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Chronic urticaria and angioedema are diseases often managed by Allergy and Immunology specialists. Recent international guidelines have outlined a stepwise approach to management of patients using dose escalation of second-generation antihistamines followed by use of omalizumab and finally cyclosporine in more refractory cases. In select patients (those with refractory chronic urticaria), nonbiologic alternative medications with anti-inflammatory or immunosuppressant activity may be considered. Angioedema without wheals may have several different pathophysiologic mechanisms. Optimal management of mast cell-mediated angioedema is less clear but is often managed similar to chronic spontaneous urticaria. Drug-induced angioedema due to angiotensin-converting enzyme inhibitors is a common cause of angioedema in the emergency department. Although bradykinin is thought to be a primary mediator for this type of angioedema, studies of targeted therapies have been generally disappointing. In contrast, several targeted therapies have been proven successful using acute and preventive approaches for management of hereditary angioedema. Further developments, including novel biologics, novel oral therapies, and gene therapy approaches, may hopefully continue to broaden therapeutic options to ensure optimal individual management of patients with hereditary angioedema.

Background and Objective: Chronic spontaneous urticaria (CSU) is a distressing disease. We report real-world data from the global Chronic Urticaria Registry (CURE) about associations between various CSU states and sleep impairment, plus important health-related quality-of-life (HRQoL) outcomes and compared different methods to assess CSU states. Methods: CURE data were collected at baseline and 6-monthly follow-ups (FU). Assessments included CSU states using the Urticaria Control Test (UCT), weekly Urticaria Activity Score (UAS7), and Physician Global Assessment (PhyGA) of treatment response. Complete response to treatment (CR, UAS7 = 0), complete control of disease (CC, UCT = 16), and PhyGA = CR were assessed, plus the Dermatology Life Quality Index and the Chronic Urticaria Quality-of-Life Questionnaire (CU-Q2oL) sleep domain. Results: Overall, 2078 patients were included. At baseline, 9.8%, 17.9%, and 42.3% of patients had UCT = 16, UAS7 = 0, or PhyGA = CR, respectively, which increased at FU1 and FU2. Patients with higher UCT scores had better sleep and HRQoL. The presence of angioedema without wheals, episodic disease, omalizumab treatment, and male sex were associated with CC (P

Background Severe anaphylaxis (SA) in Hymenoptera venom allergy has been associated with a number of risk factors. However, the effect of several of those risk factors on the severity of anaphylaxis is poorly defined. Objective To evaluate risk factors for SA in Hymenoptera venom allergy. Methods We evaluated data from 500 patients who were referred to our department for the diagnosis of Hymenoptera venom allergy during a period of 11 years to identify risk factors for SA. Results Six significant risk factors for SA were identified (P Conclusion Apart from BST and older age, male sex, short interval from sting to reaction, and absence of U/A are also risk factors for SA. The association between elevated BST level and SA was largely confined to those who had an absence of U/A after field sting, possibly because of the higher risk of concurrent systemic mastocytosis. Patients with an SA after a field sting do not have an elevated risk of systemic reactions during the initiation of venom immunotherapy compared with patients with mild anaphylaxis; therefore, additional preventive measures are not necessary.

BACKGROUND: Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) causes swelling in the skin and upper airways and pain in the abdomen because of mucosal swelling. C1-INH-HAE is frequently misdiagnosed, leading to delays in diagnosis, inadequate treatment, and unnecessary procedures.OBJECTIVE: To evaluate the history of misdiagnosis in patients participating in the Icatibant Outcome Survey (IOS).METHODS: The IOS is an observational study in which safety and effectiveness of icatibant have been evaluated since 2009. As part of the IOS, patients record any misdiagnoses received before being diagnosed as having C1-INH-HAE.RESULTS: In January 2016, a total of 418 of 633 IOS patients with C1-INH-HAE type I or II had provided misdiagnosis data. Of these, 185 of 418 (44.3%) received 1 or more prior misdiagnoses. The most common misdiagnoses were allergic angioedema (103 of 185) and appendicitis (50 of 185). A variety of other misdiagnoses were reported, including a substantial number of gastrointestinal disorders (excluding appendicitis). Misdiagnosis rates were similar between males (41.1%) and females (46.5%) and between C1-INH-HAE type I (43.7%) and type II (51.6%). Patients with family members diagnosed as having C1-INH-HAE were significantly less likely to be misdiagnosed than patients without a family history (140 of 366 [41.7%] vs 38 of 58 [65.5%], respectively; P = .001). Patients with a prior misdiagnosis had longer median delay to C1-INH-HAE diagnosis (13.3 years) than patients without (1.7 years; P < .001).CONCLUSION: From this large database, approximately 50% of patients with C1-INH-HAE type I or II have previously had their conditions misdiagnosed, most commonly as allergic angioedema or appendicitis. Misdiagnosis results in marked delays in receiving the correct diagnosis, during which time patients cannot access effective, lifesaving treatment.TRIAL REGISTRATION: ClinicalTrials.gov: NCT01034969.

Background Venom-induced anaphylaxis (VIA) is a common, potentially life-threatening hypersensitivity reaction associated with (1) a specific symptom profile, 2) specific cofactors, and 3) specific management. Identifying the differences in phenotypes of anaphylaxis is crucial for future management guidelines and development of a personalized medicine approach. Objective This study aimed to evaluate the phenotype and risk factors of VIA. Methods Using data from the European Anaphylaxis Registry (12,874 cases), we identified 3,612 patients with VIA and analyzed their cases in comparison with sex- and age-matched anaphylaxis cases triggered by other elicitors (non-VIA cases [n = 3,605]). Results VIA more frequently involved more than 3 organ systems and was associated with cardiovascular symptoms. The absence of skin symptoms during anaphylaxis was correlated with baseline serum tryptase level and was associated with an increased risk of a severe reaction. Intramuscular or intravenous epinephrine was administered significantly less often in VIA, in particular, in patients without a history of anaphylaxis. A baseline serum tryptase level within the upper normal range (8-11.5 ng/mL) was more frequently associated with severe anaphylaxis. Conclusion Using a large cohort of VIA cases, we have validated that patients with intermediate baseline serum tryptase levels (8-11 ng/mL) and without skin involvement have a higher risk of severe VIA. Patients receiving β-blockers or angiotensin-converting enzyme inhibitors had a higher risk of developing severe cardiovascular symptoms (including cardiac arrest) in VIA and non-VIA cases. Patients experiencing VIA received epinephrine less frequently than did cases with non-VIA.

Background Safety and tolerability of venom immunotherapy (VIT) in patients with concomitant disease and comedications, especially β-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs), are under discussion. Objective To identify risk factors for the occurrence of systemic reactions (SRs) during the build-up phase of a 3-day rush VIT with focus on comorbidities and related comedications. Methods Data of 175 three-day rush VIT courses ( Vespula venom, n = 161; honeybee venom, n = 14) were analyzed. Starting with 0.02 μg of venom, the maintenance dose of 100 μg was reached in 15-dose increments within 3 days. Local reactions (LRs) and SRs were documented during the build-up phase. Comorbidities and related comedications were registered. Univariate, bivariate, and multivariate data analysis was performed. Results During the 3-day rush VIT, an LR was seen in 74 (42.3%) of 175, a large LR (>10-cm diameter) in 82 (46.9%) of 175, and SRs in 19 (10.9%) of 175 VIT courses. Multivariate logistic regression revealed that female sex ( P = .01), immunotherapy with honeybee venom ( P = .003), and accompanying ACEI medication ( P = .03) were independent predictors of the development of SRs during the build-up phase of VIT. Conclusion This study revealed that female sex, honeybee VIT, and ACEI use independent predictors for SRs.

The megapinosome is an endocytic cell organel that we observed in human macrophages with electron microscopy. In a previous work we showed that it is formed by an endocytic event that we called megapinocytosis. The megapinosome is filled with a membrane surrounded trabecular meshwork that is topologically part of the cytosol. In this work we used scanning transmission electron tomography on high pressure frozen and freeze substituted human macrophages in order to unravel the three-dimensional structure of both the megapinosome and the adjacent structures. The megapinosome consists of the trabecular meshwork and the lacunae which are connected with and topologically equivalent to the cytosol. The surrounding lumen is topologically equivalent to the structures of the vesicular pathway. In addition, we show the connections of the trabecular meshwork with the cytosol and the connection of the megapinosomes to a complex tubular and cisternal system covering a large part of the macrophages that we named megapinosome complex. We assume that our methodological approach, based on high pressure freezing from a defined physiological state and three-dimensional imaging, renders the tubular components of the macrophages better visible than the classical two-dimensional imaging of chemically fixed cells used as a "blueprint" for textbook illustrations. The cell biological functions of the megapinosome are largely enigmatic. Probably, megapinosomes assures storage of surface membranes that can be promptly made available when a macrophage needs to change shape to move through a tissue, to uptake extracellular material or dead cells as well as to fight against microbes.

In addition to cholesterol-lowering properties, statins exhibit lipid-independent immunomodulatory, anti-inflammatory actions. However, high concentrations are typically required to induce these effects in vitro, raising questions concerning therapeutic relevance. We present evidence that endothelial cell sensitivity to statins depends upon shear stress. Using heme oxygenase-1 expression as a model, we demonstrate differential heme oxygenase-1 induction by atorvastatin in atheroresistant compared with atheroprone sites of the murine aorta. In vitro, exposure of human endothelial cells to laminar shear stress significantly reduced the statin concentration required to induce heme oxygenase-1 and protect against H(2)O(2)-mediated injury. Synergy was observed between laminar shear stress and atorvastatin, resulting in optimal expression of heme oxygenase-1 and resistance to oxidative stress, a response inhibited by heme oxygenase-1 small interfering RNA. Moreover, treatment of laminar shear stress-exposed endothelial cells resulted in a significant fall in intracellular cholesterol. Mechanistically, synergy required Akt phosphorylation, activation of Kruppel-like factor 2, NF-E2-related factor-2 (Nrf2), increased nitric-oxide synthase activity, and enhanced HO-1 mRNA stability. In contrast, heme oxygenase-1 induction by atorvastatin in endothelial cells exposed to oscillatory flow was markedly attenuated. We have identified a novel relationship between laminar shear stress and statins, demonstrating that atorvastatin-mediated heme oxygenase-1-dependent antioxidant effects are laminar shear stress-dependent, proving the principle that biomechanical signaling contributes significantly to endothelial responsiveness to pharmacological agents. Our findings suggest statin pleiotropy may be suboptimal at disturbed flow atherosusceptible sites, emphasizing the need for more specific therapeutic agents, such as those targeting Kruppel-like factor 2 or Nrf2.

A single jet model is described and used to analyze the performance of an 8-stage Andersen cascade impactor (ACI). The two-dimensional axisymmetric jet flow field was calculated numerically by solving the Navier-Stokes equations and particle trajectories were then analyzed to obtain the collection efficiency curves at different flow rates. The resulting efficiency curves and corresponding cutoff diameters were compared and found to be in good agreement with the available experimental data. We also examined the effect of gravity on impactor performance and discuss the limitations of the single jet model.

Hand dermatitis is a common diagnosis seen in dermatologic and general practice. It can present with typical morphology, but uncommon manifestations are possible. This review reports on common and uncommon presentations of irritant and allergic hand dermatitis focusing on uncommon localizations, time course, and morphology such as follicular, pustular, bullous, ulcerous, erythema exsudativum multiforme-like, purpuric, lichenoid, pigmented, and depigmented skin lesions. Clinical diagnosis can be challenging. Even histopathology is not always very helpful. Thorough evaluation of the patient's history and investigation of clinical morphology are the cornerstones of diagnosis.

1. A low molecular weight, cadmium-binding protein has been isolated from Lumbriculus variegatus . 2. The protein has an apparent molecular weight of 19 kD as estimated by Sephadex G-75 chromatography and is thought to be a dimer. It shows high absorbance at 254 nm and low absorbance at 280 nm. 3. Amino acid analysis revealed a high content of cysteine (16.5%), and elevated amounts of aspartate (10.9%), serine (10.6%), glutamate (9.3%), glycine (11.7%), leucine (10%) and lysine (10%). The content of aromatic amino acids was low. 4. After SDS-polyacrylamid gel electrophoresis three distinct bands with molecular weights of 19, 11.5 and 10.2 kDa, respectively, were found. The three bands are assumed to represent the dimer, the monomer and a partially carboxymethylated monomer. 5. The protein is suggested to play an important role in the detoxification of cadmium.

1. After feeding with metal-contaminated substrate from a lead-mining area, high concentrations of cadmium and zinc were measured in the hepatopancreas of the terrestrial slug Arion lusitaniens. 2. Centrifugation of hepatopancreas homogenates from both control and metal-fed animals revealed that most of the cadmium was associated with the supernatant, whereas a large proportion of zinc was bound to the pellet. 3. In both control and metal-fed groups cadmium-binding components have been found by ion exchange and gel chromatography. 4. All the cadmium from control slugs was bound to components with a mol. wt higher than 20,000. 5. In metal-fed animals, however, all cadmium was associated with an inducible protein with an apparent mol. wt of 10,000. 6. This component showed an elevated absorption at 254 nm and reduced absorption at 280 nm. 7. Amino acid analysis revealed high amounts of glycine (18%), cysteine (10%), aspartate (12%), serine (13%), and glutamate (14%). 8. The component belongs to the family of metallothionein-like proteins and is thought to play a role in the detoxification of cadmium.