Hymenoptera Venom Immunotherapy Meets Factitious Disorder.

Factitious disorder on self is a psychiatric disorder in which individuals fabricate or induce signs or symptoms of a disease. Factitious anaphylaxis, with symptoms suggestive of a life-threatening allergic reaction, is extremely rare. Several cases of factitious disorder reactions during allergen immunotherapy for airborne allergens have been reported. We report the case of a young female patient who presented factitious anaphylaxis during venom immunotherapy to vespid venom extract. Symptoms of stridor, dyspnea, coughing and loss of consciousness were observed during the built-up phase of venom immunotherapy, mimicking allergic reactions to the venom extracts. Diagnosis of factitious disorder prompted the discontinuation of venom immunotherapy.

Improved childhood asthma control after exposure reduction interventions for desert dust and anthropogenic air pollution: the MEDEA randomised controlled trial.

INTRODUCTION: Elevated particulate matter (PM) concentrations of anthropogenic and/or desert dust origin are associated with increased morbidity among children with asthma. OBJECTIVE: The Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches randomised controlled trial assessed the impact of exposure reduction recommendations, including indoor air filtration, on childhood asthma control during high desert dust storms (DDS) season in Cyprus and Greece. DESIGN, PARTICIPANTS, INTERVENTIONS AND SETTING: Primary school children with asthma were randomised into three parallel groups: (a) no intervention (controls); (b) outdoor intervention (early alerts notifications, recommendations to stay indoors and limit outdoor physical activity during DDS) and (c) combined intervention (same as (b) combined with indoor air purification with high efficiency particulate air filters in children's homes and school classrooms. Asthma symptom control was assessed using the childhood Asthma Control Test (c-ACT), spirometry (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)) and fractional exhaled nitric oxide (FeNO). RESULTS: In total, 182 children with asthma (age; mean=9.5, SD=1.63) were evaluated during 2019 and 2021. After three follow-up months, the combined intervention group demonstrated a significant improvement in c-ACT in comparison to controls (ß=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (ß=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (ß=4.26, 95% CI 0.54 to 7.99, p=0.025), the need for any asthma medication and unscheduled clinician visits, but not FVC% and FeNO, were significantly improved in the combined intervention compared with controls. CONCLUSION: Recommendations to reduce exposure and use of indoor air filtration in areas with high PM pollution may improve symptom control and lung function in children with asthma. TRIAL REGISTRATION NUMBER: NCT03503812.

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study.

BACKGROUND: Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition. METHODS: The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression. RESULTS: A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25). CONCLUSIONS: The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Allergy-Test-Based Elimination Diets for the Treatment of Eosinophilic Esophagitis: A Systematic Review of Their Efficacy.

Eosinophilic esophagitis (EoE) is an immune-mediated esophageal disorder, linked with sensitization to food and airborne allergens. Dietary manipulations are proposed for the management of EoE inflammation and are often successful, confirming the etiological role of food allergens. Three different dietary approaches are widely used: the elemental, the empirical, and the allergy-test-driven approach. We performed a systematic review to assess the evidence on the association of allergens, detected by allergy tests, with clinically confirmed triggers of EoE. We systematically searched PubMed, Scopus, Embase, and the Cochrane Library, through 1 June 2021. We sought studies examining the correlation of skin-prick tests (SPT), atopy patch tests (APT), specific IgE, and serum-specific IgG4, with confirmed triggers of EoE. Data on the use of prick-prick tests were also extracted. Evidence was independently screened by two authors against predefined eligibility criteria. Risk of bias was assessed with the ROBINS-I tool. Of 52 potentially eligible studies, 16 studies fulfilling quality criteria were included. These studies used one to three different allergy tests detecting food sensitization. The positive predictive value was generally low to moderate but higher when a combination of tests was used than single-test evaluations. None of the selected studies used serum-specific IgG4. Although an extreme methodological variability was noticed in the studies, allergy-based elimination diets were estimated to be efficient in 66.7% of the cases. The efficacy of targeted elimination diets, guided by SPT, sIgE, and/or APT allergy tests, does not appear superior to empirical ones. In the future, tests using esophageal prick testing or ex vivo food antigen stimulation may prove more efficient to guide elimination diets.

Pityriasis Rosea Induced by COVID-19 Vaccination.

It is increasingly recognized that SARS-CoV-2 infection and COVID-19 vaccines have been associated with skin disorders, including pityriasis rosea. It has been reported that pityriasis rosea has been triggered by several vaccines, as a rare side-effect. We present two cases of COVID-19 vaccine-induced pityriasis rosea. Skin lesions appeared in a 49-year-old female 8 days after the first dose of the BNT162b2 mRNA vaccine and in a 53-year-old male 7 days after the second dose of the same vaccine. The exanthem was self-limited in both patients over a period of a month. LEARNING POINTS: Physicians should be aware that pityriasis rosea is a rare side-effect of COVID-19 vaccination.Pityriasis rosea is self-limiting and no medical treatment is usually required.

Workup and Clinical Assessment for Allergen Immunotherapy Candidates.

Allergen Immunotherapy (AIT) is a well-established, efficient, and safe way to treat respiratory and insect-venom allergies. After determining the diagnosis of the clinically relevant culprit allergen, AIT can be prescribed. However, not all patients are eligible for AIT, since some diseases/conditions represent contraindications to AIT use, as described in several guidelines. Allergists are often preoccupied on whether an extensive workup should be ordered in apparently healthy AIT candidates in order to detect contra-indicated diseases and conditions. These preoccupations often arise from clinical, ethical and legal issues. The aim of this article is to suggest an approach to the workup and assessment of the presence of any underlying diseases/conditions in patients with no case history before the start of AIT. Notably, there is a lack of published studies on the appropriate evaluation of AIT candidates, with no globally accepted guidelines. It appears that Allergists are mostly deciding based on their AIT training, as well as their clinical experience. Guidance is based mainly on experts' opinions; the suggested preliminary workup can be divided into mandatory and optional testing. The evaluation for possible underlying neoplastic, autoimmune, and cardiovascular diseases, primary and acquired immunodeficiencies and pregnancy, might be helpful but only in subjects for whom the history and clinical examination raise suspicion of these conditions. A workup without any reasonable correlation with potential contraindications is useless. In conclusion, the evaluation of each individual candidate for possible medical conditions should be determined on a case-by-case basis.

Allergen Immunotherapy: New Insights into an Old Treatment.

The continuous advancement of biomedical sciences has offered an extreme boost in improving the diagnosis and therapy of allergic diseases [...].

A multi-disciplinary approach to the diagnosis and management of allergic diseases: An EAACI Task Force.

BACKGROUND: Guidelines for management of patients with allergic conditions are available, but the added value of nurses, allied healthcare professionals (AHPs), and general practitioners (GPs), in the management of allergic disease, has not been fully clarified. The European Academy of Allergy and Clinical Immunology (EAACI) appointed a task force to explore this issue. AIM: To investigate the added value of nurses, AHPs, and GPs in management of allergic diseases, in an integrated model of care. METHODS: A search was made of peer-reviewed literature published between 2010 and December 2020 (Cochrane Library, PubMed, and CINAHL) on the involvement of the various specific healthcare providers (HCPs) in the management of allergic diseases. RESULTS: Facilitative models of care for patients with allergies can be achieved if HCP collaborates in the diagnosis and management. Working in multi-disciplinary teams (MDT) can increase patients' understanding of the disease, adherence to treatment, self-care capabilities, and ultimately improve quality of life. The MDT competencies and procedures can be improved and enhanced in a climate of mutual respect and shared values, and with inclusion of patients in the planning of care. Patient-centered communication among HCPs and emphasis on the added value of each profession can create an effective integrated model of care for patients with allergic diseases. CONCLUSION: Nurses, AHPs, and GPs, both individually and in collaboration, can contribute to the improvement of the management of patients with allergic disease. The interaction between the HCPs and the patients themselves can ensure maximum support for people with allergies.

Alliance with the School Personnel Is Crucial for the Management of Food Allergy and Anaphylaxis in School Children.

BACKGROUND: School nurses play an important role in coping with food allergy (FA) in schoolchildren, but in schools with no school nurse, the school personnel should be prepared to manage health emergencies. This study aimed to evaluate allergy management competences in primary schools in Cyprus. METHODS: The study was conducted September 2016 to May 2017 in 11/13 primary schools, selected by stratified random sampling. Information was collected from a principal/designated teacher using a questionnaire from the EuroPrevall Project, adapted for Cypriot teachers. RESULTS: An average of six children with FA per school was reported in the preceding three years. Protocols for the management of chronic diseases, including allergies, were in place in 8/11 schools. Regarding recognition of FA, 8/11 respondents knew some of the signs and symptoms. In an allergic emergency, 9/11 would call the child's parent/caregiver first and 2/11 emergency medical support. Epinephrine auto-injector (EIA) was reported by 2/11 respondents to be available in the school, but only one reported training in its use. CONCLUSIONS: The preparedness of primary schools in Cyprus did not meet safety standards regarding the preparedness of school personnel to cope with an allergic reaction in children with FA, including the use of EIA.

Early life triggers for food allergy that in turn impacts dietary habits in childhood.

INTRODUCTION AND OBJECTIVES: In order to investigate food allergy's prevalence, risk factors and eating behavior of children with relevant anamnesis, a study was performed in Cypriot primary schools. PATIENTS: A specially composed questionnaire for self-reported adverse reactions to food, created in the context of the EuroPrevall study, was distributed in 13 representative primary schools across the country. Participants were sub-grouped into three groups; healthy (H), those with unconfirmed food hypersensitivity reactions (FA-) and children with a confirmed diagnosis by a physician IgE-mediated food allergy (FA+). Food habits, family health history and lifestyle factors were assessed and groups' outcomes were compared with each other. RESULTS: For the study, 202 questionnaires were completed and returned; 31 children (19 FA- and 12 FA+) reported an adverse food reaction. Significant risk factors for developing FA+ were being the first born or having siblings with asthma, attended a day nursery, but also maternal alcohol drinking during pregnancy, parental smoking and parental occupation in food processing or use of latex gloves. The presence of children in the kitchen during cooking showed a protective role. Dietary habits of FA+ children were significantly diminished in terms of variety and frequency of consumption in comparison to the rest, in which had a greater overlap. CONCLUSION: Further research is required for the interesting risk or protective factors revealing from the current investigation. The negative effect of food allergy in the dietary habits of food allergic children documented in the literature, is strongly supported herein.

Early life triggers for food allergy that in turn impacts dietary habits in childhood

Introduction and objectives: In order to investigate food allergy’s prevalence, risk factors and eating behavior of children with relevant anamnesis, a study was performed in Cypriot primary schools. Patients: A specially composed questionnaire for self-reported adverse reactions to food, created in the context of the EuroPrevall study, was distributed in 13 representative primary schools across the country. Participants were sub-grouped into three groups; healthy (H), those with unconfirmed food hypersensitivity reactions (FA-) and children with a confirmed diagnosis by a physician IgE-mediated food allergy (FA+). Food habits, family health history and lifestyle factors were assessed and groups’ outcomes were compared with each other. Results: For the study, 202 questionnaires were completed and returned; 31 children (19 FA- and 12 FA+) reported an adverse food reaction. Significant risk factors for developing FA+ were being the first born or having siblings with asthma, attended a day nursery, but also maternal alcohol drinking during pregnancy, parental smoking and parental occupation in food processing or use of latex gloves. The presence of children in the kitchen during cooking showed a protective role. Dietary habits of FA+ children were significantly diminished in terms of variety and frequency of consumption in comparison to the rest, in which had a greater overlap. Conclusion: Further research is required for the interesting risk or protective factors revealing from the current investigation. The negative effect of food allergy in the dietary habits of food allergic children documented in the literature, is strongly supported herein (AU)

Allergen Immunotherapy: Biomarkers and Clinical Outcome Measures.

Clinical trials for allergen immunotherapy products' development and approval are conducted, aiming to monitor safety and efficacy of them. Symptom scores and the use of rescue medication are the primary clinical endpoints used in the conducted clinical trials, while Quality of Life scores and symptom-free days are measurements also used as secondary endpoints. Although the use of in vitro biomarkers might have been more practical and objective, there are yet no broadly used reliable ones accurately reflecting the clinical effects of allergen immunotherapy. On the contrary, in vivo biomarkers, such as the nasal allergy provocation test, are reliable and successfully used. The aim of this review is to describe how to adapt and use biomarkers and clinical outcomes in the everyday practice of Allergists who perform allergen immunotherapy.

The role of mobile health technologies in allergy care: An EAACI position paper.

Mobile health (mHealth) uses mobile communication devices such as smartphones and tablet computers to support and improve health-related services, data and information flow, patient self-management, surveillance, and disease management from the moment of first diagnosis to an optimized treatment. The European Academy of Allergy and Clinical Immunology created a task force to assess the state of the art and future potential of mHealth in allergology. The task force endorsed the "Be He@lthy, Be Mobile" WHO initiative and debated the quality, usability, efficiency, advantages, limitations, and risks of mobile solutions for allergic diseases. The results are summarized in this position paper, analyzing also the regulatory background with regard to the "General Data Protection Regulation" and Medical Directives of the European Community. The task force assessed the design, user engagement, content, potential of inducing behavioral change, credibility/accountability, and privacy policies of mHealth products. The perspectives of healthcare professionals and allergic patients are discussed, underlining the need of thorough investigation for an effective design of mHealth technologies as auxiliary tools to improve quality of care. Within the context of precision medicine, these could facilitate the change in perspective from clinician- to patient-centered care. The current and future potential of mHealth is then examined for specific areas of allergology, including allergic rhinitis, aerobiology, allergen immunotherapy, asthma, dermatological diseases, food allergies, anaphylaxis, insect venom, and drug allergy. The impact of mobile technologies and associated big data sets are outlined. Facts and recommendations for future mHealth initiatives within EAACI are listed.

Ways to increase adherence to allergen immunotherapy.

Adherence to allergen immunotherapy (AIT) is crucial for its efficacy. Subcutaneous AIT requires monthly visits (or more extended in the case of venom immunotherapy), while sublingual AIT is performed with a daily intake of allergen drops. Non-adherence to an AIT schedule and premature discontinuation are common problems. Various studies have shown controversial results on the rate of AIT adherence. The aim of this review is to describe the problem of non-adherence and to offer some evidence-based advice to allergologists on how to increase it. Better patient education at the beginning of treatment, sharing with patients the decision on which type of immunotherapy to select and showing sincere interest in their treatment concerns are some tips that can help to increase adherence. A well organized allergologist time schedule not only increases safety but also offers the possibility of close follow-up and an increase in patient loyalty.

Safety and Efficacy of a Progressively Prolonged Maintenance Interval of Venom Immunotherapy.

BACKGROUND: The long-term protection provided by venom immunotherapy (VIT) is related to the dose administered and to its long duration; the latter, however, becomes inconvenient for patients in countries like Greece, with many islanders or inhabitants of distant mountainous areas. Maintenance interval prolongation reduces the number of office visits - saving time and money - and as a consequence contributes to the patients' compliance. The aim of this prospective study was to evaluate the safety and efficacy of VIT on a progressively prolonged maintenance interval (PPMI). METHOD: 450 venom-allergic patients were reviewed for participation in our study; all of them were initially treated with a modified rush or an ultrarush protocol using freshly reconstituted, pure venoms. Upon reaching the maintenance dose, the VIT interval was scheduled to be gradually prolonged - by 1 week each time - aiming at a maximal interval of 26 weeks. RESULTS: 267/450 patients consented to participate in our VIT PPMI protocol: 98 were treated with vespid(s) venom, 142 with honeybee venom, and 27 with both. The mean duration of patient follow-up was 9.1 ± 4.2 years. The majority of systemic reactions due to VIT injections occurred up to the 8-weeks PPMI; few additional reactions were documented in a small fraction (2.9%) of our patient population beyond 9 weeks and up to 16 weeks; all were caused by honeybee VIT. No reactions were observed during VIT administration at the 26-week interval. Ninety-six patients reported 204 field sting occurrences by the culprit insect. Ten systemic reactions (8 mild and 2 moderate in severity) were registered between the 9- and 18-week PPMI; the honeybee was the culprit insect in all cases. 108 field stings by the offending insect were sustained beyond the 20- and up to the 26-week PPMI; there were no reactions at all. CONCLUSIONS: Progressively prolonging the VIT maintenance interval up to 26 weeks appears to be safe and efficacious.

Erratum to: Allergen immunotherapy for allergic rhinoconjunctivitis: protocol for a systematic review.

[This corrects the article DOI: 10.1186/s13601-016-0099-6.].

Erratum to: Allergen immunotherapy for insect venom allergy: protocol for a systematic review.

[This corrects the article DOI: 10.1186/s13601-016-0095-x.].

Allergen immunotherapy for allergic rhinoconjunctivitis: a systematic overview of systematic reviews.

BACKGROUND: The European Academy of Allergy and Clinical Immunology (EAACI) is developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis (ARC). To inform the development of recommendations, we sought to critically assess the systematic review evidence on the effectiveness, safety and cost-effectiveness of AIT for ARC. METHODS: We undertook a systematic overview, which involved searching nine international biomedical databases from inception to October 31, 2015. Studies were independently screened by two reviewers against pre-defined eligibility criteria and critically appraised using the Critical Appraisal Skills Programme (CASP) Systematic Review Checklist for systematic reviews. Data were descriptively synthesized. RESULTS: Our searches yielded a total of 5932 potentially eligible studies, from which 17 systematic reviews met our inclusion criteria. Eight of these were judged to be of high, five moderate and three low quality. These reviews suggested that, in carefully selected patients, subcutaneous (SCIT) and sublingual (SLIT) immunotherapy resulted in significant reductions in symptom scores and medication requirements. Serious adverse outcomes were rare for both SCIT and SLIT. Two systematic reviews reported some evidence of potential cost savings associated with use of SCIT and SLIT. CONCLUSIONS: We found moderate-to-strong evidence that SCIT and SLIT can, in appropriately selected patients, reduce symptoms and medication requirements in patients with ARC with reassuring safety data. This evidence does however need to be interpreted with caution, particularly given the heterogeneity in the populations, allergens and protocols studied. There is a lack of data on the relative effectiveness, cost-effectiveness and safety of SCIT and SLIT. We are now systematically reviewing all the primary studies, including recent evidence that has not been incorporated into the published systematic reviews.

Physicians' experience and opinion on contraindications to allergen immunotherapy: The CONSIT survey.

BACKGROUND: Allergen immunotherapy (AIT) is the only disease-modifying treatment in allergy but several contraindications limit its use. OBJECTIVE: To collect the outcome of using AIT in theoretically contraindicated situations in real patients in the Contraindications to Specific ImmunoTherapy (CONSIT) survey. METHODS: The CONSIT is an electronic European Academy of Allergy and Clinical Immunology survey conducted to gather the safety outcomes of patients undergoing subcutaneous, sublingual, or venom AIT and the opinions of physicians on each of 17 selected conditions: children younger than 5 years; starting AIT during pregnancy; controlled severe asthma; arrhythmias; coronary disease; cancer; autoimmune disease; bone marrow and solid organ transplantation; human immunodeficiency virus and acquired immunodeficiency syndrome; previous anaphylaxis during AIT; use of ß-blockers, angiotensin-converting inhibitors, cyclosporine, and methotrexate; and inability to communicate. Safety using AIT was reported in a 3-point scale: 1, "no problems"; 2, "minor problems" (requiring only dose modifications); and 3, "major problems" (AIT not tolerated). Each physician was asked about the degree of contraindication that each condition should have: no contraindication (score 1), relative contraindication (score 2), or absolute contraindication (score 3). RESULTS: Five hundred twenty physicians (75% Europeans, 89% allergists) reported on approximately 45,000 patients undergoing AIT with any of these conditions. Major problems were infrequent, occurring more frequently in patients with asthma (9.9%) and with previous anaphylaxis from AIT (9.5%). Regarding opinions, experienced physicians scored a significantly lower mean for all conditions than non-experienced physicians for all routes. CONCLUSION: Major problems were infrequent and experienced physicians were less likely to be restrictive in the use of AIT.