidelines, to analyse
the reasons. Potential explanations are increasing
economic pressure, insufficient medical education,
poor patient compliance and the possibility that
recom mendations of guidelines cannot be
implemented for practical reasons. The results
might be a basis for a study of new guidelines and
helpful in improvement of educational program -
mes. As it is a matter of safety and legal conse -
quences, it is important to achieve a pan-
European consensus to obtain EAACI guidance and
on how EAACI could probably do more to ensure
homogeneity in this respect in Europe. Similarly,
as in the other health promotion initiatives, in all
settings it must be scientifically sound, culturally
acceptable, and managerially feasible. Evidence by
itself is not enough to generate action. Leadership
is essential, this being “the capacity to influence
others to work together to achieve a common
purpose” [32, 33].
Acknowledgments
We declare no financial relationship with
biotechnology/pharmaceutical manufacturers
mentioned in this manuscript.
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anagement of venom allergic patients in Poland
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    • "Medical doctors of all specialties must be informed about HVA and the possibility of its causal treatment. A Polish study on the current practice in HVA treatment by allergologists shows a high congruence with EAACI guidelines [55].Table 1. Classification of allergic reactions to insect stings [35,48] Large 3. Others: nephrotic syndrome, Schönlein-Henoch purpura, serum sickness, soft tissue necrosis. "
    [Show abstract] [Hide abstract] ABSTRACT: During their lifetimes, 94.5% of all people are stung by wasps, honey-bees, hornets or bumble-bees (order Hymenoptera). After a sting, most of them have typical local symptoms, 5-15% of the stung individuals develop local allergic reactions and 3-8.9% manifest systemic allergic reactions (SR) which may be potentially life-threatening in 10% of them. In the mild forms of Hymenoptera venom allergy (HVA), grades I and II according to Mueller, the leading symptoms are urticaria and edema, respectively. Severe SR are classified as grades III (respiratory symptoms) and IV (cardiovascular symptoms). Rare manifestations of HVA are Kounis syndrome and Tako-tsubo cardiomyopathy. All HVA patients with SR require standard (skin test, sIgE, tryptase) or extended (component diagnosis, basophil activation test) HVA diagnosis. All the patients with SR manifesting hypertension and disturbances in consciousness should be diagnosed for mastocytosis. Additionally, a relationship was found between the severity of HVA symptoms and intake of ACEI. A similar, though less documented, reservation concerns the use of beta blockers. HVA patients who have experienced SR are potential candidates for venom immunotherapy (VIT) which is effective in 80-100% of the individuals treated for 3-5 years. A heightened risk of a VIT failure is reported in patients with mastocytosis and these treated with ACEI. In certain groups (bee-keepers, these who react with SR to stings during VIT, as well as those with SR to maintenance doses of VIT) higher maintenance dose is recommended. Indications, contradictions, treatment protocols and dosage are regulated by the international guidelines of allergy societies.
    Full-text · Article · Sep 2015 · Polskie archiwum medycyny wewnȩtrznej
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    • "We also observed a lower level of discomfort in patients treated with a longer lasting conventional protocol. From the medical point of view, shorter protocols, though requiring a higher number of subcutaneous injections in a short time, are safe, and they allow immunoprotection to be achieved in a shorter time, and at lower costs, so there is a rising tendency in health care to use shorter protocols worldwide, including in Poland [22]. It is also difficult to explain why a shorter duration of the initial phase of treatment may increase the feeling of discomfort expressed as being troubled by looking for insects in different situations. "
    [Show abstract] [Hide abstract] ABSTRACT: Venom allergy, though rare, may seriously influence health-related quality of life (HRQoL). There is a paucity of research on HRQoL of adolescents and young adults with Hymenoptera venom allergy. The aim was to assess the level of HRQoL and to evaluate its independent predictors in Polish adolescents and young adults treated with venom immunotherapy. A multicenter cross-sectional study based on the Vespid Allergy Quality of Life Questionnaire (VQLQ) adapted for Polish adolescents was used. The study sample included 87 patients (14-21 years) studied at different stages of venom immunotherapy (VIT). Statistical analysis was done with multivariate linear regression. Anxiety level was higher in patients with 4(th) grade of Mueller's classification (anaphylactic shock) than in those with 3(rd) grade (B = 0.84, 95% CI = 0.07-1.61, p = 0.03). Caution increased along with an increase of anxiety of adolescents treated with VIT (B = 0.54, 95% CI = 0.39-0.68, p < 0.01). Level of limitations increased with increasing caution of adolescents (B = 0.63, 95% CI = 0.35-0.91, p < 0.01). Discomfort increased along with a rise of caution of patients (B = 0.38, 95% CI = 0.22-0.55, p < 0.01). Similarly, it increased with an increase of their feeling of limitations (B = 0.37, 95% CI = 0.23-0.51, p < 0.01). The level of discomfort in adolescents treated with VIT was lower in those who were treated with conventional protocol in comparison to those treated with rush or ultra-rush ones (B = -0.47, 95% CI = -0.90 - -0.03, p = 0.04). Severity of anaphylactic reaction is an independent determinant of anxiety level in adolescents treated with VIT. The VIT protocol affects HRQoL of treated patients.
    Full-text · Article · Dec 2012 · Archives of Medical Science
  • [Show abstract] [Hide abstract] ABSTRACT: Allergic diseases are very common in developed countries, particularly among children, adolescents and young adults. Currently, allergies are being considered as an epidemic of the 21st century. According to the Polish Society of Allergology, the percentage of adults suffering from asthma in our country is 5.4%, and in children 10%. The authors describe current knowledge regarding the pathomechanism, incidence, epidemiology and diagnostics of the most common significant allergic diseases, including allergic rhinitis, asthma, allergic conjunctivitis, atopic dermatitis and urticaria. One of the most common allergic diseases is allergic rhinitis, which is the result of an allergic inflammation of the nasal mucosa mediated by immunoglobulin E. Asthma is a lifelong chronic inflammatory disorder of the airways associated with a variety of structural changes occurring in children and adults of all ages. This disease is characterized by bronchial hyperreactivity and obstruction which often disappear either spontaneously or with treatment. Atopic dermatitis is a chronic and relapsing inflammatory skin disease with a varying clinical spectrum, and may often play the role of the first stage of the atopic march. Urticaria is a heterogeneous group of diseases, characterized by the presence of wheals and/or angioedema. The mainstay of allergy diagnosis is in vivo and in vitro testing. In vivo testing includes skin prick tests, prick-by-prick tests, atopy patch tests and also skin application skin test. In vitro testing includes measurement of serum total and antigen-specific IgE using various methods. During the last years, also component-resolved diagnostics have gained growing importance as a useful tool in clinical investigation of IgE-mediated allergies.
    No preview · Article · Jan 2012
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