蜜蜂和黄蜂毒液过敏治疗中英文对照外文翻译文献Word下载.docx
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蜜蜂和黄蜂毒液过敏治疗中英文对照外文翻译文献Word下载.docx
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2TARTEAM
LiverpoolReviewsandImplementationGroup(LRiG),UniversityofLiverpool
Correspondenceto:
RumonaDickson,Ms
Director,LRiG
UniversityofLiverpool
Room2.12
WhelanBuilding
TheQuadrangle
BrownlowHill
Liverpool
L693GB
FordetailsofexpertisewithintheTARteam,seesection7.
3PLAINENGLISHSUMMARY
Allergicreactionstobeeandwaspvenommayoccurinvenom-sensitivepatientsimmediatelyfollowingasting,andcanvaryinseverity,withinitiallymildsymptomssometimesprogressingtocriticalconditionswithinseconds.Themostseveresystemicallergicreactions(generalisedreactions)areknownasanaphylaxis,areactioncharacterisedbyabnormallylowbloodpressure,faintingorcollapse,andinextremereactionsthesesymptomscancausedeath.
EachyearintheUKtherearebetweentwoandninedeathsfromanaphylaxiscausedbybeeandwaspvenom.Theimmediatetreatmentforsevereallergicreactionstobeeandwaspvenomconsistsofemergencytreatmentwithdrugstodecreasethepatient’sresponsetothevenomandsupportbreathing,ifrequired.
Toavoidfurtherreactions,theuseofsensitisationtobeeandwaspvenom,throughaprocessknownasvenomimmunotherapy(VIT),hasbeeninvestigated.Venomimmunotherapyconsistsofsubcutaneousinjectionsofincreasingamountsofvenomintopatientswithahistoryofanaphylaxistobeeandwaspvenom.Pharmalgen®
hashadUKmarketingauthorisationforthediagnosisandtreatment(usingVIT)ofallergytobeevenom(usingPharmalgen®
BeeVenom)andwaspvenom(usingPharmalgen®
WaspVenom)sinceMarch1995,anditisusedbymorethan40centresacrosstheUK.ThisreviewaimstoassesswhetherusingPharmalgen®
inVITisclinicallyusefulwhentreatingpeoplewithahistoryofseverereactiontobeeandwaspstings.ThereviewwillcomparepreventativetreatmentwithPharmalgen®
toothertreatmentoptions,includinghighdoseantihistamines,adviceontheavoidanceofbeeandwaspstingsandadrenalineauto-injectorprescriptionandtraining.Ifsuitabledataareavailable,thereviewwillalsoconsiderthecosteffectivenessofusingPharmalgen®
forVITandothersubgroupsincludingchildrenandpeopleathighriskoffuturestingsorsevereallergicreactionstofuturestings.
4DECISIONPROBLEM
4.1Clarificationofresearchquestionandscope
Pharmalgen®
isusedforthediagnosisandtreatmentofimmunoglobinE(IgE)-mediatedallergytobeeandwaspvenom.TheaimofthisreportistoassesswhethertheuseofPharmalgen®
isofclinicalvaluewhenprovidingVITtoindividualswithahistoryofseverereactiontobeeandwaspvenomandwhetherdoingsowouldbeconsideredcosteffectivecomparedwithalternativetreatmentoptionsavailableintheNHS.
4.2Background
BeesandwaspsformpartoftheorderHymenoptera(whichalsoincludesants),andwithinthisorderthespeciesthatcausethemostfrequentallergicreactionsaretheVespidae(wasps,yellowjacketsandhornets),andtheApinae(honeybees).1
Beeandwaspstingscontainallergenicproteins.Inwasps,thesearepredominantlyphospholipaseA1,2hyaluronidase2andantigen5,3andinbeesarephospholipaseA2andhyaluronidase.4Followinganinitialsting,atype1hypersensitivityreactionmayoccurinsomeindividualswhichproducestheIgEantibody.Thissensitisescellstotheallergen,andanysubsequentexposuretotheallergenmaycausetheallergentobindtotheIgEmolecules,whichresultsinanallergicreaction.
Theseallergenstypicallyproduceanintense,burningpainfollowedbyerythema(redness)andasmallareaofoedema(swelling)atthesiteofthesting.Thesymptomsproducedfollowingastingcanbeclassifiedintonon-allergicreactions,suchaslocalreactions,andallergicreactions,suchasextensivelocalreactions,anaphylacticsystemicreactionsanddelayedsystemicreactions.5-6Systemicallergicreactionsmayoccurinvenom-sensitivepatientsimmediatelyfollowingasting,7andcanvaryinseverity,withinitiallymildsymptomssometimesprogressingtocriticalconditionswithinseconds.1
Themostseveresystemicallergicreactionisknownasanaphylaxis.Anaphylacticreactionsareofrapidonset(typicallyupto15minutespoststing)andcanmanifestindifferentways.Initialsymptomsareusuallycutaneousfollowedbyhypotension,withlight-headedness,faintingorcollapse.Somepeopledeveloprespiratorysymptomsduetoanasthma-likeresponseorlaryngealoedema.Inseverereactions,hypotension,circulatorydisturbances,andbreathingdifficultycanprogresstofatalcardio-respiratoryarrest.
Anaphylaxisoccursmorecommonlyinmalesandinpeopleunder20yearsofageandcanbesevereandpotentiallyfatal.8
4.3Epidemiology
Itisestimatedthattheprevalenceofwaspandbeestingallergyisbetween0.4%and3.3%.9Theincidenceofsystemicreactionstowaspandbeevenomisnotreliablyknown,butestimatesrangefrom0.15-3.3%,10-11Systemicallergicreactionsarereportedbyupto3%ofadults,andalmost1%ofchildrenhaveamedicalhistoryofseverestingreactions.9,12Afteralargelocalreaction,5–15%ofpeoplewillgoontodevelopasystemicreactionwhennextstung.13Inpeoplewithamildsystemicreaction,theriskofsubsequentsystemicreactionsisthoughttobeabout18%.13HymenopteravenomareoneofthethreemaincausesoffatalanaphylaxisintheUSAandUK.14-15Insectstingsarethesecondmostfrequentcauseofanaphylaxisoutsideofmedicalsettings.16BetweentwoandninepeopleintheUKdieeachyearasaresultofanaphylaxisduetoreactionstowaspandbeestings.17Onceanindividualhasexperiencedananaphylacticreaction,theriskofhavingarecurrentepisodehasbeenestimatedtobebetween60%and79%.13
In2000,theregisteroffatalanaphylacticreactionsintheUKfrom1992onwardswasreportedbyPumphreytodeterminethefrequencyatwhichclassicmanifestationsoffatalanaphylaxisarepresent.18Ofthe56post-mortemscarriedout,19deathswererecordedasreactionstoHymenopteravenom(33.9%).Aretrospectivestudyin2004examinedalldeathsfromanaphylaxisintheUKbetween1992and2001,andestimated22.19%tobereactionstoHymenopteravenom(47/212).Thisfurtherbreaksdowninto29/212(13.68%)asreactionstowaspstings,and4/212(1.89%)asreactionstobeestings.Theremaining14/212wereunidentifiedHymenopterastings(6.62%).19
4.4Currentdiagnosticoptions
Currently,individualscanbetestedtodetermineiftheyareatriskofsystemicreactionstobeeandwaspvenom.Theprimarydiagnosticmethodforsystemicreactionstobeeand/orwaspstingsisvenomskintesting.
SkintestinginvolvesintradermalinjectionwiththefiveHymenopteravenomproteinextracts,withvenomconcentrationsintherangeof0.001to1.0μg/ml.Thisestablishestheminimumconcentrationgivingapositiveresult(areactionoccurringintheindividual).Asvenomtestsshowunexplainedvariabilityovertime,20andasnegativeskintestscanoccurfollowingrecentanaphylaxis,itisrecommendedthattestsberepeatedafter1to6months.21
Othermethodsofdiagnosisinpatientsfollowingananaphylacticreactionincluderadioallergosorbenttest(RAST),whichdetectsallergen-specificIgEantibodiesinserum.Thistestislesssensitivethanskintestingbutisusefulwhenskintestscannotbedone,forexampleinpatientswithskinconditions.22-23
4.5Currenttreatmentoptions
Preventativetreatmentsincludeeducationonhowtoavoidbeeandwaspvenom,andprescriptionofhighdoseantihistamines.Patientswithahistoryofmoderatelocalreactionsshouldbeprovidedwithanemergencykit,24containingaH1-blockingantihistamineandatopicalcorticosteroidforimmediateusefollowingasting.Patientswithahistoryofanaphylaxisshouldbeprovidedwithanemergencykitcontainingarapid-actingH1-blockingantihistamine,anoralcorticosteroidandanauto-injectorforselfadministration,containingepinephrine.
Injectedepinephrine(asympathomimeticdrugwhichactsonbothalphaandbetareceptors)isregardedastheemergencytreatmentofchoiceforcasesofacuteanaphylaxisasaresultofHymenopterastings.25Foradults,therecommendeddoseisbetween0.30mg/mland0.50mg/mlI.M,and0.01ml/kgI.M.forchildren.Individualswithahistoryofanaphylacticreactionsarerecommendedtocarryautoinjectorscontainingepinephrine(commonlyknownasEpiPen®
Adrenaclick®
Anapen®
orTwinject®
).Theseareintendedforimmediateself-administrationbyindividualswithahistoryofhypersensitivitytoHymenopterastingsandotherallergens.
PreventivemeasuresfollowingsuccessfultreatmentofasystemicallergicreactiontoHymenopteravenomconsistsofeitherallergenavoidanceorspecificallergenimmunotherapy,knownasVIT.Venomimmunotherapyisconsideredtobeasafeandeffectivetreatment.26Currently,VITcanbeusedwithseveralregimes,includingPharmalgen®
(manufacturedbyALKAbello,andlicensedintheUK),Aquagen®
andAlutardSQ®
(bothmanufacturedbyALKAbelloandunlicensedintheUKbutlicensedinsomepartsofEurope),VENOMENHAL®
(HALAllergy,Leiden,Netherlands,unlicensedintheUK),Alyostal®
(Stallergenes,AntonyCedex,France,unlicensedintheUK),andVenomil®
(Hollister-StierLaboratoriesLLC,unlicensedintheUK).Venomimmunotherapyisrecommendedtopreventfuturesystemicreactions.ItisrecommendedthatVITisconsidered‘whenpositivetestresultsforspecificIgEantibodiescorrelatewi
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