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Dworaczyk DA, Hunt AL, Di Spirito M, Lor M, Dretchen KL, Lamson MJ, Pollock J, Ward T. A 13.2 mg epinephrine intranasal spray demonstrates comparable pharmacokinetics, pharmacodynamics, and safety to a 0.3 mg epinephrine autoinjector. J Allergy Clin Immunol Glob 2024; 3:100200. [PMID: 38328805 PMCID: PMC10847913 DOI: 10.1016/j.jacig.2023.100200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/10/2023] [Accepted: 09/05/2023] [Indexed: 02/09/2024]
Abstract
Background Recent acute anaphylaxis guideline updates have identified remaining unmet needs based on currently available therapeutic options as a critical focus. Objective We compared the pharmacokinetic, pharmacodynamic, safety, and tolerability profiles of intranasal epinephrine with intramuscular epinephrine administered by autoinjector and manual syringe. Methods An open-label, 3-period crossover study was conducted in 116 healthy adult volunteers to assess the bioavailability of a single 13.2 mg intranasal dose of epinephrine compared to a 0.3 mg intramuscular autoinjector and a 0.5 mg manual syringe. Patients with epinephrine concentrations of 50, 100, and 200 pg/mL at 10, 20, 30, and 60 minutes after dosing were also evaluated. Results Pharmacokinetic parameters for the 13.2 mg intranasal dose exceeded those of the 0.3 mg autoinjector with a rapid and higher maximum observed concentration (intranasal, 429.4 pg/mL; autoinjector, 328.6 pg/mL) and greater systemic exposure (AUC0-360; intranasal, 39,060 pg∙min/mL; autoinjector, 17,440 pg∙min/mL). Similar results were observed compared to the 0.5 mg manual syringe. Pharmacokinetic parameters for opposite-nostril and same-nostril dosing were higher than both intramuscular doses, except time to reach maximum observed concentration, which was bracketed between the 2 intramuscular doses (intranasal opposite and same nostril, 20 minutes; autoinjector, 14.9 minutes; manual syringe, 45 minutes). Similar effects on blood pressure and heart rate were observed for intranasal and autoinjector administration. Intranasal epinephrine was safe and well tolerated. No serious or unexpected adverse events were reported, confirming results from earlier clinical studies. Conclusions Bidose epinephrine spray addresses the unmet medical and patient needs for a needle-free, convenient, and effective dose-delivery system for self-administration of epinephrine that is as good as or better than the 0.3 mg autoinjector.
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Vega-Castro A, Castro L, Carballada F, Alfaya T, Marquès L, Ruíz-León B. Hymenoptera Allergy Diagnosis through Their Presence on Human Food. Toxins (Basel) 2023; 15:680. [PMID: 38133184 PMCID: PMC10748280 DOI: 10.3390/toxins15120680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
Venom immunotherapy (VIT) protects up to 98% of treated Hymenoptera allergy patients from reactions with new stings. A correct diagnosis with the identification of the venom causing the allergic reaction is essential to implementing it. The knowledge of the Hymenoptera foraging habits when the sting takes place in a food environment would allow the culprit insect to be known. Images of Hymenoptera occurring in environments where there was human food were recorded in Spain, including the date of the image, the place description and its geolocation. The insects' genus and species were identified by an entomologist. Results: One hundred and fifty-five images depicting 71 insects were analyzed. The identified insects were Vespula (56), Vespa (7), Polistes (4), Cerceris (2), Bombus (1) and Apis (1). Most (97.1%) of the images were obtained in summer and early autumn, outdoors in terraces (64%). Meat was the food associated with 47.9% of the images. In protein-rich foods, Vespula was found in 89%. Conclusions: Vespula was the main Hymenoptera associated with food environments in our country (78.87%), and in most of the cases (71%), the food involved is a source of protein, such as meat or seafood. In that environment, the probability that the insect is a Vespula would be 89%.
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Affiliation(s)
- Arantza Vega-Castro
- Allergy Service, University Hospital of Guadalajara, 19002 Guadalajara, Spain
- IDISCAM (Instituto de Investigación de Castilla la Mancha), 45071 Toledo, Spain
| | | | - Francisco Carballada
- Allergy Service, HULA (Hospital Universitario Lucus Augusti), 27003 Lugo, Spain;
| | - Teresa Alfaya
- Allergy Service, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
| | - Lluís Marquès
- Allergy Service, Hospital Universitari Arnau de Vilanova, 25198 Lleida, Spain;
- Instituto de Investigación Biomédica de Lleida, 25198 Lleida, Spain
| | - Berta Ruíz-León
- Allergy Service, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain;
- Instituto Maimónides de Investigación Biomédica, 14004 Córdoba, Spain
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3
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Sturm GJ, Boni E, Antolín-Amérigo D, Bilò MB, Breynaert C, Fassio F, Spriggs K, Vega A, Ricciardi L, Arzt-Gradwohl L, Hemmer W. Allergy to stings and bites from rare or locally important arthropods: worldwide distribution, available diagnostics, and treatment. Allergy 2023. [PMID: 37191880 DOI: 10.1111/all.15769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
Insect venom allergy is the most frequent cause of anaphylaxis in Europe and possibly worldwide. The majority of systemic allergic reactions after insect stings are caused by Hymenoptera and among these, vespid genera induce most of the systemic sting reactions (SSR). Honey bees are the second leading cause of SSR. Depending on the global region, other Hymenoptera such as different ant genera are responsible for SSR. Widely distributed hornets and bumblebees or local vespid or bee genera rarely induce SSR. Hematophagous insects such as mosquitoes and horse flies usually cause (large) local reactions while SSR occasionally occur. This position paper aims to identify either rare or locally important insects causing SSR as well as rarely occurring SSR after stings or bites of widely distributed insects. We summarized relevant venom or saliva allergens and intended to identify possible cross-reactivities between the insect allergens. Moreover, we aimed to locate diagnostic tests for research and routine diagnosis, which are sometimes only regionally available. Finally, we gathered information on available immunotherapies. Major allergens of most insects were identified, and cross-reactivity between insects was frequently observed. While some diagnostics and immunotherapies are locally available, standardized skin tests and immunotherapies are generally lacking in rare insect allergy.
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Affiliation(s)
- Gunter Johannes Sturm
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Elisa Boni
- Allergy and Immunology Department, Metropolitan Laboratory AUSL Bologna, Maggiore Hospital, Bologna, Italy
| | - Darío Antolín-Amérigo
- Allergy Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
- Allergy Unit, Department of Internal Medicine, Ospedali Riuniti Ancona University Hospital, Ancona, Italy
| | - Christine Breynaert
- Department of General Internal Medicine - Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, Leuven, Belgium
| | - Filippo Fassio
- Allergy and Clinical Immunology Unit, Ospedale San Giovanni di Dio, Azienda USL Toscana Centro, Florence, Italy
| | - Kymble Spriggs
- Department of Allergy & Immunology, Monash Medical Centre, Clayton, Australia
- Department of Allergy & Immunology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | - Arantza Vega
- Allergy Department, University Hospital of Guadalajara, Spain
- ARADyAL Spanish Thematic Network and Co-operative Research Centre RD16/0006/0023
| | - Luisa Ricciardi
- Allergy and Clinical Immunology Unit, AOU Policlinico G.Martino, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
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4
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Stevens WW, Kraft M, Eisenbarth SC. Recent insights into the mechanisms of anaphylaxis. Curr Opin Immunol 2023; 81:102288. [PMID: 36848746 PMCID: PMC10023498 DOI: 10.1016/j.coi.2023.102288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/27/2023]
Abstract
Anaphylaxis is an acute life-threatening systemic allergic reaction that can have a wide range of clinical manifestations. The most common triggers for anaphylaxis include food, medication, and venom. What is curious regarding anaphylaxis is how so many different agents can induce a severe systemic clinical response but only in a select subgroup of patients. Over the past decade, several important advances have been made in understanding the underlying cellular and molecular mechanisms contributing to anaphylaxis, with mast cells (MCs) being an essential component. Classically, cross-linked immunoglobulin E (IgE) bound to its high- affinity receptor induces MC mediator release. However, toll-like, complement, or Mas-related G-protein-coupled receptors also activate mouse and human MCs. While anaphylaxis secondary to foods historically has been more extensively characterized clinically and mechanistically, more recent studies have shifted focus toward understanding drug-induced anaphylaxis. The focus of this review is to highlight recent basic science developments and compare what is currently known regarding anaphylaxis to food, medications, and venom.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Magdalena Kraft
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephanie C Eisenbarth
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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5
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Höfer V, Martini M, Dölle-Bierke S, Worm M, Bilò MB. Health-related quality of life in food and venom induced anaphylaxis and role of influencing factors. Clin Exp Allergy 2023; 53:295-306. [PMID: 36565032 DOI: 10.1111/cea.14268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 12/25/2022]
Abstract
The impact on health-related quality of life (HRQL) plays a key role for patients suffering from allergies and anaphylaxis. In this narrative review we review the HRQL in allergic patients suffering from food and venom allergy, both being the most frequent elicitors of severe allergic, potential life-threatening reactions and provide an overview on the current knowledge and identified gaps. The data show that for food and venom allergy standardized assessment tools to measure HRQL are available and have been successfully applied. Our analysis shows that multiple factors can modulate HRQL in these patient groups. These include sociodemographic data like patients' age and sex, fear of accidental reactions but also external factors like the social environment and the appreciation of the seriousness of the condition by others. External factors may have a significant impact on HRQL and should be considered in patient-related outcome assessments to avoid biased measurements possibly affecting the results. The assessment of the quality of life in the context of specific immunotherapy should consider lifestyle factors and ideally, the individual change in HRQL should be measured. Although there are many data indicating a negative impact on HRQL in food allergic children and their caregivers, limited data are existing from adults with food allergy and venom allergic patients from all age groups. Also, the use of standardized questionnaires should be extended to allow for a better comparability of results between studies. Therefore, translation to additional languages is necessary. Taken together, the eliciting allergen, the severity of the allergic disease but moreover multiple external factors impact the outcome in HRQL and should be considered in HRQL assessment.
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Affiliation(s)
- Veronika Höfer
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Matteo Martini
- Allergy Unit, Ospedali Riuniti Marche Nord, Fano, Italy.,Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Sabine Dölle-Bierke
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy
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6
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Abstract
Venoms are complex mixtures of toxic compounds delivered by bite or sting. In humans, the consequences of envenomation range from self-limiting to lethal. Critical host defence against envenomation comprises innate and adaptive immune strategies targeted towards venom detection, neutralisation, detoxification, and symptom resolution. In some instances, venoms mediate immune dysregulation that contributes to symptom severity. This review details the involvement of immune cell subtypes and mediators, particularly of the dermis, in host resistance and venom-induced immunopathology. We further discuss established venom-associated immunopathology, including allergy and systemic inflammation, and investigate Irukandji syndrome as a potential systemic inflammatory response. Finally, this review characterises venom-derived compounds as a source of immune modulating drugs for treatment of disease.
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Affiliation(s)
- Rachael Y. M. Ryan
- Division of Tropical Health and Medicine, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, QLD, Australia
- School of Environment and Sciences, Griffith University, Nathan, QLD, Australia
| | - Jamie Seymour
- Division of Tropical Health and Medicine, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, QLD, Australia
| | - Alex Loukas
- Division of Tropical Health and Medicine, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, QLD, Australia
| | - J. Alejandro Lopez
- School of Environment and Sciences, Griffith University, Nathan, QLD, Australia
- QIMR Berghofer Medical Research Institute, The University of Queensland, Herston, QLD, Australia
| | - Maria P. Ikonomopoulou
- Translational Venomics Group, Madrid Institute for Advanced Studies (IMDEA) in Food, CEI UAM+CSIC, Madrid, Spain
- Institute for Molecular Bioscience, University of Queensland, Brisbane, QLD, Australia
| | - John J. Miles
- Division of Tropical Health and Medicine, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, Australia
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7
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Dubini M, Pravettoni V, Rivolta F, Segatto G, Asero R, Montano N. Remission of a case of multiple Hymenoptera stings-associated chronic urticaria during venom immunotherapy. Clin Case Rep 2021; 9:e04188. [PMID: 34026184 PMCID: PMC8133085 DOI: 10.1002/ccr3.4188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 04/04/2021] [Indexed: 12/04/2022] Open
Abstract
Hymenoptera stings mostly cause acute urticaria but we describe a case of CU after wasp stings which remitted during venom immunotherapy. IgE-mechanisms have not been fully clarified in CU, except for isolated circumstances. In our case immunotherapy has played a positive role reducing immune cells reactivity and improving urticaria symptoms.
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Affiliation(s)
- Marco Dubini
- Allergy and Clinical Immunology ResidencyUniversity of MilanMilanItaly
| | - Valerio Pravettoni
- General Medicine, Immunology and Allergology UnitIRCCS Foundation Ca' GrandaOspedale Maggiore PoliclinicoMilanItaly
| | - Federica Rivolta
- General Medicine, Immunology and Allergology UnitIRCCS Foundation Ca' GrandaOspedale Maggiore PoliclinicoMilanItaly
| | - Giulia Segatto
- Allergy and Clinical Immunology ResidencyUniversity of MilanMilanItaly
| | | | - Nicola Montano
- General Medicine, Immunology and Allergology UnitIRCCS Foundation Ca' GrandaOspedale Maggiore PoliclinicoMilanItaly
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8
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Schuler CF 4th, Volertas S, Khokhar D, Yuce H, Chen L, Baser O, Montejo JM, Akin C. Prevalence of mastocytosis and hymenoptera venom allergy in the United States. J Allergy Clin Immunol 2021:S0091-6749(21)00652-7. [PMID: 33895259 DOI: 10.1016/j.jaci.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/26/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mastocytosis is a risk factor for hymenoptera venom anaphylaxis (HVA). Current guidelines recommend measuring tryptase in patients with HVA and that those with mastocytosis pursue lifelong venom immunotherapy (VIT). Available data on HVA and mastocytosis largely derive from European single-center studies, and the prevalence of HVA with and without mastocytosis in the United States is unknown. OBJECTIVE We sought to determine the prevalence of HVA and mastocytosis in the United States using an insurance claims database and evaluate the impact of mastocytosis on VIT in patients with HVA in a US cohort. METHODS The IBM Watson Database, consisting of insurance claims from approximately 27 million US patients in 2018, was queried to identify patients with HVA and/or mastocytosis. Furthermore, a retrospective study of 161 patients undergoing VIT between 2015 and 2018 at the University of Michigan was conducted. RESULTS In the IBM Watson Database, the prevalence of HVA was 167 per 100,000 (0.167%) and the prevalence of mastocytosis 10 per 100,000 (0.010%) overall and 97 per 100,000 (0.097%) among those with HVA. Mastocytosis showed a 9.7-fold increase among patients with HVA versus the general population. In the U-M cohort, 2.6% of patients with VIT had mastocytosis. Tryptase level did not correlate with venom reaction severity but was higher in patients with systemic VIT reactions. CONCLUSIONS We observed a lower US HVA prevalence than previously reported. Mastocytosis was more common in US patients with HVA, though at lower rates than previously reported. In patients with VIT there was no correlation between tryptase level and reaction severity.
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9
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Cichocka-Jarosz E, Brzyski P, Jedynak-Wąsowicz U, Nittner-Marszalska M; Immunotherapy Section of Polish Society of Allergology Working Group. Current practices in diagnosis of Hymenoptera venom allergy in Poland. Postepy Dermatol Alergol 2021; 38:222-9. [PMID: 36751544 DOI: 10.5114/ada.2021.106200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022] Open
Abstract
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.
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10
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Francuzik W, Kraft M, Scherer Hofmeier K, Ruëff F, Pföhler C, Treudler R, Lang R, Hawranek T, Wagner N, Worm M. Anaphylaxis in middle-aged patients. Allergol Select 2021; 5:133-9. [PMID: 33778366 DOI: 10.5414/ALX02216E] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
Age is one of the most important factors influencing the course of anaphylaxis: moreover, the frequency of elicitors of anaphylaxis is age-associated. We analyzed 8,465 anaphylactic episodes in adult patients in three age groups with a focus on patients in the middle-age group (35 – 65 years old). Insect venom was the most frequent trigger in this age group (51.2%) followed by drugs (22.8%) and food (17.3%). Severe reactions were observed in 40.1% of middle-aged patients and occurred more frequently in this age group than in patients below 35 years (27.6%) and less frequently than in patients over 65 years (55.6%). The symptoms and comorbidity profile also changed with age, most significantly regarding the increase in rates of concomitant cardiologic diseases and (severe) cardiovascular symptoms.
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11
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Krishna MT, Worm M, Bilo MB. Editorial: Anaphylaxis - A Distinct Immunological Syndrome, but How Much Do We Really Understand? Front Immunol 2019; 10:2943. [PMID: 31921193 PMCID: PMC6930909 DOI: 10.3389/fimmu.2019.02943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 01/17/2023] Open
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Beatrice Bilo
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy.,Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
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12
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Bilò MB, Tontini C, Martini M, Corsi A, Agolini S, Antonicelli L. Clinical aspects of hymenoptera venom allergy and venom immunotherapy. Eur Ann Allergy Clin Immunol 2019; 51:244-258. [PMID: 31594296 DOI: 10.23822/eurannaci.1764-1489.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Summary Hymenoptera venom allergy (HVA) is the most frequent cause of anaphylaxis in Europe, accounting for most of the severe reactions occurring in adults, and being the second cause of anaphylaxis in children. Prevention of further episodes in patients who developed a systemic reaction (SR) is based on the correct management of the allergic emergency, the referral to an allergist for a correct diagnosis, prescription of adrenaline auto-injectors (AAI) and specific venom immunotherapy (VIT), if recommended. Diagnosis is based on the classification of the type of reaction, confirmation of an IgE-mediated pathogenesis and the identification of the offending insect. The use of component resolved diagnostics may be helpful in case of poly-sensitization or negative allergy tests with a proven history of previous SRs. When a severe SR occurs, baseline serum tryptase levels should always be assessed. The prescription of AAI is recommended or suggested for untreated patients, patients undergoing VIT and after discontinuation of treatment, according to multiple evidence. VIT is the most effective treatment available for HVA patients, as confirmed by recent European guidelines. VIT has an early, sustained and persistent protective effect and modifies the natural course of the disease. Moreover, VIT proved to be safe and well tolerated. According to a recent systematic review, no treatment-related fatalities were recorded to date. Compared to AAI, VIT significantly improves the quality of life of HVA patients by reducing the anxiety and limitations in daily activities caused by the fear of stinging insects. The memory of a life-threatening experience is the most likely reason why adherence to VIT is higher compared to immunotherapy with inhalant allergens. Several risk factors in HVA have been identified that can influence not only the severity of sting reactions in untreated patents, but also the occurrence of side effects, treatment effectiveness and the risk of relapse after discontinuation of VIT. Patient and treatment-related risk factors must be considered while selecting the best candidates for VIT, the type and duration of treatment. In this paper we address the most important issues related to HVA and VIT that may have an impact on daily clinical practice.
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Affiliation(s)
- M B Bilò
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - C Tontini
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Italy
| | - M Martini
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Allergy and Clinical Immunology School, Polytechnic University of Marche, Ancona, Italy
| | - A Corsi
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Allergy and Clinical Immunology School, Polytechnic University of Marche, Ancona, Italy
| | - S Agolini
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Allergy and Clinical Immunology School, Polytechnic University of Marche, Ancona, Italy
| | - L Antonicelli
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Italy
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13
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Bilò MB, Martini M, Pravettoni V, Bignardi D, Bonadonna P, Cortellini G, Kosinska M, Macchia D, Mauro M, Meucci E, Nittner‐Marszalska M, Patella V, Pio R, Quercia O, Reccardini F, Ridolo E, Rudenko M, Severino M. Large local reactions to Hymenoptera stings: Outcome of re-stings in real life. Allergy 2019; 74:1969-1976. [PMID: 31074868 DOI: 10.1111/all.13863] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Large local reaction to Hymenoptera stings is usually defined as a swelling >10 cm which lasts longer than 24 hours, sometimes associated with erythema, pruritus and blisters. Currently, the risk of subsequent systemic reactions after re-stings is considered low (2%-15%). Therefore, a diagnostic workup in case of large local reaction is often judged unnecessary, as well as adrenaline auto-injector and venom immunotherapy prescription. The aim of this study was to prospectively evaluate the outcome of re-stings in a real-world setting, in patients with a history of one previous large local reaction. METHODS We consecutively enrolled patients who experienced their first large local reaction (as per EAACI definition), treated with antihistamine and steroids. They were followed for field re-stings and assessed for risk of subsequent systemic reactions. RESULTS We enrolled 662 patients. Out of the 225 re-stung subjects, 24% did not experience reactions, 52% reported a second large local reaction and 24% had systemic reactions. The risk of subsequent systemic reactions was higher in case of skin test reactivity to Apis mellifera or Vespula species (OR 2.1 and 3.8, respectively), in particular if positive at 0.001 µg/mL concentration (OR 13.4 and 16.5, respectively). CONCLUSIONS Systemic reactions, after a previous large local reaction, occur more frequently than that reported by literature. After analysing the predictive role of large local reactions for systemic reactions, we demonstrated that an accurate diagnostic workup may be considered, particularly skin tests. Further studies in different countries are needed to confirm these results and large local reaction management.
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Affiliation(s)
- Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences Università Politecnica delle Marche Ancona Italy
| | - Matteo Martini
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Valerio Pravettoni
- General Medicine, Immunology and Allergy Unit ‐ IRCCS Foudation Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | | | - Patrizia Bonadonna
- U.S.D. Allergology Integrated University‐Hospital of Verona Verona Italy
| | - Gabriele Cortellini
- Allergy Unit, Internal Medicine Department, Rimini Hospital Local Health Unit of Romagna Rimini Italy
| | - Magdalena Kosinska
- Department of Internal Diseases and Allergology Medical University of Wroclaw Wroclaw Poland
| | | | - Marina Mauro
- UOS Allergology ASST Lariana Sant'Anna Hospital Como Italy
| | - Elisa Meucci
- Allergy Unit, Hospital S. Giovanni di Dio Florence Italy
| | | | - Vincenzo Patella
- Division Allergy and Clinical Immunology, Department of Medicine ASL Salerno "Santa Maria della Speranza" Hospital Salerno Italy
| | - Roberta Pio
- A.O.U San Giovanni di Dio e Ruggi d'Aragona Salerno Italy
| | - Oliviero Quercia
- High Specialization Unit of Allergology, Hospital of Faenza AUSL (Local Health Unit) of Romagna Faenza Italy
| | - Federico Reccardini
- SOC Pneumologia‐Fisiopatologia Respiratoria, Azienda Sanitaria Universitaria Integrata di Udine Udine Italy
| | - Erminia Ridolo
- Allergologia e Immunologia Clinica, Dipartimento di Medicina e Chirurgia Università degli studi di Parma Parma Italy
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Cichocka-Jarosz E, Stobiecki M, Nittner-Marszalska M, Jedynak-Wąsowicz U, Brzyski P; Immunotherapy Section of the Polish Society of Allergology Working Group (PTA). Venom allergy treatment practices in Poland in comparison to guidelines: next edition of the national audit. Postepy Dermatol Alergol 2019; 36:346-53. [PMID: 31333352 DOI: 10.5114/ada.2019.85642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/01/2018] [Indexed: 11/17/2022] Open
Abstract
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 μg. 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 β-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.
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Muraro A, Fernandez-Rivas M, Beyer K, Cardona V, Clark A, Eller E, Hourihane JO, Jutel M, Sheikh A, Agache I, Allen KJ, Angier E, Ballmer-Weber B, Bilò MB, Bindslev-Jensen C, Camargo CA, Cianferoni A, DunnGalvin A, Eigenmann PA, Halken S, Hoffmann-Sommergruber K, Lau S, Nilsson C, Poulsen LK, Rueff F, Spergel J, Sturm G, Timmermans F, Torres MJ, Turner P, van Ree R, Wickman M, Worm M, Mills ENC, Roberts G. The urgent need for a harmonized severity scoring system for acute allergic reactions. Allergy 2018; 73:1792-1800. [PMID: 29331045 DOI: 10.1111/all.13408] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 11/29/2022]
Abstract
The accurate assessment and communication of the severity of acute allergic reactions are important to patients, clinicians, researchers, the food industry, and public health and regulatory authorities. Severity has different meanings to different stakeholders with patients and clinicians rating the significance of particular symptoms very differently. Many severity scoring systems have been generated, most focusing on the severity of reactions following exposure to a limited group of allergens. They are heterogeneous in format, none has used an accepted developmental approach, and none has been validated. Their wide range of outcome formats has led to difficulties with interpretation and application. Therefore, there is a persisting need for an appropriately developed and validated severity scoring system for allergic reactions that work across the range of allergenic triggers and address the needs of different stakeholder groups. We propose a novel approach to develop and then validate a harmonized scoring system for acute allergic reactions, based on a data-driven method that is informed by clinical and patient experience and other stakeholders' perspectives. We envisage two formats: (i) a numerical score giving a continuum from mild to severe reactions that are clinically meaningful and are useful for allergy healthcare professionals and researchers, and (ii) a three-grade-based ordinal format that is simple enough to be used and understood by other professionals and patients. Testing of reliability and validity of the new approach in a range of settings and populations will allow eventual implementation of a standardized scoring system in clinical studies and routine practice.
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16
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Lee S, Hess EP, Lohse C, Gilani W, Chamberlain AM, Campbell RL. Trends, characteristics, and incidence of anaphylaxis in 2001-2010: A population-based study. J Allergy Clin Immunol 2017; 139:182-188.e2. [PMID: 27378753 DOI: 10.1016/j.jaci.2016.04.029] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/31/2016] [Accepted: 04/06/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anaphylaxis is a potentially life-threatening systemic allergic reaction. OBJECTIVE We aimed to determine the incidence rate and causes of anaphylaxis during a 10-year period in Olmsted County, Minnesota. METHODS Using the resources of the Rochester Epidemiology Project, a comprehensive records linkage system, we performed a population-based incidence study in Olmsted County, Minnesota, from 2001 through 2010. All cases with a diagnosis of anaphylactic shock and 20% of cases with related diagnoses were manually reviewed. The relationships of age group, sex, and year of anaphylaxis with incidence rates were assessed by fitting Poisson regression models. RESULTS Six hundred thirty-one cases of anaphylaxis were identified. The median age was 31 years (interquartile range, 19-44 years). The overall age- and sex-adjusted incidence rate was 42 (95% CI, 38.7-45.3) per 100,000 person-years. There was a significant increase in the overall incidence of anaphylaxis during the study period, with an average increase of 4.3% per year (P < .001). In addition, there was a 9.8% increase per year in the incidence rate of food-related anaphylaxis. Food-related anaphylaxis was most common in children aged 0 to 9 years, venom-related anaphylaxis was most common in those 20 to 39 years of age, and medication-related anaphylaxis was most common in those 30 to 39 years of age. CONCLUSION The overall incidence rate of anaphylaxis was 42 per 100,000 person-years from 2001-2010 in Olmsted County, Minnesota. The incidence of anaphylaxis increased over time, and several inciting triggers were uniquely associated with different age groups.
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Abstract
Hymenoptera venom allergy is an immunoglobulin E (IgE)-mediated hypersensitivity to the venom of insects from the Hymenoptera order and is a common cause of anaphylaxis. A diagnosis of venom allergy is made by taking an accurate medical, family and social history, alongside specific allergy testing. Systemic reactions to Hymenoptera venom occur in a small proportion of the population; these range from mild to life-threatening in severity. Treatment for local reactions involves the use of cold packs, antihistamines, analgesia and topical corticosteroids to help alleviate swelling, pain and pruritus. Venom immunotherapy is the treatment of choice for reducing the incidence of future anaphylactic reactions in individuals who have signs of respiratory obstruction or hypotension. Venom immunotherapy is the most effective treatment in reduction of life-threatening reactions to venom, and can improve quality of life for individuals. Treatment should only be provided by experienced staff who are able to provide emergency care for anaphylaxis and life-threatening episodes. A risk assessment to deliver treatment should be undertaken before treatment is commenced.
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Affiliation(s)
| | - Victoria Timms
- St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, England
| | - Roisin Fitzsimons
- St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, England
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18
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Dzviga C, Matevi C, Bonniaud P, Lavaud F, Girodet B, Birnbaum J, Lambert C. Survey on practice of venom immunotherapy in France. Arch Med Sci 2016; 12:150-5. [PMID: 26925131 PMCID: PMC4754376 DOI: 10.5114/aoms.2016.57591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/27/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Venom immunotherapy (VIT) is the only efficient prevention for sting-induced anaphylaxis, but its application is not without risks and needs precautions and standardization. European guidelines were proposed in 2005, but recent practice surveys and more recent knowledge raise the need for an update. The aim of this study was to analyze VIT practices in France, based on previous surveys in Europe but also extended to outcome event management. MATERIAL AND METHODS A paper questionnaire was sent widely to persons involved in venom treatment. RESULTS Eighty-six responses could be included from physicians actively involved in VIT induction evenly distributed in France. The survey shows that VIT was engaged from grade III down to grade I reactions, starting preferentially with the ultra-rush protocol. Premedication was used by 42% only and risks induced by co-treatment with β-blockers were well known but not with angiotensin-converting enzyme inhibitors. However, side effects were very variably managed from arrest to enhancement in doses, time-delay or duration. Similarly, we observed a large discrepancy in treatment evaluation (skin tests, biology, timing and interpretation), decision making for treatment termination (when and how long to be prolonged) and post-treatment follow-up (adrenaline kit, event record) as well as procedures in case of late relapse (new induction, different doses). CONCLUSIONS Our study shows that most recommendations were fully or partially followed and may need reminding, but many points need to be completed or updated with new tools and knowledge acquired during the last 10 years.
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Affiliation(s)
- Charles Dzviga
- Allergology Unit, University Hospital, Saint-Etienne, France
| | | | | | | | | | - Joelle Birnbaum
- Allergology Unit, APHM University Hospital, Marseille, France
| | - Claude Lambert
- Immunology Laboratory, University Hospital, Saint-Etienne, France
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Çelıksoy MH, Sancak R, Söğüt A, Güner SN, Korkmaz A. Characteristics of venom allergic reactions in Turkish beekeepers and alternative treatment modalities. Int Forum Allergy Rhinol 2014; 4:555-8. [PMID: 24668848 DOI: 10.1002/alr.21314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/28/2014] [Accepted: 02/03/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of this work was to determine the characteristics of allergic reactions that may occur after a bee sting and alternative treatment methods in Turkish beekeepers. METHODS A written questionnaire was administered to beekeepers from the Ordu, Samsun, Sinop, Amasya, and Çorum provinces located in the Central Black Sea Region of Turkey. RESULTS The study included 301 beekeepers, 295 (98%) of whom were male. Their mean age was 48.2 ± 11.5 years. The mean beekeeping duration was 15.3 ± 10.5 years. A total of 270 participants (89.9%) had a history of bee stings in the previous 12 months. Systemic reactions, large local reactions, and local reactions were seen in 21 (6.9%), 193 (64.1%), and 12 (4.0%) beekeepers, respectively. The face was the most frequently stung body site, and swelling generally occurred in the eyelids. The size of the swellings decreased within 12 to 24 hours in 259 (86.1%) beekeepers. The size of the swellings was 1 × 2 cm in diameter in 157 (52.2%) beekeepers. Natural protection against bee stings had developed by 12 months in 140 (46.5%) beekeepers. In total, 61.5% of the beekeepers applied alternative treatments (eg, garlic, onion water, yogurt), whereas 14.0% (3/21) were admitted to a hospital with a systemic reaction. In total, 10.6% and 14.2% of beekeepers were aware of adrenaline auto-injector and venom immunotherapy, respectively. CONCLUSION This study indicates insufficient knowledge and attitudes among Turkish beekeepers regarding bee sting reactions.
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Affiliation(s)
- Mehmet Halil Çelıksoy
- Ondokuz Mayıs University, Faculty of Medicine, Department of Pediatric Allergy and Immunology, Samsun, Turkey
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