Stepwise approach towards adoption of allergen immunotherapy for allergic rhinitis and asthma patients in daily practice in Belgium: a BelSACI-Abeforcal-EUFOREA statement.

Allergic rhinitis (AR) affects 23-30% of the European population with equal prevalence reported in Belgium. Despite guidelines on the correct use of effective treatment, up to 40% of AR patients remain uncontrolled. Allergen immunotherapy (AIT) has been shown to improve the level of control up to 84% of patients being controlled by AIT. Recently, new guidelines for AIT have been published, supporting the clinical evidence for effectiveness of various subcutaneous and sublingual products for AIT in patients who are allergic to airborne allergens. AIT in AR patients not only reduces nasal and/or ocular symptoms but also induces tolerance and has preventive potential. Adoption of AIT into daily clinical practice in Belgium and other European countries is hampered primarily by reimbursement issues of each of the single products but also by several patient- and physician-related factors. Patients need to be better informed about the effectiveness of AIT and the different routes of administration of AIT. Physicians dealing with AR patients should inform patients on tolerance-inducing effects of AIT and are in the need of a harmonized and practical guide that supports them in selecting eligible patients for AIT, in choosing evidence-based AIT products and in following treatment protocols with proven efficacy. Therefore, a stepwise and holistic approach is needed for better adoption of AIT in the real-life setting in Belgium.

First-line attitudes in acute medicine.

First-line attitudes in acute medicine. The often complex problems of the trauma and/or severely ill patient present many challenges to front-line emergency staff. Multiple injuries and/or systems of the body involved require careful and timely prioritization and intervention. Optimum evaluation and resuscitation involves repetitive, systematic ipproaches that are known as the "primary", "secondary" and "tertiary" surveys. The primary survey focuses in general on the ABCDE approach of "Airway, Breathing, Circulation, Disability, Expoure", and is designed to recognize and to treat immediate life-threatening conditions within the initial minutes. This primary resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely traumatized patients. This approach is applicable in all clinical emergencies, whether the patient is located in the street, at home, in the emergency room, and even in the intensive care or the general wards of the hospital. This approach is widely accepted by experts, and is likely to improve outcomes by helping healthcare professionals to focus on the most life-threatening clinical problems. In an acute setting, high-quality ABCDE skills among all treating team members can save valuable time and improve team performance. The secondary and the tertiary surveys are intended to diagnose all injuries before formulating definitive management strategies. This chapter briefly describes how to perform the ABCDE approach in general, and how to conduct the secondary and the tertiary surveys. A more detailed use of this approach within a specific medical condition will be described in later chapters of this report.

Protection of respiratory integrity and haemodynamic stabilization.

Protection of respiratory integrity and haemodynamic stabilization. OBJECTIVES: To perform an analysis of the protection of respiratory integrity and haemodynamic stabilization based on the literature review and the experiences and perspectives of emergency and ENT specialists. METHODOLOGY: A comprehensive literature search was undertaken through PubMed and MEDLINE, using the following keywords: [protection of the respiratory integrity], [intubation], [hypotension] and [haemodynamic stabilization]. Articles were selected if the topic was relevant to current ENT and emergency practice. Additional articles were identified through a careful review of reference lists in Uptodate. A critical review of ENT and emergency specialists was carried out. Evidence staging and recommendation levels were established using the Paul Shekelle scale. RESULTS: Firstly, protection of the airway is necessary before starting haemodynamic stabilization. Fibre-optic examination and laryngeal intubation form the gold standard of diagnosis and treatment in the protection of the airway. For circulation, a short catheter with a large size allows the management of intravenous fluids, with vasopressors if necessary. Aetiologic and specific treatments are also very important. CONCLUSIONS: Appropriate and collaborative management is necessary with the "ABCDE" approach: Airway and im- mobilization of the neck; Breathing; Circulation; Disability and Exposure. A fibre-optic examination is the gold standard of airway diagnosis. Laryngeal intubation is the most effective treatment for protection of the respiratory integrity. The management of circulation includes the implementation of a venous route to initiate administration of IVFs, preferably with isotonic saline. Vasopressors and inotropes are used as second line agents. A multidisciplinary and team approach is preferred, in order to achieve diagnosis and therapeutics simultaneously.

Management of burn wounds of the head and neck region.

Management of burn wounds of the head and neck region. Management of the severely burned patient is ery often a challenge, not only due to major disturbances in anatomy and physiological processes, but also because the relatively low incidence of this pathology in both civilian and military practice results in care providers'lack of experience. The purpose of this educational document is to provide doctors confronted with these formidable trauma patients with basic management guidelines as well as some practical tips. In summary, and most importantly, these patients should be reated as any other multitrauma patient. First aid is essential and can be provided by non-medical staff. Initial medical nanagement should focus on the usual, familiar trauma algorithms of ABCDEF from the emergency management of evere burns (EMSB) manual' or the ABCDEs of the manual of advanced trauma life support (ATLS)2 or advanced burn life support (ABLS). Medical care should proceed through the following steps - Step one: establish a reliable intravenous nfusion; step two: protect the airway; step three: establish and maintain a haemodynamic state compatible with sufficient organ perfusion in order to reduce aggravation of the burn wounds and increase overall survival likelihood; step four: provide analgesia with adequate sedation and provide anaesthesia for escharotomy, fasciotomy or other surgical injuries; step five: maintain normothermia; step six: feed the patient by starting enteral nutrition as early as possible; step seven: prevent infection using antiseptic wound management, systemic antibiotics and tetanus prophylaxis. All of these intricate steps require continuous reassessment and adjustment, but the existence of other wounds (blast injuries, penetrating and blunt trauma) even further complicates the management of burn casualties.

Facing coagulation disorders after acute trauma.

Facing coagulation disorders after acute trauma. PROBLEMS/OBJECTIVES: Trauma is the leading cause of mortality for persons between one and 44 years of age, essentially due to bleeding complications. METHODOLOGY: We screened the PubMed, Scopus and Cochrane Library databases, using specific keywords. Only publications in English were considered. MAIN RESULTS: The pathophysiology of trauma-induced coagulopathy (TIC) is complex and includes the classic "lethal triad" (i.e., haemodilution, acidosis, hypothermia) but may also include activation of protein C, endothelial and platelet dysfunction, and fibrinogen depletion. The time between trauma and treatment of the resultant massive bleeding should be as short as possible using techniques for rapid control of bleeding and avoiding aggravating factors (hypothermia, metabolic acidosis and hypocalcaemia). If given within three hours of injury, tranexamic acid (TXA) reduces all causes of mortality in trauma patients and reduces transfusion requirements. In a bleeding patient, crystalloids are preferred to colloids and the ratio of fresh frozen plasma to packed red blood cells should be at least 1:2. Damage control surgery (DCS) should be considered for patients who present with, or are at risk for developing, the "lethal triad", multiple life-threatening injuries or shock, and in mass casualty situations. DCS can also aid in the evaluation of the extent of tissue injuries and the control of haemorrhage and infection. Finally, there is currently no evidence of the added value of laboratory assays in the management of TIC. CONCLUSIONS: TIC appears quickly after trauma and should be anticipated and detected as soon as possible. TXA plays a central role in the management of such patients. Each institution should establish a local algorithm for the management of bleeding patients.

Pre-hospital interventions: introduction to life support systems.

Pre-hospital interventions: introduction to life support systems. Crucial decisions in pre-hospital emergency care are often made; therefore, a tactical emergency medical support team (TEMS) should maintain the capacity to capture the situation instantaneously and in all circumstances. However, low exposure to severe trauma cases can be a weakness for emergency specialists, which makes pre-hospital assessment more difficult. Pre-hospital interventions (PHI) are usually classified in Western countries into BLS (basic life support) and ALS (ad- vanced life support) levels, according to the methods used. This review introduces tactical combat casualty care for medical personnel (TCCC) guidelines, designed for basic care management under fire or in a hostile environment. The phases of TCCC are: (1) care under fire (or in an unstable environment); (2) tactical field care; and (3) tactical evacuation care, and are mainly dependent on the different hazard zones (hot, warm or cold). In a mass casualty situation due to disaster or cataclysm, standardized protocol and triage are unquestionably required for identifying the environmental risks, for categorizing the casualties in accordance with medical care priorities, and for the initial management of casualty care. When considering conflict situations, or chemical, biological, radiological, or nuclear (CBRN) events, processes always start at the local level. Even before the detection and analysis of agents can be undertaken, zoning, triage, decontamination, and treatment should be initiated promptly. Otorhinolaryngologists should be aware of PHI procedures for completing preliminary assessment and management together with emergency specialists or TEMS.

At risk populations: from children to the elderly.

At risk populations:from children to the elderly. PROBLEMS/OBJECTIVES: When considering emergencies in children and elderly people, the risks and consequences are considerably different. For example, the anatomical differences of children have direct consequences on intubation and airway physiology influences breathing, circulation and neurological outcomes.Pharmacotherapy should be adapted for children according to their differences (maturational changes) where drug metabolism and disposition is concerned and for the elderly, to geriatric pharmacokinetics, pharmacodynamics, the existence of poly-medications and the risk of adverse drug reactions. METHODOLOGY: Literature review Results: Children respond better to rapid medical care than adults. Hypoxia is dangerous for the child and is responsible for bradycardia and cardiac arrest. Hypoxia can be deleterious for elderly patients because of their fragility, e.g., less metabolic reserves, poor muscular compensation and higher risk of heart failure. CONCLUSIONS: It is widely accepted that children require paediatric-specific assessment/treatment equipment and pharmacotherapy. When compared to adults, there is no difference in the Royal College of Physician guidelines for elderly people's reanimation, however, other criteria such as polypathology, co-morbidity, polypharmacy, fragility, risk of delirium, adverse drug reaction, poor outcome and quality of life should be considered.

Civilian law: from occupational medicine to occupational event.

Civilian law:from occupational medicine to occupational event. Despite the growing importance of objective measurements, the health effects of many occupational risk factors are currently not fully quantified. Occupational noise, as a widespread risk factor, is illustrative in this regard; there is a strong body of evidence linking it to an important health outcome (hearing loss), but it is less decisively associated with others (such as psychological disorders). It is also distinct from environmental noise, and therefore falls under the responsibility of employers as well as individuals. Noise-induced hearing loss (NIHL) is, at present, incurable and irreversible. However, it is preventable, if effective and global hearing conservation programmes can be implemented. These programmes should not be isolated efforts, but should be integrated into the overall hazard prevention and control programme of the workplace. Belgian law encompasses a set of provisions for prevention and the protection of the health and safety of workers within the workplace, including aspects pertaining to the hygiene of the workplace and psychosocial aspects at work (stress, violence, bullying and sexual harassment, among others). In principle, combating environmental noise is fully addressed in this country. However, other levels of policy-making also play an important role in this regard. For example, the federal government is in charge of product standards, and therefore also of noise emission standards for products. The interpretation and enforcement of Belgian legislation on well-being at work converts European directives and international agreements on well-being at work into Belgian law.

Long-term complications after facial, pharyngeal, laryngeal and tracheal traumas.

Long-term complications after facial, pharyngeal, laryngeal and tracheal traumas. OBJECTIVE: To review and summarize the existing evidence for long-term anatomical and functional complications after pharyngeal, laryngeal and tracheal traumas. DATA SOURCES: The MEDLINE database and the bibliographies of relevant studies were selected, analysed and appraised prior to December 2015. METHODS: With regard to the search strategy, the selected items were: ((long-term complications) AND pharyngeal) AND laryngeal) AND tracheal) AND traumas. Abstracts and titles were screened for relevance, while full articles of the se- lected records were evaluated and critically appraised after inclusion. Data concerning life-threatening situations, as well as long-term severe adverse effects were collected.

Recruitment and activation of circulating neutrophils after sinus surgery.

OBJECTIVE: After failure of pharmacological treatment, sinus surgery is the recommended alternative treatment for chronic sinusitis with or without nasal polyps. During post-operative healing, adequate local neutrophil activation plays an important role in the repair process. This pilot study aimed to systematically explore the participation of circulating neutrophils in early-phase wound repair of the nasal and paranasal mucosa after sinus surgery, with a special focus on neutrophil recruitment and activation patterns. METHODOLOGY: We conducted a single-center outcome study of patients undergoing sinus surgery. Whole blood samples were collected from eleven patients before surgery and at post-surgical time points of 1 hour and 1, 7, 14, and 30 days. Hematological analysis was conducted to count circulating neutrophils and evaluate their overall activation status. Using flow cytometry, neutrophil expression of membrane CD11b, CD11c, and CD15 was also measured, and oxidative burst analysis was performed. RESULTS: After sinus surgery, neutrophilia increased by 1 hour after surgery, reached a maximum at Day 1, and showed a gradual return toward baseline by Day 30. The oxidative burst initially decreased during the first hours after surgery, increased at Day 14, and returned toward normal by Day 30. Lewis X factor and the expression of CD11b and CD11c exhibited a bimodal change over time, in an inverted phase compared to the oxidative reaction. CONCLUSIONS: Circulating neutrophils are involved in the first phase of wound healing after sinus surgery as indicated by increased abundance, early membrane changes, and the modulation of their oxidative capacities.

Immunohistochemical studies of wound healing after monopolar electrocautery and ultrasound submucosal inferior nasal turbinate reduction in sheep.

BACKGROUND: Extracellular matrix (ECM) proteins such as fibronectin and collagen III, enzymes such as matrix metalloproteinases and macrophages have been demonstrated to intervene in nasal and paranasal sinuses wound healing. AIM OF THE STUDY: To compare concentration of ECM proteins, enzymes and the recruitment of macrophages during wound repair after monopolar electrocautery in contrast with ultrasound submucosal surgical tissue reduction of inferior nasal turbinate (INT) tested in sheep. MATERIALS AND METHODS: Prospective controlled study in sheep. Immunostaining for collagen III, fibronectin, CD68 and matrix metalloproteinase-9 (MMP9) was applied in tissue specimens of INT mucosa after monopolar electrocoagulation (MEC) and ultrasound tissue reduction (UTR). Twelve INTs were studied 1, 3 and 8 weeks post-operatively in each interventional group (MEC and UTR) and 5 INTs were studied in animals of the control group (without surgery). The immunoreactivity was quantitatively graded between 0% to 100% immunoreactivity by a blinded senior pathologist. RESULTS: At the end of the study period collagen III, fibronectin and MMP9 were increased in both groups compared to the levels of the control group. When compared to control group, CD68 immunoreactivity was found higher in MEC group but not in UTR group. Fibronectin subepithelial immunoreactivity exhibited a substantial negative correlation with mucosal epithelial cell necrosis, a substantial positive correlation with fibrosis in MEC-treated specimens and a significant positive correlation with sinusoid engorgement in UTR-treated specimens. Collagen III tissue immunoreactivity showed a particularly significant negative correlation with sinusoid engorgement in MEC-treated specimens. CONCLUSION: Correlation of fibronectin and collagen III immunoreactivity to histopathologic findings suggests different ECM repair processes between MEC and UTR turbinate tissue reduction. The use of CD68 and MMP9 provides additional clues to the mode of actions of these techniques and to the molecular and cellular events of the nasal mucosa wound healing process.

Different aspects of respiration: relationships between the upper and lower respiratory tracts, and the middle ear cleft, nasal versus oral breathing.

This paper outlines the normal functioning of the child's upper airway: defending the lower airway by means of air conditioning, filtration, initiation of inflammatory reactions or immune responses. We investigate the hypothetical mechanisms that explain the influence of, and interrelations between, mouth breathing and obstructive sleep apnoea on craniofacial development. We advise orthodontic diagnosis and/or intervention at a young age.

Chronic inflammation of upper airways in children: basic principles.

PROBLEMS/OBJECTIVES: A child's immune system has to initiate the immune response from scratch and cannot depend on a memory-type of immune response. Moreover, the immune system in newborns is also less efficient in inducing cytokine responses. In consequence, newborns and children are more susceptible to upper-airway infections and inflammation than adults. This manuscript summarises basic considerations relating to immune and inflammatory response in the upper airways and presents data about the processes involved in immunity development and maturation in children. METHOD: Literature review. RESULTS: Inflammation is a complex set of interactions between soluble factors and cells that can arise in any tissue in response to both exogenous (infectious, toxic...) and endogenous (auto-immune, ischaemia...) insults. It interacts actively with the adaptive immune response by launching the antigen processing and presenting phases. Reduced cytotoxic response during foetal life, poor T-lymphocyte response to mitogens, immaturity of T and B lymphocytes, inadequate cytokine synthesis, a marked deficiency of antibody production and reduced neutrophil, complement and natural killer activity are important contributors to the complex physiological deficiency of immunological function in neonates and young children. CONCLUSIONS: The importance of the control and self-limitation of the inflammatory reaction is demonstrated by observations that, in certain chronic infectious or inflammatory conditions, the inflammatory response causes more damage to the host than the microbe.

Biological conditions affecting chronic inflammation in upper airways in children.

PROBLEMS/OBJECTIVES: A child's immune system cannot depend on a memory-type immune response and it also induces cytokine responses less efficiently. Biological conditions like allergy or cystic fibrosis, immune deficiency or gastrooesophageal reflux can induce and maintain background inflammation in children's upper airways, making newborns and children more susceptible to upper airway infections and inflammations. This paper will describe in brief how allergy, cystic fibrosis, immune deficiency, nasal and paranasal anatomical variants, and gastro-oesophageal reflux (GOR) can affect the immune and inflammatory responses in upper airways and how they could interfere with immunity development and maturation in children. METHODOLOGY: Literature review. RESULTS: Chronic inflammation induced by infection, allergy, cystic fibrosis or immune deficiency is multifactorial in origin and is strongly influenced by physiological, immunological, anatomical, environmental and, above all, genetic parameters. Finally, the direct role played by nasal and paranasal anatomical variants and GOR is also discussed. CONCLUSIONS: These conditions should be screened systematically in all children presenting chronic clinical features of upper airway inflammation.

Specific medical and surgical treatment for chronic inflammatory diseases in children.

Treatment for chronic inflammatory conditions in children should take into account the specific pathophysiological and clinical processes underlying these disorders. These guidelines provide a framework for both the medical and surgical treatment of chronic inflammatory diseases such as otitis media, allergic rhinitis and chronic rhinosinusitis, chronic inflammation of tonsils and adenoids, and laryngitis. In addition, the role of vaccinations and immunomodulatory therapies is discussed. Whenever possible, the evidence levels for specific treatments comply with the Oxford Levels of Evidence.

Viruses and bacteria in acute asthma exacerbations--a GA² LEN-DARE systematic review.

A major part of the burden of asthma is caused by acute exacerbations. Exacerbations have been strongly and consistently associated with respiratory infections. Respiratory viruses and bacteria are therefore possible treatment targets. To have a reasonable estimate of the burden of disease induced by such infectious agents on asthmatic patients, it is necessary to understand their nature and be able to identify them in clinical samples by employing accurate and sensitive methodologies. This systematic review summarizes current knowledge and developments in infection epidemiology of acute asthma in children and adults, describing the known impact for each individual agent and highlighting knowledge gaps. Among infectious agents, human rhinoviruses are the most prevalent in regard to asthma exacerbations. The newly identified type-C rhinoviruses may prove to be particularly relevant. Respiratory syncytial virus and metapneumovirus are important in infants, while influenza viruses seem to induce severe exacerbations mostly in adults. Other agents are relatively less or not clearly associated. Mycoplasma and Chlamydophila pneumoniae seem to be involved more with asthma persistence rather than with disease exacerbations. Recent data suggest that common bacteria may also be involved, but this should be confirmed. Although current information is considerable, improvements in detection methodologies, as well as the wide variation in respect to location, time and populations, underline the need for additional studies that should also take into account interacting factors.

The ARIA guidelines in specialist practice: a nationwide survey.

PROBLEM: In 2001, the ARIA guidelines were published to assist healthcare practitioners in managing allergic rhinitis (AR) according to the best evidence. Very limited information, however, is avail-able on the impact of these guidelines on clinical practice. METHODS: All Belgian Otorhinolaryngologists were invited to complete a questionnaire, covering demographic and professional characteristics, knowledge, use and perception of the ARIA guidelines and 4 clinical case scenarios of AR. RESULTS: Of the 258 (44%) Belgian Otorhinolaryngologists who participated, almost 90% had ever heard about ARIA and 64% had followed a lecture specifically dedicated to the ARIA guidelines. Furthermore, 62% stated to always or mostly follow the ARIA treatment algorithms in the daily management of AR patients. In the clinical case section, adherence to the ARIA guidelines raised with increased self-reported knowledge and use of the ARIA guidelines and among participants that considered the guidelines more userfriendly. Of the respondents, 51% were considered as good com-pliers. Younger age was a significant predictor for good compliance. CONCLUSION: More efforts are required to improve the translation of scientific knowledge into clinical practice and to further identify which factors may influence guideline compliance.