Omalizumab in the treatment of Morbihan syndrome in an adolescent girl - case report and literature review.

Morbihan syndrome (MS) is characterized by solid facial edema, usually related to rosacea or acne vulgaris. The facial edema deforms the patient's features, can impair peripheral vision, and affects quality of life. Its pathophysiology remains unclear. The disease usually has a slow and chronic course. MS most commonly affects middle-aged Caucasian men with rosacea and is rare in people below 20 years of age. MS is a diagnosis of exclusion. There is no standard treatment for MS, though systemic isotretinoin and antihistamines are mainly used. We present the case of an adolescent girl with MS nonresponding to 19 months of isotretinoin treatment with add-on antihistamines. Therapy with monthly administration of omalizumab (anti-IgE) for 6 months was an effective therapeutic option, improving the quality of life. Our case is the second description of omalizumab use in Morbihan syndrome, the first in an adolescent.

Omalizumab in the treatment of Morbihan syndrome in an adolescent girl – case report and literature review

Morbihan syndrome (MS) is characterized by solid facial edema, usually related to rosacea or acne vulgaris. The facial edema deforms the patient’s features, can impair peripheral vision, and affects quality of life. Its pathophysiology remains unclear. The disease usually has a slow and chronic course. MS most commonly affects middle-aged Caucasian men with rosacea and is rare in people below 20 years of age. MS is a diagnosis of exclusion. There is no standard treatment for MS, though systemic isotretinoin and antihistamines are mainly used. We present the case of an adolescent girl with MS nonresponding to 19 months of isotretinoin treatment with add-on antihistamines. Therapy with monthly administration of omalizumab (anti-IgE) for 6 months was an effective therapeutic option, improving the quality of life. Our case is the second description of omalizumab use in Morbihan syndrome, the first in an adolescent. (AU)

Atopic dermatitis and gestational age - is there an association between them? A review of the literature and an analysis of pathology.

Introduction: The connection between prematurity and atopic dermatitis (AD) is an intensively investigated topic with existing knowledge gaps. The last review with a meta-analysis in this field was published in 2018. Since then, there have been great advances in the comprehension of AD pathophysiology. Aim: To update the knowledge and to discuss the recent findings in the field of AD and its association with prematurity in light of the newest publications. Material and methods: An electronic search of Medline was conducted, limited to the last eleven years. The screening of the full version of English articles was performed to ensure the fulfilment of the selection criteria. Results: Thirteen articles met the inclusion criteria, with a total of over 4 million participants. In the majority of the studies (n = 8), prematurity was associated with a lower risk of atopic dermatitis, although there were also publications (n = 5) that did not find an association between these factors. Conclusions: According to this study, prematurity is associated with a lower risk of atopic dermatitis.

Stinging insect identification in children with Hymenoptera venom allergy and their parents.

Introduction: The treatment of Hymenoptera venom allergy (HVA) is based among others on the proper identification of the culprit insect. Aim: To assess the accuracy in identifying stinging insects by children with HVA and their parents. Material and methods: Participants were recruited from a paediatric medical centre. The data on their demographics, sting history and ability of insect identification (based on pictures) were obtained using a questionnaire. The study sample consisted of 102 children with HVA and their parents as well as 98 children without HVA and their parents. Results: The rates of subjects correctly identifying insects in the groups were 91.2%, 92.5%, 78.8%, 82.4%, respectively. When compared to children with HVA, those without HVA were less likely to correctly identify the bee, bumblebee and hoverfly. In this group, the correct identification of the wasp was more common among children living in the countryside. The correct identification of the bee and bumblebee by children without HVA was more common among children living in the city. Conclusions: Some children with HVA and their parents cannot correctly identify stinging insects despite previous life-threatening allergic reactions. The ability to identify stinging insects may depend on the HVA diagnosis and place of residence.

Skin prick tests are not useful for the qualification for venom immunotherapy in children.

Background: The basis for qualification for venom immunotherapy (VIT) is the fulfilment of both the clinical and immunological criteria. Diagnostic tests that confirm the immunological criterion of an IgE-mediated sensitization include skin prick tests (SPT), intradermal tests (IDT), and serum specific IgE (sIgE) for the culprit venom. Objective: This study aimed to assess the usefulness of SPT as the immunological marker in the diagnosis of insect venom sensitization in children with history of systemic reaction (SR) to insect sting evaluated by means of I-IV-grades Mueller's scale. There are no such studies in children. Methods: This cross-sectional study sample consisted of 416 children aged 3-18 years (mean age 10.6 ± 3.8), 76% males, all with the history of a systemic reaction (SR) after a Hymenoptera sting (48% of grade III/IV according to Mueller scale), diagnosed between 1999 and 2019 in the tertiary referral centre. The standard diagnostic tests were used. Specificity, sensitivity, and positive and negative predictive values were computed to assess the diagnostic properties of the clinical tests to distinguish between mild and severe SR. To assess the relative value of an individual test in predicting the qualification to VIT we incorporated the Shapley value (SV). Results: Positive SPT results were found in up to no more than 3% of children; among them less than 1% had only positive SPT and were negative for sIgE and IDT. Approximately 85% of the children had detectable venom sIgE, followed by positive IDT (75%). Almost 70% of children had positive both sIgE and IDT results. In children with grade III/IV reaction, about 80% of children had positive results of both of these tests. sIgE and IDT had sensitivity >0.80, whereas SPT had high specificity (>0.97) in differentiating between mild and severe SR. Relative value of diagnostic tests in predicting qualification to VIT varied between venoms. Bee venom IDT had higher SV (0.052) than sIgE (0.041). In contrast, wasp venom sIgE had higher SV (0.075) than IDT (0.035). Conclusion: SPTs are not an useful immunological marker of venom sensitization in children, and eliminating SPT does not result in a loss of diagnostic accuracy. Limiting diagnostics to venom sIgE and IDT would shorten the procedure and reduce costs. Future studies are needed to determine if venom sIgE as the first line diagnostic test, with IDT added only if the venom sIgE is undetectable, is an optimal diagnostic process.

Food-Induced Anaphylaxis: Data From the European Anaphylaxis Registry.

BACKGROUND: Food is one of the most common elicitors of anaphylaxis, with an increasing incidence over recent years. OBJECTIVES: To characterize elicitor-specific phenotypes and identify factors enhancing the risk or severity of food-induced anaphylaxis (FIA). METHODS: We analyzed data from the European Anaphylaxis Registry applying an age- and sex-matched analysis of associations (Cramer's V) for single food triggers and calculated odds ratios (ORs) for severe FIA. RESULTS: We identified 3,427 cases of confirmed FIA showing an age-dependent elicitor ranking (for children: peanut, cow's milk, cashew, and hen's egg; and for adults: wheat flour, shellfish, hazelnut, and soy). The age- and sex-matched analysis revealed defined symptom patterns for wheat and cashew. Wheat-induced anaphylaxis was more frequently associated with cardiovascular symptoms (75.7%; Cramer's V = 0.28) and cashew-induced anaphylaxis with gastrointestinal symptoms (73.9%; Cramer's V = 0.20). Furthermore, concomitant atopic dermatitis was slightly associated with anaphylaxis to hen's egg (Cramer's V = 0.19) and exercise was strongly associated with anaphylaxis to wheat (Cramer's V = 0.56). Additional factors influencing the severity were alcohol intake in wheat anaphylaxis (OR = 3.23; CI, 1.31-8.83) and exercise in peanut anaphylaxis (OR = 1.78; CI, 1.09-2.95). CONCLUSIONS: Our data show that FIA is age-dependent. In adults, the range of elicitors inducing FIA is broader. For some elicitors, the severity of FIA seems to be related to the elicitor. These data require confirmation in future studies considering a clear differentiation between augmentation and risk factors in FIA.

Cow's milk and hen's egg anaphylaxis: A comprehensive data analysis from the European Anaphylaxis Registry.

BACKGROUND: Cow's milk (CM) and hen's egg (HE) are leading triggers of anaphylaxis in early childhood. The aim of this study was to identify clinical phenotypes and therapeutic measures for CM anaphylaxis (CMA) compared to HE anaphylaxis (HEA) in children up to 12 years of age, based on a large pan-European dataset from the European Anaphylaxis Registry. METHODS: Data from 2007 to 2020 on clinical phenotypes and treatment from 10 European countries, as well as Brazil, were analysed. The two-step cluster analysis was used to identify the most frequent phenotypes. For each trigger, three clusters were extracted based on sex, age, and existence of symptoms in four vitally important systems. RESULTS: Altogether 284 children with CMA and 200 children with HEA were identified. They were characterised as male (69% vs. 64%), infants (65% vs. 61%), with a most frequent grade III of Ring&Messmer classification (62% vs. 64%), in CMA versus HEA, respectively. Respiratory symptoms occurred more often in CMA (91% vs. 83%, p = 0.010), especially in infants (89% vs. 79%, p = 0.008). Cardiovascular symptoms were less frequent in CMA (30% vs. 44%, p = 0.002), in both infants (33% vs. 46%, p = 0.027), and older children (25% vs. 42%, p = 0.021). The clusters extracted in the CMA group were characterised as: (1) mild dermal infants with severe GI (40%), 2. severe dermal (35%), 3. respiratory (25%). While in HEA group: 1. infants with severe GI and/or reduction of alertness (40%), (2) conjunctival (16%), (3) mild GI without conjunctivitis (44%). The severity of the reaction was independent from the amount of ingested allergen protein, regardless of trigger. The first-line adrenaline application differed between the countries (0%-92%, as well as the reasons for not administering adrenaline, p < 0.001). CONCLUSIONS: Despite the similarity of their age, sex, and severity grade, the clinical profiles differed between the CMA and HEA children. Adrenaline was underused, and its administration was country dependent. Further studies are needed to assess to what extent the differences in the clinical profiles are related to matrix and/or absorption effects, and/or the allergen itself.

The 2020 update on anaphylaxis in paediatric population.

The objective of the review is to present recent updates on anaphylaxis in paediatric population worldwide. The article summarizes the results of epidemiological studies, diagnostic methods and treatments. We present a new WAO definition of anaphylaxis (2019), which broader criteria excluding dermal symptoms should facilitate faster life-saving adrenaline use. Adrenaline remains the best treatment to manage severe symptoms and to prevent biphasic reactions. There is ongoing effort to increase adrenaline use, such as modified autoinjectors, individual training, and diversified dosing. There are five independent risk factors of lethal anaphylaxis in children, including history of asthma, almost immediate onset of symptoms, unwell appearance, tachycardia and hypotension. We also report improvements in diagnostics, like component-resolved diagnostics, and novel therapies stimulating immunotolerance. We signal the development of ICD-11 with updated coding of anaphylaxis, which corresponds better to clinical observations.

Is the clinical manifestation of anaphylaxis in children influenced by the trigger of reaction?

INTRODUCTION: The number of anaphylaxis diagnoses in children is rising, being still based on the clinical picture. AIM: To determine whether triggers of anaphylaxis influence its clinical characteristics in children and adolescents. MATERIAL AND METHODS: The study group included 114 children (5 months-17 years, mean age: 8.0 ±4.8 years), (66%: boys) with the episode of anaphylaxis up to 1 year back. Medical data were entered to the NORA Registry by means of a validated structured on-line questionnaire. RESULTS: Three most frequent triggers of anaphylaxis were: insect venom (47.4%), food (35.1%), drugs (5.3%), with a predominance of food (egg white, cow's milk, nuts and peanuts) in the 0-6 years age group, while insect venom (bee predominance) in the 7-17 years age group (p = 0.016). Clinical manifestations differed between food vs. venom allergic reactions and presented as gastro-intestinal (GI) (61.4%) (p = 0.004), respiratory (RS) (93.9%) (p = 0.036), and cardiovascular (CVS) (74.6%) (p = 0.022) symptoms. Among objective symptoms, vomiting was the most common symptom in the 0-2 years age group (47.1%) (p = 0.006), while hypotension in those aged 7-12 years (40%) (p = 0.010). Severity of symptoms evaluated as Mueller's grade (IV - 74.5%) and as Ring and Messmer's grade (III - 65.8%), depended on the trigger (p = 0.028, p = 0.029, respectively). Life-threatening symptoms occurred in 26 children (fall of the blood pressure - 22%, loss of consciousness - 4.4%). CONCLUSIONS: The clinical manifestation of anaphylaxis in children is both trigger and age dependent, irrespective of the gender. A typical patient with food anaphylaxis was younger, presenting predominantly GI symptoms, while a typical patient with venom anaphylaxis was older, with mostly cardiovascular symptoms.

Intervention in anaphylaxis: the experience of one paediatric centre based on NORA reports.

Introduction: Intramuscular adrenaline administration is the primary intervention in anaphylaxis. Aim: To analyse the data on intervention in children admitted due to anaphylaxis to the tertiary paediatric centre and compare them to the data from the Network for Online-Registration of Anaphylaxis. Material and methods: A validated structured on-line questionnaire was used to collect data concerning the first and second-line intervention in anaphylaxis. The study was conducted in cooperation with the European Anaphylaxis Registry. Results: The study group comprised 114 children (76 boys, 66.87%) aged 5 months-17 years with the predominance of moderate-to-severe anaphylaxis (grade III in Ring and Messmer's, and grade IV in Mueller's scale). In 103 (90.4%) children the first line of medical intervention was provided by medical staff. In the first-line intervention 39 (34.8%) children were given adrenaline. Five (4.4%) children were given the second dose of adrenaline and were admitted to the intensive care unit. In the second-line intervention adrenaline was given to 12 (15.6%) children. In one third it was at least the second reaction to the same trigger. Children treated with adrenaline were older (9.3 ±4.8 years), in comparison to those not treated (7.3 ±4.6 years, p = 0.034). Directly after the episode of anaphylaxis the children got the prescription for the adrenaline autoinjector in 35.1%, emergency training in 7.9%, and counselling on the avoidance of the anaphylaxis trigger in 30.7%. Grade III R&M reaction increased 3-fold the odds of AAI prescription (95% CI: 1.08-8.15). Conclusions: There is a strong need to continue education on proper management of anaphylaxis in children.

Current practices in diagnosis of Hymenoptera venom allergy in Poland.

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

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry.

BACKGROUND: Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. METHODS: Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. RESULTS: 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). CONCLUSIONS: The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Atopic Dermatitis - Current State of Research on Biological Treatment.

Atopic dermatitis (AD) is the most common atopic disease in young children and most common skin disease in childhood. In the Polish population, the incidence of AD in the group of children aged 6-14 is about 4% and it is underestimated. The disease is chronic and recurrent, and the leading symptom is skin pruritus that in the mechanism of the vicious circle is accompanied by scratching that causes generalized infections. The overall problems lead to a decrease in the quality of life of the child and its parents and to an increased risk of psychosomatic diseases. The complex pathomechanism of AD is due to chronic inflammation of the skin, in which various cell phenotypes are involved. The management is comprehensive and it is aimed at reducing inflammation, improving the skin barrier function, reducing the symptoms of dryness and itching of the skin and secondarily improving the quality of life. The treatment includes intensive skincare, anti-inflammatory treatment based on the proactive use of topical glucocorticosteroids and topical calcineurin inhibitors. Periods of exacerbation of lesions require intensified treatment. In particularly severe, recurrent cases, treatment options can be extended to systemic immunosuppressive drugs, with awareness of their adverse effects. Previous year has brought significant progress in the current treatment of AD in the form of biological treatment. Cytokines and other mediators that play an important role in the pathogenesis of skin inflammation have become a target for new forms of therapy. Drugs for which interleukin (IL)-4 and IL-13 are the targets are particularly represented. Dupilumab is the first biological drug approved for the general treatment of children aged >12 years with moderate to severe AD. Another therapeutic option for topical use is crisaborole, a phosphodiesterase-4 inhibitor. This study presents the current state of research on biological drugs in AD.

Risk Factors and Characteristics of Biphasic Anaphylaxis.

BACKGROUND: Anaphylaxis is an immediate hypersensitivity reaction. However, a biphasic course with the second onset of symptoms can occur hours after the initial phase. Little is known about the causes of biphasic anaphylaxis making the identification of patients at risk difficult. OBJECTIVE: To identify factors predisposing for biphasic anaphylaxis for the better understanding of these reactions. METHODS: Data from the Anaphylaxis Registry (from 11 countries) including 8736 patients with monophasic and 435 biphasic anaphylaxis were analyzed. RESULTS: The rate of biphasic reactions in this large cohort was 4.7%. The identified risk factors were reaction severity (grade III/IV vs grade II: odds ratio [OR] = 1.34; 95% confidence interval [CI]: 1.1-1.62); multiorgan involvement; skin, gastrointestinal, severe respiratory, and cardiac symptoms; anaphylaxis caused by peanut/tree nut (OR = 1.78; 95% CI: 1.38-2.23) or an unknown elicitor (OR = 1.96; 95% CI: 1.41-2.72); exercise as a cofactor (OR = 1.44; 95% CI: 1.17-1.78); chronic urticaria as a comorbidity (OR = 2.12; 95% CI: 1.19-3.78); a prolonged interval between the contact with the elicitor and start of primary symptoms (OR for >30 vs <30 min: 1.38; 95% CI: 1.08-1.76); and antihistamine treatment (OR = 1.52; 95% CI: 1.14-2.02). CONCLUSION: A biphasic course of anaphylaxis occurs more frequently in severely affected patients with multiorgan involvement. However, we identified multiple additional predictors, suggesting that the pathogenesis of biphasic reactions is more complex than being a rebound of a severe primary reaction.

Secondary prevention measures in anaphylaxis patients: Data from the anaphylaxis registry.

BACKGROUND: Patients with a history of anaphylaxis are at risk of future anaphylactic reactions. Thus, secondary prevention measures are recommended for these patients to prevent or attenuate the next reaction. METHODS: Data from the Anaphylaxis Registry were analyzed to identify secondary prevention measures offered to patients who experienced anaphylaxis. Our analysis included 7788 cases from 10 European countries and Brazil. RESULTS: The secondary prevention measures offered varied across the elicitors. A remarkable discrepancy was observed between prevention measures offered in specialized allergy centers (84% of patients were prescribed adrenaline autoinjectors following EAACI guidelines) and outside the centers: Here, EAACI guideline adherence was only 37%. In the multivariate analysis, the elicitor of the reaction, age of the patient, mastocytosis as comorbidity, severity of the reaction, and reimbursement/availability of the autoinjector influence physician's decision to prescribe one. CONCLUSIONS: Based on the low implementation of guidelines concerning secondary prevention measures outside of specialized allergy centers, our findings highlight the importance of these specialized centers and the requirement of better education for primary healthcare and emergency physicians.

Refractory Anaphylaxis: Data From the European Anaphylaxis Registry.

Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 µg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances-requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.

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

INTRODUCTION: Venom immunotherapy treatment (VIT) is the only causal treatment of hymenoptera venom anaphylaxis, which aims to provide long-lasting immunoprotection against severe reactions to subsequent stings. AIM: To reassess the compliance of VIT procedures in the Polish allergy centres with the European guidelines. MATERIAL AND METHODS: A structured questionnaire survey conducted in all 33 VIT-centres. The response rate was 94%. RESULTS: The ultrarush initial protocol was the most common protocol (71%, n = 22), usually lasting for 3.5 h (50%, n = 7). The most frequent (36%, n = 11) time interval from the initial to the first maintenance dose (MD) was 14 days, ranging from 7 to 35 days. All centres used an MD of 100 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 ß-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.

Quality of life in parents of children and adolescents after systemic sting reactions.

INTRODUCTION AND OBJECTIVES: The study aimed at evaluating the impact of Hymenoptera venom allergy (HVA) in children and adolescents, on their parents' QoL, taking into account their socio-demographic characteristics. MATERIAL AND METHODS: The study sample consisted of 101 parents of children and adolescents aged 9-17 years, with a history of systemic reaction after insect sting who were referred for consultations in the tertiary level allergology department. The mean age of the parents was 39 years (SD=8.1; range 25-65 years); the majority were mothers (68%) and rural inhabitants (62%). QoL in parents of HVA children and adolescents was measured with the Parents of Children with Hymenoptera Venom Allergy Quality of Life Scale, a questionnaire covering 5 dimensions: anxiety, caution, limitations and discomfort, support provided to the child and feeling of safety, each measured on the scale ranging from 1 to 5. Independent predictors of QoL were estimated using the Generalized Linear Model. RESULTS: Parents of urban children and adolescents treated with venom immunotherapy (VIT) up to 3 years (B=-1.37, 95CI= (-2.22;-0.53); p=0.001) and of rural children treated for more than 3 years (B=-0.94, 95CI=(-1.55;-0.33); p=0.003) reported lower anxiety than parents studied at diagnosis. In urban parents, individuals studied at VIT beginning reported a lower feeling of safety (B=-0.63, 95CI=(-1.11;-0.15); p=0.010); those studied up to 3 years of treatment reported a higher feeling of safety (B=0.64, 95CI=(0.11;1.16); p=0.018) than those studied at diagnosis. Contrariwise, in rural parents, those studied at the beginning of immunotherapy reported a higher feeling of safety than those studied at diagnosis (B=0.51, 95CI=(0.13;0.88); p=0.008). CONCLUSIONS: The longest VIT duration in children and adolescents with HVA is related to the decreased anxiety of their parents. Parent's feeling of safety depends on the stage of treatment and place of residence.

Health-related quality of life in children and adolescents after systemic sting reaction.

INTRODUCTION AND OBJECTIVES: Insect stings are the second trigger of anaphylaxis in children and adolescents, causing a potentially life-threatening reactions. Hence health-related quality of life (HRQoL) is an important issue for Hymenoptera venom allergy (HVA) patients. The aim of this cross-sectional study was to evaluate the impact of HVA on young patients' HRQoL, including their socio-demographic characteristics. MATERIAL AND METHODS: The study sample included 102 patients aged 8-17 (Mean 12.5 years, SD=3.0), who were under diagnosis or venom immunotherapy due to systemic reaction after an insect sting in one of the tertiary referential centers in Poland. They were mostly boys (70%), and mainly from rural areas (63%). HRQoL of studied patients was measured with the Children's Hymenoptera Venom Allergy Quality of Life Scale, a questionnaire covering 6 dimensions: anxiety, caution, limitations, discomfort, support received from parents and a feeling of safety, each measured from 1 to 5. Independent predictors of HRQoL were estimated using the Generalized Linear Model. RESULTS: In the group of children being dermal reactors, girls reported a higher level of anxiety (B=1.17, 95%CI=(0.30;2.03), p=0.008). In the group of children with grade 2 it was the girls who reported lower anxiety (B=-1.33, 95%CI=(-2.38;-0.29), p=0.013). Boys treated longer than 3 years had their level of anxiety significantly lower than those studied at diagnosis (B=-0.65, 95%CI=(-1.23;-0.07), p=0.028). The feeling of safety was higher in children living in villages than in those living in towns (B=0.30, 95%CI=(0.03;0.56), p=0.031). CONCLUSIONS: The gender, treatment duration and stage of anaphylactic reaction influenced level of anxiety. The level of feeling of safety was related to the place of living.

Hymenoptera sting in the head and neck region is not a risk factor for grade IV systemic reactions in patients with venom allergy.

INTRODUCTION Hymenoptera insect stings (ISs) in the head and neck (H&N) region are commonly considered to be a risk factor for grade IV systemic reactions (SRs) in patients with Hymenoptera venom allergy (HVA). However, clinical data addressing this issue are scarce. OBJECTIVES The aim of our study was to verify whether ISs in the H&N region were related to a higher risk of grade IV SRs in patients with HVA. PATIENTS AND METHODS This retrospective cross­sectional study included 195 patients aged 2 to 74 years and treated with venom immunotherapy due to at least a grade II SR to ISs. The study sample comprised 109 adults (56%; mean [SD] age, 41.08 [14.62] years; male, 50.5%) and 86 children (mean [SD] age, 9.53 [4.37] years; male, 72.1%; P <0.001 for age and P = 0.002 for sex). The IS site was divided into 7 categories. RESULTS The H&N region was the most common site for the IS (one­third of the study group). In the entire study population, the risk of grade IV SRs was numerically, though insignificantly higher for ISs in the trunk (odds ratio [OR], 1.58; 95% CI, 0.42-5.92; P = 0.50) and legs (OR, 1.56; 95% CI, 0.49-5.10; P = 0.45), as compared with the H&N region. The H&N region showed a similar risk of grade IV SRs when compared with all the other IS sites combined into a single category (OR, 0.87; 95% CI, 0.43-1.75, P = 0.7). CONCLUSIONS ISs in the H&N region were not confirmed to be a risk factor for grade IV SRs in patients with HVA, regardless of age and sex.