Use of a composite symptom score during challenge in patients with suspected aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin-exacerbated respiratory disease is characterized by asthma, chronic rhinosinusitis, nasal polyposis, and sensitivity to aspirin and other nonsteroidal anti-inflammatory drugs. Confirmation of the diagnosis requires provocation challenge with resulting upper and/or lower airways reactivity. Currently, determination of a positive challenge result is based solely on clinical judgment that synthesizes subjective symptoms and objective measures, as a concomitant increase in nasal or bronchial airways resistance is measured in only half of patients. OBJECTIVE: To describe a quantitative scoring system, based on symptoms typically reported during provocation challenge, used to identify a positive challenge result. METHODS: A total of 115 patients were asked to record 10 symptoms, rated on a scale from 1 (mild) to 10 (most severe), at regular intervals during intranasal ketorolac with modified oral aspirin challenge performed in our office. Composite scores, a simple sum of all individual scores, were calculated at each time point and compared with baseline, prechallenge values. RESULTS: One hundred of the 115 patients were determined to have a positive challenge result. A statistically significant difference in composite scores was observed in reactors vs nonreactors. All nonreactors recorded an increase in composite score of less than 5, whereas 69% of reactors recorded an increase of 5 or more. CONCLUSION: Our 10-symptom composite score provides a quantitative and comparable measure of symptoms that typically present during a challenge with a positive result. Although an external validation is needed to confirm its diagnostic performance characteristics, a change in composite score of 5 or more appears to be specific to reactors.

A 30-year-old woman with chronic hives, intermittent fevers, and joint pain.

Chronic urticaria with concomitant systemic symptoms may be seen in several rheumatologic and autoinflammatory conditions. Although most of these conditions tend to improve with corticosteroids, symptoms often recur with dose tapering. The appearance of the rash in addition to the symptom pattern and laboratory data must be considered to differentiate potential causes. We presented a unique case of chronic urticaria with fevers and arthralgias. A diagnosis was made, and the patient had rapid improvement with targeted therapy.

Rapid Aspirin Challenge in Patients with Aspirin Allergy and Acute Coronary Syndromes.

Aspirin allergy in a patient with acute coronary syndrome represents one of the more urgent challenges an allergist may face. Adverse reactions to aspirin are reported in 1.5% of patients with coronary artery disease. A history of adverse reaction to aspirin often leads to unnecessary withholding of this medication or use of alternative antiplatelet therapy which may be inferior or more costly. Aspirin therapy has been shown to reduce morbidity and mortality in patients with coronary artery disease. Rapid aspirin challenge/desensitization in the aspirin allergic patient has been consistently shown to be both safe and successful in patients with acute coronary syndromes.

Transgenic insertion of the cyanobacterial membrane protein ictB increases grain yield in Zea mays through increased photosynthesis and carbohydrate production.

The C4 crop maize (Zea mays) is the most widely grown cereal crop worldwide and is an essential feedstock for food and bioenergy. Improving maize yield is important to achieve food security and agricultural sustainability in the 21st century. One potential means to improve crop productivity is to enhance photosynthesis. ictB, a membrane protein that is highly conserved across cyanobacteria, has been shown to improve photosynthesis, and often biomass, when introduced into diverse C3 plant species. Here, ictB from Synechococcus sp. strain PCC 7942 was inserted into maize using Agrobacterium-mediated transformation. In three controlled-environment experiments, ictB insertion increased leaf starch and sucrose content by up to 25% relative to controls. Experimental field trials in four growing seasons, spanning the Midwestern United States (Summers 2018 & 2019) and Argentina (Winter 2018 & 2019), showed an average of 3.49% grain yield improvement, by as much as 5.4% in a given season and up to 9.4% at certain trial locations. A subset of field trial locations was used to test for modification of ear traits and ФPSII, a proxy for photosynthesis. Results suggested that yield gain in transgenics could be associated with increased ФPSII, and the production of longer, thinner ears with more kernels. ictB localized primarily to the microsome fraction of leaf bundle-sheath cells, but not to chloroplasts. Extramembrane domains of ictB interacted in vitro with proteins involved in photosynthesis and carbohydrate metabolism. To our knowledge, this is the first published evidence of ictB insertion into a species using C4 photosynthesis and the largest-scale demonstration of grain yield enhancement from ictB insertion in planta. Results show that ictB is a valuable yield gene in the economically important crop maize, and are an important proof of concept that transgenic manipulation of photosynthesis can be used to create economically viable crop improvement traits.

Patch Testing Ingredients of Dermabond and Other Cyanoacrylate-Containing Adhesives.

BACKGROUND: Cyanoacrylates are strong adhesives used for a variety of medical, industrial, and cosmetic applications and have been implicated as a cause of allergic contact dermatitis. OBJECTIVE: The aim of the study was to review our experience in patch testing with cyanoacrylates. METHODS: We reviewed patch test results of 38 patients with a clinical history of contact dermatitis due to a cyanoacrylate-containing adhesive (mostly Dermabond). Testing used cyanoacrylates of >99% purity diluted to 10% to 30% in petrolatum (pet.), undiluted octyl cyanoacrylate, and/or Dermabond Mini or Advanced "as is." Patch tests were also performed with methacrylates, formaldehyde (a cyanoacrylate impurity), benzalkonium chloride, and cyanoacrylate polymerization inhibitors. Three patients were also tested with Dermabond Mini on abraded skin. RESULTS: Commercial cyanoacrylate patch testing material (ethyl cyanoacrylate 10% pet.) detected 29% of Dermabond-allergic patients, whereas patch testing with octyl cyanoacrylate 10% pet. increased detection to 50%. Testing with higher concentrations and/or on abraded skin further increased yield. Thirteen (37%) of our 35 cyanoacrylate-allergic patients were also allergic to methacrylates or acrylates. CONCLUSIONS: Octyl cyanoacrylate is the usual allergenic ingredient in Dermabond. Patch testing with high concentrations is often required. Testing Dermabond on abraded skin further improves diagnostic sensitivity by more closely simulating clinical use.

Surgery-Related Contact Dermatitis: A Review of Potential Irritants and Allergens.

Surgical procedures utilize an increasing number of medical products including antiseptics, anesthetics, gloves, suture materials, tissue adhesives, topical antibiotics, and bandages. Many of these products have irritant potential. Allergic contact dermatitis has also been reported. This review covers preoperative, operative, and postoperative exposures that may result in contact dermatitis. Testing with standard patch panels such as T.R.U.E. Test and the North American Contact Dermatitis Group 65 allergen series does not evaluate for all relevant contactants. A thorough understanding of potential exposures is vital to effectively evaluate a patient with surgery-related contact dermatitis. A systematic approach is needed to ensure that standard patch panels and supplementary patches adequately address each encountered contactant.

Current complications and treatment of aspirin-exacerbated respiratory disease.

INTRODUCTION: Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.

Improvement in Asthma Control Using a Minimally Burdensome and Proactive Smartphone Application.

BACKGROUND: Integrated chronic disease treatment models that enable patient self-care and shared treatment decision making have recently been shown to improve medication adherence and outcomes. Smartphone applications (apps) are a readily available means to enable this model, although sustained user engagement remains a challenge. OBJECTIVE: To assess the efficacy of improving asthma control using a proactive smartphone app without required regular inputs. METHODS: We designed a minimally intrusive smartphone app to provide individualized and timely support to patients with asthma based on the National Asthma Education and Prevention Program guidelines and Scripps management pathways. In this proof-of-concept study, we enrolled 60 adults with poorly controlled asthma to test the usability and effectiveness of this app over a 4-month period. The Asthma Control Test survey was used to assess control before, during, and after app use. As a corollary, a retrospective chart review was also used to assess changes in lung function and prescribed courses of systemic corticosteroids. RESULTS: Our patients, with a mean age of 50 years, reported an improvement in Asthma Control Test scores from 16.6 (inadequate to poor) to 20.5 (controlled) over the study period. Concurrently, there was a 7.9% absolute increase in FEV1, while courses of systemic corticosteroids decreased from 0.5 to 0.3 courses per 6-month period. Fifty-eight of 60 patients completed the final survey, with high satisfaction reported. CONCLUSIONS: This app improved asthma control in a cohort of patients with uncontrolled asthma (age range, 17-82 years), while minimizing burdensome inputs and proactively providing individualized teaching and treatment support. The app and treatment model are scalable to cost-effectively manage chronic disease.