Efficacy of venom immunotherapy given every 3 or 4 months: a prospective comparison with the conventional regimen.

BACKGROUND: Standard venom immunotherapy involves the administration of the maintenance dose every 4 to 6 weeks. This regimen may have adherence problems, especially in the long term; thus, extended intervals have been proposed. OBJECTIVE: We prospectively compared the efficacy of 3- or 4-month extended maintenance dose vs the conventional regimen. METHODS: Patients receiving immunotherapy with a single venom were offered the extended maintenance dose (EMD) and were then followed up for field re-stings. Only the re-stings by the insect for which the patients received immunotherapy were considered. A comparable group of patients receiving the conventional maintenance dose (CMD) was used for comparison by logistic regression analysis. RESULTS: Seventy-six patients (60 male; mean age, 48 years) receiving the EMD were re-stung on 247 occasions by the insect for which they were receiving immunotherapy. The group receiving CMD included 110 patients (82 male; mean age, 44 years) certainly re-stung on 167 occasions by the specific insect. The percentage of re-sting without reaction was 93.5% in the EMD group and 81.5% in the CMD group, with a significant difference in favor of the former (P=.001). At logistic regression analysis, only age, but not maintenance dose protocol, was predictive of subsequent systemic reactions. CONCLUSION: The EMD is as effective and safe as the CMD. An increased maintenance seems to be the best option in term of convenience and economic savings.

Safety of uSCIT-MPL-4: prevalence and risk factors of systemic reactions in real life.

Aim: We assessed the safety of allergoid adjuvanted by monophosphoryl lipid A (uSCIT-MPL-4) in a real-life setting. Materials & methods: Patients treated with uSCIT-MPL-4 were followed-up for 1 year. Systemic reactions (SRs) were registered and the association with potential risk factors was evaluated. Results: 2929 patients were included. Grade 0, 1, 2, 3 and 4 SR reactions were observed respectively in 3.3, 1.5, 0.31, 0.07 and 0.07% of patients. A significant association was detected between Grade ≥1 SRs and: female gender, number of administrations, previous local reactions. Conclusion: uSCIT-MPL-4 is safe. Local reactions should be accurately assessed as they may represent a risk factor for Grade ≥1 SRs, together with gender and number of doses/year.

Trends and determinants of Emergency Room admissions for asthma: A retrospective evaluation in Northeast Italy.

BACKGROUND: Asthma still represents a cause of death and hospital admissions worldwide. Our study aimed at analyzing the trend of Emergency Room (ER) asthma admissions in Northeast Italy in order to investigate the relevance of specific patient-related determinants and environmental triggers (pollens, mold spores, and pollutants). METHODS: Retrospective data from admissions for asthma exacerbations registered between the years 2013 and 2015 in two main ERs in Northeast Italy were collected. Data about patients' age, sex and nationality were recorded. Classification of disease severity followed the current Italian ER triage scoring system (white: no need for emergency treatment; green: need for fast treatment; yellow: severe condition; red: life-threatening condition). Data on pollen/mold spore counts and pollutants were analyzed. RESULTS: Overall, 1745 â€‹ER admissions for asthma were registered, with a persistent and significant increase year by year. A slight prevalence of females and patients over 50 years old was observed. Immigrants accounted for 32%, 36% and 26% of admissions respectively in 2013, 2014 and 2015. The prevalence of immigrants' admissions was significantly higher when comparing the relative ratio of immigrant populations/Italian nationals (p â€‹< â€‹0.05). The admissions were coded as follows: white, 6.30%; green, 35.36%; yellow, 39.37%; red, 18.97%. People aged ≥50 years were more frequently admitted with a red code, but the trend was not statistically significant (p â€‹= â€‹0,0815). By contrast, amongst immigrants there was a higher prevalence of white and green codes observed in comparison with Italian nationals. Grass pollen peak and PM10 high levels represented environmental determinants of ER admissions increase. CONCLUSIONS: The increasing rate of asthma-related ER admissions highlights the need for implementing asthma control strategies. Investigating the traits of patients referring to ER for asthma exacerbations, as well as environmental-related determinants, may help in identifying at-risk individuals and in orienting preventive strategies accordingly. Immigrants represent the most vulnerable sub-population, and their potential difficulties in accessing treatments and health services should be specifically addressed. Overall, implementing patient education in order to improve treatment adherence, as well as providing an asthma action plan to every asthmatic patient, continue to be the most urgent needs.

Chronic Urticaria Patient Perspective (CUPP): The First Validated Tool for Assessing Quality of Life in Clinical Practice.

BACKGROUND: There is a need for validated tools to assess health-related quality of life (HRQoL) in routine clinical practice. OBJECTIVE: The aim of this study was to validate the Chronic Urticaria Patient Perspective (CUPP) for assessment of patients with chronic urticaria (CU) in clinical practice. METHODS: A provisional CUPP was developed from candidate items identified by following an iterative process in a retrospective analysis of 249 Chronic Urticaria Quality of Life Questionnaire questionnaires. The psychometric properties of the CUPP were then tested on a sample of patients enrolled in 13 Italian centers. RESULTS: The study population in the validation phase comprised 152 patients. The 10-item version of the CUPP showed satisfactory internal consistency (Cronbach's alpha values of 0.76 at visit 1 and 0.90 at visit 2), good criteria, and discriminative and convergent validity. Reliability was assessed in 34 patients with no changes in health (Global Rating Scale = 0 at visit 2) and was satisfactory (CCC [concordance correlation coefficient] = 0.9). Changes in CUPP scores were significantly associated with changes in Urticaria Activity Score (UAS)-Hive count (r = 0.36, P < .001), UAS-Itch severity (r = 0.48, P < .001), and UAS-Total score (r = 0.342, P < .001), all of which indicated good responsiveness. The minimal important difference was 1.5. CONCLUSIONS: CUPP is a simple 10-question tool with good psychometric properties that provides a valid, reliable, and standardized measurement of HRQoL in patients with CU.

Fatal asthma; is it still an epidemic?

BACKGROUND: Asthma mortality has declined since the 1980s. Nevertheless the World Health Organization (WHO) identified asthma as responsible for 225.000 deaths worldwide in 2005, and 430.000 fatal cases are expected by 2030. Some unexpected and concentrated fatal asthma events all occurred between 2013 and 2015 in Veneto, a North Eastern region of Italy, which prompted a more in-depth investigation of characteristics and risk factors. METHODS: A web search including key words related to fatal asthma in Italy between 2013 and 2015 has been performed. Concerning the cases that occurred in Veneto, subjects' clinical records have been evaluated and details about concomitant weather conditions, pollutants and pollen count have been collected. RESULTS: Twenty-three cases of asthma deaths were found in Italy; 16 of them (69%) occurred in the Veneto Region. A prevalence of male and young age was observed. Most of patients were atopic, died in the night-time hours and during the weekends. The possible risk factors identified were the sensitization to alternaria, previous near fatal asthma attacks and the incorrect treatment of the disease. Weather condition did not appear to be related to the fatal exacerbations, whereas among the pollutants only ozone was detected over the accepted limits. Smoking habits, possible drug abuse and concomitant complementary therapies might be regarded as further risk factors. DISCUSSION: Although not free from potential biases, our web search and further investigations highlight an increasing asthma mortality trend, similarly to what other observatories report. The analysis of available clinical data suggests that the lack of treatment more than a severe asthma phenotype characterizes the fatal events. CONCLUSIONS: Asthma mortality still represents a critical issue in the management of the disease, particularly in youngsters. Once more the inadequate treatment and the lack of adherence seem to be not only related to the uncontrolled asthma but also to asthma mortality.

Are physicians aware of the side effects of angiotensin-converting enzyme inhibitors?: a questionnaire survey in different medical categories.

STUDY OBJECTIVE: Angiotensin-converting enzyme inhibitors (ACE-I) are considered safe, but they are associated with characteristic side effects, namely cough and angioedema, usually requiring discontinuation. We perceived that referrals for these side effects have become more and more frequent; therefore, we evaluated the degree of knowledge on the safety of ACE-I in different medical categories. DESIGN: A questionnaire (13 questions) on side effects of ACE-I was posted to physicians. SETTING: Everyday clinical practice. PARTICIPANTS: Cardiologists, allergists, and general practitioners (GPs) from the National Healthcare System. MEASUREMENT AND RESULTS: Three hundred twelve physicians were contacted, and 154 returned questionnaires that could be analyzed. Of the 154 physicians (mean age, 45 years) 48 were cardiologists, 52 were GPs, and 54 were allergists. The percentage of correct answers was low: 31.9% for cardiologists, 40% for GPs, and 33% for allergists. Thus, GPs provided a significantly higher percentage of correct answers with respect to the remaining categories (p = 0.05). The lower rate of correct answers (0 to 15.9%) concerned the time of onset of cough and the action to take. Cardiologists seemed to be less aware of the fact that angiotensin receptor blockers (sartans) can cross-react with ACE-I. CONCLUSION: Overall, there was a poor knowledge of the side effects of ACE-I. This may account for the increased referrals for chronic cough and angioedema.

How far from correct is the use of adrenaline auto-injectors? A survey in Italian patients.

Self-administered adrenaline through an auto-injector is the main out-of-hospital treatment for anaphylaxis, and patients should be trained to promptly and correctly use the device. The aim of the study was to verify the proper use of the device and the correct drug administration, and to identify possible misuse by patients. In seven Italian Allergy clinics, patients who were previously provided with self-injectable adrenaline were recruited at the follow-up visit required for the renewal of their prescription. All patients completed a questionnaire covering details of their allergic reactions, and knowledge of the device. The correct use was verified by the physician using a trainer with a four-step examination. 242 patients were included; 46 patients (18 %) did not always carry the auto-injector, and 35 patients (14 %) reported situations in which they were doubtful about whether to use adrenaline. Only 39 % of patients properly managed the device, while some patients (6 %) failed in all four steps. The majority of patients considered it appropriate to use adrenaline at the onset of respiratory symptoms (56 %). The factor most closely related to proper use of the device was the education of the patient (p = 0.03), while age and the time from first prescription did not affect the ability to properly use the auto-injector. Even though accurate training is conducted, many patients are still unable to properly use the adrenaline auto-injector in case of anaphylaxis. Allergists should review the instructions provided to the patients every time a renewal of the auto-injector is prescribed.

Anaphylaxis due to patent blue dye during lymphography, with negative skin prick test.

We report here a case of anaphylaxis due to patent blue dye, which was administered to an adult female during a lymphographic intraoperative procedure. The patient was not atopic, and other possible causes of anaphylaxis (anesthetics, latex) had been carefully excluded through routine tests. The skin-prick test and patch test carried out with patent blue (PB) dye were negative, but the intradermal test with 100 microliters of the dye showed a remarkable positivity. There was no available commercial, specific IgE assay for PB dye, but the negativity of prick tests would exclude the involvement of an IgE-mediated mechanism. We want to highlight the possible danger derived from a dye that is considered inert, and that is now increasingly being used in surgical procedures.

Nimesulide and meloxicam are a safe alternative drugs for patients intolerant to nonsteroidal anti-inflammatory drugs.

BACKGROUND: Pseudoallergic reactions to ASA and NSAIDs in general are frequent and difficult to manage. The challenge with the suspected drug is considered unethical, therefore the only possible approach is a challenge with alternative drugs. Selective COX2 inhibitors are considered the most suitable alternative drugs. We describe the comparative results and follow-up of an oral challenge with nimesulide and meloxicam, in NSAIDs intolerant patients. METHODS: 381 patients (118 male, 263 female, mean age 53.2 years) with a well documented pseudoallergic reaction to NSAIDs underwent an oral challenge with these alternative drugs. All 381 patients were given nimesulide 88 of them were also given meloxicam. All patients were re-interviewed at six-month intervals up to two years after challenge. RESULTS: 98.4% of the patients tolerated nimesulide and 95.4% tolerated meloxicam. The reactions occurred during challenges were mild and easily manageable. Three out of the six nimesulide-intolerant patients could tolerate meloxicam, whereas only one of the four meloxicam-intolerant patients could tolerate nimesulide. At the follow-up, 96% of patients with previous negative challenge could tolerate nimesulide and within the patients which took meloxicam after challenge no pseudoallergic reaction occurred. CONCLUSIONS: The herein described challenge with alternative drugs, meloxicam and nimesulide, is a safe tool for the management of NSAIDs-intolerant patients. The two tested drug are safe and reliable alternatives for these patients.

Anaphylaxis as occupational risk.

PURPOSE OF REVIEW: Anaphylaxis is a severe form of allergic reaction that may cause death. Main triggers of anaphylaxis have been reported to also cause occupational anaphylaxis (OcAn). The purpose of this article was to summarize the current scientific evidence on OcAn and review the specific literature published in 2012 and 2013. RECENT FINDINGS: Allergens derived from Hymenoptera and natural rubber latex are the most frequently reported triggers of OcAn, but other high and low-molecular weight agents have been described. Among the latter, foods, insects, snakes, chemicals, and medications have been described in the last 2 years. Furthermore, reviews on the clinical significance of immunological contact urticaria as a risk factor for systemic allergic reaction and on Hymenoptera venom immunotherapy have been published. SUMMARY: OcAn is a serious event, and several agents and occupations have been identified as responsible. In any occupational setting, where there is a worker with a history of previous anaphylactic reactions, and in occupations at greater risk, a written emergency management plan of anaphylaxis episodes, along with the availability of adrenaline and trained personnel, are mandatory. Venom immunotherapy should be considered for patients with Hymenoptera venom allergy.