Serological Cross-Reactivity of Various Aspergillus spp. with Aspergillus fumigatus: A Diagnostic Blind Spot.

INTRODUCTION: Aspergillus fumigatus is the most common airborne allergen of the Aspergillus family. However, allergies to Aspergillus spp. are increasing, and subsequently, allergies to Aspergillus species other than fumigatus are also on the rise. Commercial diagnostic tools are still limited to Aspergillus fumigatus. Hence, there is a need for improved tests. We decided to investigate the correlation between serological sensitization to A. fumigatus and other Aspergillus species. METHODS: Hundred and seven patients with positive skin prick tests to A. fumigatus were included in this study. Immunoglobulin E (IgE) concentrations against A. fumigatus, A. terreus, A. niger, A. flavus, and A. versicolor were measured from specimens by fluorescent enzyme-linked immunoassays. RESULTS: Patients showed considerably higher IgE concentrations against A. fumigatus (6.00 ± 15.05 kUA/L) than A. versicolor (0.30 ± 1.01 kUA/L), A. niger (0.62 ± 1.59 kUA/L), A. terreus (0.45 ± 1.12 kUA/L), or A. flavus (0.41 ± 0.97 kUA/L). Regression analysis yielded weak positive correlations for all Aspergillus spp., but low r2 values and heteroscedastic distribution indicate an overall poor fit of the calculated models. CONCLUSION: Serological sensitization against A. fumigatus does not correlate with sensitization against other Aspergillus spp. To detect sensitization against these, other diagnostic tools like a skin prick test solution of different Aspergillus spp. are needed.

Sensitization against medical hyaluronidase in patients with confirmed hypersensitivity against hymenoptera species and its clinical implications.

BACKGROUND: Hyaluronidase is an ubiquitious enzyme, present, amongst others, in hymenoptera venom and in medical formulations. The latter include use as an emergency treatment or to correct undesired outcomes of medical and aesthetic procedures using hyaluronic acid fillers. By performing detailed allergy work-ups including prick-testing we investigated here if patients with a history of allergic reaction to hymenoptera venom are also sensitized to medical grade hyaluronidase. METHODS: Ninety patients with a history of type-1 reaction to hymenoptera venom with and without a history of previous specific venom immunotherapy were included in the study. All underwent skin prick tests for medical hyaluronidase. All patients also underwent serological analysis for Api m2, the only commercially available IgE-test for a hymenoptera hyaluronidase. RESULTS: Of the 90 patients with previous type-1 reactions to hymenoptera venom hyaluronidase included in the study, 60 had undergone previous venom immunotherapy, 30 did not. A majority (73/90) were allergic to wasps, followed by honeybees (14/90) and 3 were allergic to both. Neither patients having undergone previous immunotherapy nor those allergic to bees showed positive skin prick tests to medical hyaluronidase. Of those with a wasp allergy and naïve to immunotherapy, over 20% (5/23) showed positive skin prick tests to medical hyaluronidase. Healthy controls (0/30) without previous allergic reactions to hymenoptera did not show positive skin prick tests to medical hyaluronidase. CONCLUSION: Sensitization to hyaluronidase is most common in wasp-allergic patients who have not had previous specific immunotherapy. As allergic reactions to medical hyaluronidase are reported to be scarce, this group is probably at the highest risk to develop anaphlaxis to medical hyaluronidase. While all patients with untreated anaphylaxis to hymenoptera venom should consult an allergy specialist, particularly those with untreated wasp allergies need to seek a specialist's advice before treatment with medical hyaluronidase is initiated.

Contact allergies to dental materials in patients.

BACKGROUND: Concerns regarding contact allergies and intolerance reactions to dental materials are widespread among patients. Development of novel dental materials and less frequent amalgam use may alter sensitization profiles in patients with possible contact allergy. OBJECTIVES: To analyse current sensitization patterns to dental materials in patients with suspected contact allergy. METHODS: This retrospective, multicentre analysis from the Information Network of Departments of Dermatology (IVDK) selected participants from 169 834 people tested in 2005-2019 and registered with (i) an affected area of 'mouth' (and 'lips'/'perioral'), (ii) with the dental material in question belonging to one of three groups (dental filling materials, oral implants or dentures or equivalents) and (iii) with patch-testing done in parallel with the German baseline series, (dental) metal series and dental technician series. RESULTS: A total of 2730 of 169 834 tested patients met the inclusion criteria. The patients were predominantly women (81.2%) aged ≥ 40 years (92.8%). The sensitization rates with confirmed allergic contact stomatitis in women (n = 444) were highest for metals (nickel 28.6%, palladium 21.4%, amalgam 10.9%), (meth)acrylates [2-hydroxyethyl methacrylate (HEMA) 4.8%] and the substances propolis (6.8%) and 'balsam of Peru' (11.4%). The most relevant acrylates were HEMA, 2-hydroxypropyl methacrylate, methyl methacrylate, ethylene glycol dimethacrylate and pentaerythritol triacrylate. Few men were diagnosed with allergic contact stomatitis (n = 68); sensitization rates in men were highest for propolis (14.9%) and amalgam (13.6%). CONCLUSIONS: Allergic contact stomatitis to dental materials is rare. Patch testing should not only focus on metals such as nickel, palladium, amalgam and gold, but also (meth)acrylates and the natural substances propolis and 'balsam of Peru'.

Modelling of patient journey in chronic spontaneous urticaria: Increasing awareness and education by shorten patients' disease journey in Germany.

BACKGROUND: Chronic spontaneous urticaria (CSU) is both physically and emotionally stressful, and guideline recommendations are often not optimally implemented in clinical practice. The objective of this study was to provide an overview on the patient journey in CSU and to develop a mathematical model based on solid data. METHODS: The journey of CSU patients in Germany was traced through literature review and expert meetings that included medical experts, pharmacists and representatives of patient organizations. The current situation's main challenges in the patient journey (education, collaboration and disease management) were discussed in depth. Then, a probabilistic model was developed in a co-creation approach to simulate the impact of three potential improvement strategies: (1) patient education campaign, (2) medical professional education programme and (3) implementation of a disease management programme (DMP). RESULTS: Chronic spontaneous urticaria patients are severely burdened by delays in diagnosis and optimal medical care. Our simulation indicates that in Germany, it takes on average of 3.8 years for patients to achieve disease control in Germany. Modelling all three optimization strategies resulted in a reduction to 2.5 years until CSU symptom control. On a population level, the proportion of CSU patients with disease control increased from 44.2% to 58.1%. CONCLUSION: In principle, effective CSU medications and a disease-specific guideline are available. However, implementation of recommendations is lagging in practice. The approach of quantitative modelling of the patient journey validates obstacles and shows a clear effect of multiple interventions on the patient journey. The data generated by our simulation can be used to identify strategies for improving patient care. Our approach might helping in understanding and improving the management of patients beyond CSU.

Acute Generalized Exanthematous Pustulosis: Clinical Characteristics, Pathogenesis, and Management.

BACKGROUND: Acute generalized exanthematous pustulosis (AGEP) is a potentially severe adverse cutaneous drug reaction, which typically occurs within 24-48 h after the intake of the culprit drug. SUMMARY: AGEP is characterized by numerous sterile subcorneal pustules on erythematous skin and in less than a third of cases it can be associated with organ manifestations possibly leading to life-threatening symptoms (e.g., cholestasis, nephritis, and lung and bone marrow involvement). In contrast to generalized pustular psoriasis, it can involve mucosal regions and typically resolves rapidly if the culprit drug is removed, and adequate therapy with topical or systemic steroids administered. Diagnosis based on patient history, clinical signs, and characteristic cutaneous histology is rarely challenging. Identification of the culprit drug may be aided by patch testing or lymphocyte transformation tests that are of limited value. KEY MESSAGES: Recent experimental data reviewed herein are supportive of an early role of drug-induced innate immune activation and innate cytokines such as interleukin (IL)-1, IL-36, and IL-17 in the pathogenesis of AGEP. This explains the rapid onset and neutrophilic character of the cutaneous inflammation, but also provides new avenues for in vitro tests aimed at better identifying the culprit drug.

Management and treatment outcome of DRESS patients in Europe: An international multicentre retrospective study of 141 cases.

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal drug hypersensitivity reaction. OBJECTIVE: To explore treatment approaches across Europe and their impact on the disease course, as well as prognostic factors and culprit drugs. METHODS: In this retrospective European multicentric study, we included patients with probable or certain DRESS (RegiSCAR score ≥ 4) between January 2016 and December 2020. Independent associations between clinical parameters and the risk of intensive care unit admission and mortality at three months were assessed using a multivariable-adjusted logistic regression model. RESULTS: A total of 141 patients from 8 tertiary centres were included. Morbilliform exanthem was the most frequent cutaneous manifestation (78.0%). The mean affected body surface area (BSA) was 67%, 42% of the patients presented with erythroderma, and 24.8% had mucosal involvement. Based on systemic involvement, 31.9% of the patients had a severe DRESS. Anticonvulsants (24.1%) and sulphonamides (22.0%) were the most frequent causative agents. In all, 73% of the patients were treated with systemic glucocorticoids, and 25.5% received topical corticosteroids as monotherapy. Few patients received antiviral drugs or anti-IL5. No patients received intravenous immunoglobulins. The overall mortality was 7.1%. Independent predictors of mortality were older age (≥57.0 years; fully adjusted OR, 9.80; 95% CI, 1.20-79.93; p = 0.033), kidney involvement (fully adjusted OR, 4.70; 95% CI, 1.00-24.12; p = 0.049), and admission in intensive care unit (fully adjusted OR, 8.12; 95% CI, 1.90-34.67; p = 0.005). Relapse of DRESS and delayed autoimmune sequelae occurred in 8.5% and 12.1% of patients, respectively. CONCLUSIONS: This study underlines the need for diagnostic and prognostic scores/markers as well as for prospective clinical trials of drugs with the potential to reduce mortality and complications of DRESS.

Contact allergy to ingredients of hair cosmetics in female hairdressers and female consumers-An update based on IVDK data 2013-2020.

BACKGROUND: Hair cosmetic products contain several, partly potent contact allergens, including excipients like preservatives. Hand dermatitis in hairdressers is common, scalp and face dermatitis in clients or self-users (summarised here as 'consumers') may be severe. OBJECTIVE: To compare frequencies of sensitization to hair cosmetic ingredients and other selected allergens between female patch tested patients working as hairdressers and consumers without professional background, respectively, who were tested for suspected allergic contact dermatitis to such products. METHODS: Patch test and clinical data collected by the IVDK (https://www.ivdk.org) between 01/2013 and 12/2020 were descriptively analysed, focusing on age-adjusted sensitization prevalences in the two subgroups. RESULTS: Amongst the 920 hairdressers (median age: 28 years, 84% hand dermatitis) and 2321 consumers (median age: 49 years, 71.8% head/face dermatitis), sensitization to p-phenylenediamine (age-standardised prevalence: 19.7% and 31.6%, respectively) and toluene-2,5-diamine (20 and 30.8%) were most common. Contact allergy to other oxidative hair dye ingredients was also more commonly diagnosed in consumers, whereas ammonium persulphate (14.4% vs. 2.3%) and glyceryl thioglycolate (3.9 vs. 1.2%) as well as most notably methylisothiazolinone (10.5% vs. 3.1%) were more frequent allergens in hairdressers. CONCLUSIONS: Hair dyes were the most frequent sensitizers both in hairdressers and in consumers; however, as indication for patch testing may differ, prevalences cannot directly be compared. The importance of hair dye allergy is evident, often with marked coupled reactivity. Workplace and product safety need to be further improved.

Contact allergy to the Dexcom G6 glucose monitoring system-Role of 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate in the new adhesive.

BACKGROUND: Skin reactions to the glucose monitoring systems Dexcom G5 and G6 have been rare. In 2019, the components of the adhesive were exchanged for better skin fixation. Since then, more and more patients experienced severe skin reactions. A few months ago, 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate (MBPA) was identified as a new component in the adhesive of the G6 model. Furthermore, it was suspected that isobornyl acrylate (IBOA) was also a component of the exchanged adhesive. OBJECTIVES: Our objective was to investigate if MBPA plays a major role in the increasing skin problems of patients without a history of IBOA-sensitization. Furthermore, our aim was to examine whether IBOA is contained in the newer model adhesive and may also contribute to allergic contact dermatitis (ACD). PATIENTS AND METHODS: Five patients with a newly occurred ACD caused by the glucose monitoring system Dexcom G6 were investigated. Patch testing including MBPA in three different concentrations, as well as IBOA, were performed. Gas chromatography-mass spectrometry of the newer system Dexcom G6 was carried out. RESULTS: All patients were shown to be sensitized to MBPA, while MBPA 0,5% showed the strongest reaction. On the other hand, IBOA was tested negative. CONCLUSION: In our study group, MBPA was observed to be the triggering allergen of the recently changed adhesive.

Contact sensitization to iron: A potentially underestimated metal allergen and elicitor of complications in patients with metal implants.

BACKGROUND: Little is known about sensitization to iron (Fe) in private, occupational, and medical settings, particulary implantology. OBJECTIVES: To investigate sensitization to metals, particularly to Fe, both in pre-implant individuals with presumed metal allergy and in patients with suspected metal implant allergy. To further characterize Fe-sensitized individuals. METHODS: Analysis of patch test reactions to an Fe (II) sulfate-containing metal series in 183 consecutive patients (41 pre-implant, 142 metal implant bearers). Test readings were on day (D)2, D3, and D6. Evaluation of questionnaire-aided history of metal reactivity patterns and demographics of Fe reactors. RESULTS: Metal reactivity in pre-implant/implant/total group was: to nickel 39%/30%/32%; to cobalt 17%/15%/15%; and to chromium 7%/13%/11%. Co-sensitizations cobalt/nickel (19/58) and cobalt/chromium (11/21) were significant at P < .001; co-sensitizations Fe/nickel (4/10) and chromium/knee arthroplasty (11/73) at P = .03. Ten of 183 (5.5%) reacted to Fe (2 of 41 pre-implant patients, 8 of 142 implant bearers), with 10 reacting only on D6. Fe reactivity was highest in complicated knee arthroplasty (7/73). Further peculiarities of Fe reactors included frequent isolated Fe reactivity (6/10), occupational metal exposure (7/10), previous (par)enteral Fe substitution (6/10). CONCLUSIONS: The 5.5% prevalence of Fe reactions suggests a potentially underestimated role of this metal allergen in general and in implant bearers. The latter also shows a distinct metal sensitization pattern.

Impact of allergic reactions and urticaria on mental health and quality of life.

BACKGROUND: Allergic diseases represent a major global health issue with more than one-third of the global population affected by at least one allergic condition. Allergic conditions can not only cause life-threatening anaphylactic reactions but also impact daily life with a significant influence on mental health and the quality of life (QoL). OBJECTIVES: This study aims to evaluate the health-related QoL and depression severity among patients presenting in a tertiary care allergy center. METHODS: A cross-sectional study was conducted among 596 patients presenting with allergic symptoms or previously diagnosed allergies between October 2018 and April 2019.Patients were screened for depression and the QoL impairment by using three validated scales: the Beck Depression Inventory (BDI), the Dermatologic Life Quality Index (DLQI), and the three-level version of the EuroQol 5-Dimensional (EQ-5D-3L) scale. RESULTS: One-third (34.8%) of the study population was male and two-thirds (65.2%) were female. About 73.7% (n = 427/579) of the patients suffered from at least one previously diagnosed allergic disease, most frequently to pollen (37.0%, n = 214/579) and food (27.3%, n = 158/579), and 20.0 % (n = 116/579) suffered from urticaria. About 19.3% of the total population suffered from depression. Urticaria, as well as insect venom, food/food additives, and drug allergies significantly affected the QoL and depression severity (p < 0.001), reflected by higher DLQI and BDI scores, and lower scores in the EQ5D-3L index. CONCLUSION: Our results provide evidence for a possible correlation of allergies (e.g. against insect venom, food/food additives, and drugs) and/or urticaria with a reduced QoL and a higher depression rate. Patients particularly indicated restrictions for the dimensions, pain/discomfort as well as anxiety/depression. It might be beneficial to implement a standardized questionnaire as a regular screening method for evaluating the mental health status of patients with allergies and/or urticaria.

Optical coherence tomography for patch test grading: A prospective study on its use for noninvasive diagnosis of allergic contact dermatitis.

BACKGROUND: The diagnosis of allergic contact dermatitis should be confirmed by skin patch tests. Distinguishing between irritant and allergic reactions is sometimes difficult. OBJECTIVES: To analyse the in vivo morphological changes in patch test reactions compared to healthy skin, and to detect subclinical changes in doubtful reactions using optical coherence tomography (OCT). To develop an OCT-based algorithm to support patch-test grading. METHODS: One hundred twenty-nine skin patch-test areas were scanned with OCT to evaluate the following features: architectural and vascular morphology, epidermal thickness, optical attenuation coefficient (AC), and blood flow at 0.1, 0.2, and 0.35 mm depth. RESULTS: Most common OCT features of acute contact allergic reactions in patch tests were spongiosis with microvesicles (94.8%), macrovesicles (60.3%), and coalescing vesicles (46.6%), the latter useful in differentiating acute allergic from irritant dermatitis (P-value < .05). Objective quantitative parameters correlated well with the severity grade: epidermal thickness due to spongiosis, AC (P-value < .05) and blood flow at 0.2 and 0.35 mm (P-value < .01). CONCLUSIONS: OCT as a noninvasive diagnostic tool, established for skin cancer diagnosis, is useful for evaluating contact allergic patch-test reactions. Not only morphological but also objective features such as blood flow and AC correlate with the reaction severity. Further studies are needed to explore the differences in irritant and allergic contact dermatitis.

Explaining variations in hospitals' use of strategic human resource management: How environmental and organizational factors matter.

BACKGROUND: Against the background of increasing workforce-related challenges such as staff shortages, strategic human resource management (SHRM) has gained importance in hospitals. Although the positive implications of SHRM for hospital performance are well known and commonly accepted in research and practice, hospitals still vary in its use. However, the sources of variations in hospitals' use of SHRM are largely unknown. PURPOSE: Various organizational and environmental factors were used in this study to explain the variations in hospitals' use of SHRM for physicians and nurses. METHODOLOGY: Data were obtained from a hospital survey (n = 172) on topics related to human resource management in hospitals and linked to different secondary data sets. We apply multiple linear regression modeling to investigate the association between organizational and environmental characteristics and hospitals' use of SHRM for nurses and physicians. FINDINGS: Our results suggest that organizational factors such as private for-profit and nonprofit ownership (compared to public ownership), academic teaching status, and the strategic involvement of the human resource administration are positively associated with hospitals' use of SHRM. None of the environmental factors investigated in this study was significantly related to hospitals' use of SHRM. PRACTICAL IMPLICATIONS: The study results increase our understanding of variations in hospitals' use of SHRM. Although organizational characteristics were found to explain variations in SHRM, environmental factors seem unrelated with hospitals' use of SHRM. Our results inform both hospital managers and policy makers about possible approaches to enhance SHRM use in hospitals. Furthermore, profound knowledge about factors associated with SHRM will help to enhance our understanding of anticipating changes in hospitals' use of SHRM through organizational- and environmental-oriented interventions.

Multilevel analysis exploring the relative importance of workplace resources in explaining nurses' workload perceptions: Are we setting the right focus?

BACKGROUND: Nurses' workload has become increasingly recognized as an important determinant of nurse turnover and shortage and has been also associated with poorer quality of care. Despite strong evidence that heavy workloads have negative consequences, we still lack a comprehensive understanding of the workplace characteristics that contribute most to improving nurses' workload, the relative importance of each in doing so, or indeed the workplace characteristics and other factors that drive nurses' perceptions of their workload. PURPOSE: The aim of this study was to examine workplace resources as antecedents of nurses' perceptions of their workload and to investigate their relative importance in explaining workload perceptions. We considered workplace resources related to staffing, professional relationships, and technology. METHODOLOGY: The study sample comprised nurse-reported and administrative data from U.S. Veterans Health Administration hospitals between 2014 and 2017. Our multilevel analyses are based on data from 20,330 nurses working in 273 work groups at 123 hospitals. We developed and empirically tested a theoretical model using multilevel mixed-effects linear regression. The relative importance of workplace resources was assessed by dominance analysis. RESULTS: Staffing levels, relational climate, and information technology were significantly associated with nurses' workload perceptions. Dominance analysis indicated that relational resources are the most important measure in explaining nurses' workload perceptions. PRACTICE IMPLICATIONS: This is the first study to examine the relative importance of workplace resources in explaining nurses' perceptions of their workload. Our results suggest that much might be gained by investing in interventions to boost relational resources. In turn, these findings could lead to more targeted, effective, and resource efficient interventions to improve nurses' workload.

[Anthrenus dermatitis : Case report with suggestions regarding causes and consequences]. / Anthrenus-Dermatitis : Fallbericht mit Lösungsansätzen zu Ursachen und Auswirkungen.

Beetles of the genus Anthrenus are widespread worldwide and are quite common as grain and stock pests, especially in rural regions and suburban areas. The larvae of the beetles can trigger skin and occasionally mucosal reactions upon contact. The unfamiliar but typical image of "Anthrenus dermatitis" can easily be misinterpreted if beetle larvae are not detected or a causal link with them is not suspected. In the present article, the causes of Anthrenus dermatitis are discussed using as an example the larva of the woolly flower beetle (Anthrenus verbasci). For the examination of allergic causes, a prick-to-prick test with native larval material was performed in a patient and the specific IgE was determined by CAP coupling as well as in addition to a commercially available ImmunoCAP against larvae of a related beetle species. With the help of an immunoblot, an attempt was made to determine the responsible allergens in the native larval tissue. Important anatomical fine structures of the larva of a woolly herb flower beetle were analyzed using scanning electron microscopy to understand functional processes that lead to the clinical picture of Anthrenus dermatitis. Our allergological findings suggest an IgE-mediated, immediate-type allergy.

Modern diabetes devices for continuous blood sugar measuring: Limitations due to contact allergies.

During the past years, diabetes diseases have increased significantly worldwide. However, new technologies such as continuous glucose measurement using a subcutaneous sensor are developing just as rapidly. A continuous improvement in insulin pump therapy is also contributing to an improved quality of life. A common feature of these modern devices for diabetes therapy is that they remain fixed in place on the skin for several days. In recent years, skin reactions, in particular pronounced contact dermatitis due to the devices and their adhesives have been increasingly reported. In particular, isobornyl acrylate, which used to be included in a glucose measurement sensor set, was identified as a main allergen. Development of contact allergy can result both in a necessity to quit the measuring system and in allergic cross-reactions to other systems.

Investigating the link between medical urgency and hospital efficiency - Insights from the German hospital market.

With hospital budgets remaining tight and healthcare expenditure rising due to demographic change and advances in technology, hospitals continue to face calls to contain costs and allocate their resources more efficiently. In this context, efficiency has emerged as an increasingly important way for hospitals to withstand competitive pressures in the hospital market. Doing so, however, can be challenging given unpredictable fluctuations in demand, a prime example of which are emergencies, i.e. urgent medical cases. The link between medical urgency and hospitals' efficiency, however, has been neglected in the literature to date. This study therefore aims to investigate the relationship between hospitals' urgency characteristics and their efficiency. Our analyses are based on 4094 observations from 1428 hospitals throughout Germany for the years 2015, 2016, and 2017. We calculate an average urgency score for each hospital based on all cases treated in that hospital per year and also investigate the within-hospital dispersion of medical urgency. To analyze the association of these urgency measures with hospitals' efficiency we use a two-stage double bootstrap data envelopment analysis approach with truncated regression. We find a negative relationship between the urgency score and hospital efficiency. When testing for non-linear effects, the results reveal a u-shaped association, indicating that having either a high or low overall urgency score is beneficial in terms of efficiency. Finally, our results reveal that higher within-hospital urgency dispersion is negatively related to efficiency.

The implanted glucose monitoring system Eversense: An alternative for diabetes patients with isobornyl acrylate allergy.

BACKGROUND: Some patients with diabetes develop skin reactions when using systems for continuous glucose monitoring (CGM) or insulin pumps. Regular usage and long wearing periods lead not only to skin irritation, but also to allergic contact dermatitis. It has been shown that allergens such as isobornyl acrylate (IBOA) are present in the plastic housing and also in the adhesives of medical devices used for diabetes treatment. OBJECTIVES: To evaluate the IBOA content of all parts of a newly introduced, implanted CGM system (Eversense) to check whether this can be an alternative for IBOA-sensitized patients. METHODS: The IBOA content of the implanted sensor itself (n = 3), the transmitter (n = 3), and two different types of adhesive (white adhesive [n = 4] and clear adhesive [n = 4]) was measured by gas chromatography/mass spectrometry. RESULTS: No IBOA was found in any part of this CGM system. CONCLUSIONS: Patients with an IBOA allergy may be able to use this implanted CGM system.

"Paying it forward": The link between providers' civility climate, civility toward patients and patient experience outcomes.

BACKGROUND: Interpersonal relationships are increasingly recognized as an important determinant for care performance and quality in the health care context. An unresolved issue in health care research is whether and to which extent providers' perceptions of their work relationships are associated with their interactions with patients and, in turn, patient experience outcomes. PURPOSE: The aim of this study was to investigate the extent to which nurses' experiences of their work relationship climate (i.e., civility climate) affect their interactions with patients (i.e., civility towards patients), which in turn contribute to patient experience outcomes (i.e., overall hospital rating, willingness to return, intent to recommend). Furthermore, we analyze the mediating role of civility toward patients in the relation between civility climate and patient experience outcomes. METHODOLOGY: The 2011 study sample comprised responses from 6,019 nurses and 38,619 patients at 123 Veterans Health Administration acute care inpatient hospitals located in the United States. We developed and empirically tested a theoretical model using multilevel regression modeling and assessing multilevel mediation. RESULTS: The results indicate a positive association between civility climate and civility toward patients. With regard to patient experience outcomes, the analyses reveal a direct effect of civility climate on overall hospital rating, intent to recommend, and willingness to return and an indirect effect mediated by civility toward patients. CONCLUSION AND PRACTICE IMPLICATIONS: This is one of the first studies theorizing and testing the extent to which relationship climate among providers affect their interactions with patients. The findings provide support that providers who experience a positive civility climate are more likely to pay forward this relationship experience and engage in civility toward patients. The results point to the importance of a civility climate for ensuring and potentially improving patient experience of care.

Antihistamine-resistant chronic spontaneous urticaria: 1-year data from the AWARE study.

BACKGROUND: Previous reports indicate that patients with chronic spontaneous urticaria (CSU) are undertreated and that physicians show poor adherence to guideline recommendations. Awareness of CSU has improved in recent years, but it remains unclear if this has improved the management of these patients in clinical practice. OBJECTIVE: To describe disease burden, quality of life (QoL), and treatment patterns of patients with H1 -antihistamine-refractory CSU in Germany. METHOD: A World-wide Antihistamine-Refractory chronic urticaria (CU) patient Evaluation (AWARE) is a global prospective, non-interventional study of CU in the real-world setting, supported by the manufacturer of omalizumab. Patients (18-75 years) were included who had H1 -antihistamine-refractory CSU for ≥2 months. Disease characteristics, pharmacological treatments, and QoL (dermatology life quality index [DLQI], CU-QoL questionnaire, and angioedema QoL questionnaire) are reported for patients enrolled in Germany. RESULTS: After 1 year in AWARE, CSU remained uncontrolled (urticaria control test [UCT] score <12) in 432 of 1032 (42.2%) patients. QoL impairment remained high after 1 year, with 28.2% of patients reporting that CSU had a moderate/very large/extremely large effect on the DLQI. Most patients did not receive guideline-recommended treatments at the end of the 1-year observation period. Changes in treatments were most evident at the first patient visit, with an increase in patients receiving omalizumab vs prior therapy from 8.5% to 21.4%, and a decrease in those receiving no treatment from 29.9% to 12.8%. These changes were associated with reduced hives, angioedema, UCT scores, and QoL scores at Month 3, but only modest improvements thereafter. Of 528 patients with uncontrolled CSU and who were eligible for treatment escalation, only 3% received up-dosing of H1 -antihistamines and only 5% were initiated on omalizumab during 1 year of treatment. CONCLUSIONS & CLINICAL RELEVANCE: This study highlights a significant discrepancy between recommendations for managing CSU in international guidelines, and in real-world clinical practice in Germany.

The Dexcom glucose monitoring system-An isobornyl acrylate-free alternative for diabetic patients.

BACKGROUND: Glucose monitoring systems, for example, Freestyle Libre (Abott) and Dexcom (Nintamed), are increasingly being used instead of conventional blood sugar measurement. However, many patients have experienced adverse skin reactions such as severe allergic contact dermatitis (ACD). Finally, in August 2017, the culprit allergen in Freestyle Libre, isobornyl acrylate (IBOA), was identified. OBJECTIVES: After patients have developed ACD, it is recommended that they no longer use their glucose monitoring systems. Thus, it is important to find an alternative IBOA-free device. PATIENTS AND METHODS: Five patients presented with ACD caused by Freestyle Libre. Each was patch tested with allergens from the baseline series and from a plastics and glues series, and additionally with IBOA 0.1% pet. Gas chromatography-mass spectrometry (GC/MS) of the Freestyle Libre sensor and the Dexcom sensor was performed. The Dexcom sensor remained on the skin of all patients for at least 2 days. RESULTS: All patients were sensitized to IBOA. GC/MS showed the presence of IBOA in the Freestyle Libre sensor, whereas the Dexcom sensor was IBOA-free. None of the patients had skin reactions to the Dexcom sensor. CONCLUSIONS: Patients with Freestyle Libre and IBOA allergy may use the Dexcom sensor as an alternative for glucose monitoring.