Provocation Test Research Articles

Coronary slow flow as measured by corrected TIMI frame counts is associated with impaired microvascular resistance

Abstract Background The Coronary Slow Flow Phenomenon (CSFP) reflects an increased resting microvascular resistance and has been defined as a corrected thrombolysis in myocardial infarction frame count (cTFC) >27 in the in the absence of obstructive coronary artery disease (CAD). However, there is limited and conflicting data on the diagnostic utility of CTFC with respect to gold standard coronary haemodynamic parameters; namely coronary flow reserve (CFR) and hyperaemic microvascular resistance (hMR). Purpose To evaluate the relationship between angiography-derived cTFC and the coronary haemodynamic parameters (CFR and hMR). Methods Patients with angina and non-obstructive CAD (< 50% epicardial stenosis; ANOCA) underwent comprehensive functional coronary angiography utilising a dual sensor-tipped pressure-doppler flow wire during adenosine infusion for investigation of coronary microvascular impairment, and acetylcholine provocative testing for the diagnosis of coronary artery spasm. Results In 103 patients who underwent functional coronary angiography, 60 patients had CSFP and this was associated with low flow velocity and higher microvascular resistance at rest as compared with patients without CSFP (19.2 ± 7.3 versus 22.6 ± 6.7, p=0.024; and 5.9 ± 2.0 versus 4.6 ± 1.7, p=0.009, respectively). Whilst cTFC was poorly associated with CFR (r= 0.058, p= 0.564), there was a relatively strong, positive correlation with hMR (r=0.258, p=0.008). Furthermore, receiver operating characteristic analyses demonstrated that CTFC poorly predicts an impaired CFR <2.5 (AUC, 0.479 [0.36-0.59]) but does predict an impaired hMR >2.5 (AUC, 0.623 [0.51-0.74] p=0.037). Conclusion In patients with ANOCA, cTFC is associated with coronary microvascular dysfunction as measured by microvascular resistance during hyperaemia. This data suggests the cTFC may be a surrogate marker for impaired microvascular resistance.cTFC versus hMR

Predictors of microvascular spasm by spasm provocation testing in patients having angina with no obstructive coronary arteries

Abstract Background Microvascular dysfunction in patients having angina with no obstructive coronary arteries (ANOCA) has been recognized to be associated with poor prognosis, while microvascular spasm (MVS) has not been fully studied due to its diagnostic challenge. Purpose We aimed to explore clinical and coronary physiological characteristics of MVS. Methods We retrospectively studied patients with ANOCA who underwent spasm provocation test (SPT) with intracoronary acetylcholine administration followed by coronary physiological assessment. Epicardial spasm and MVS were diagnosed in accordance with the latest guideline. Physiological indices such as coronary flow reserve (CFR), index of microcirculatory resistance (IMR) and microvascular resistance reserve (MRR) were assessed by bolus thermodilution method using pressure temperature wire in LAD and RCA. Results In a total of 141 patients, 40 (28.4%) patients were diagnosed as epicardial spasm and 22 (15.6%) were diagnosed as MVS according to the diagnostic criteria of the latest guideline. Women was more frequent (63.9% vs 27.3%, P=0.002) and IMR of LAD was significantly higher (34.80 vs 22.95, P=0.005) in patients with versus without MVS. In addition, hypertension tended to be frequent (81.8% vs 60.5%, P=0.089) in patients with MVS. In a multivariable logistic regression analysis, women (odds ratio 5.64 [OR], 95% CI 1.90 – 16.7, P=0.0018) and IMR of LAD (OR 1.02, 95% CI 1.00 – 1.05, P=0.029) were independently associated with the diagnosis of MVS. On the other hand, no clinical characteristics and physiological parameter were significantly associated with epicardial spasm. In a comparison between microvascular and epicardial spasm, women (OR 8.30, 95%CI 2.23 – 30.9, P=0.0016) and IMR of LAD (OR 1.04, 95%CI 1.00 – 1.08, P=0.0462) were still significantly more frequent in MVS patients in multivariable analysis. Conclusion Women and higher IMR of LAD were significantly frequent in patients with versus without MVS, and hypertension tended to be frequent in MVS patients.

Association of vasospastic angina with myocardial bridging and pericoronary adipose tissue attenuation on computed tomography angiography

Abstract Background Recent studies have suggested that vasospastic angina (VSA) is associated with myocardial bridging (MB). The relationship between VSA and pericoronary adipose tissue (PCAT) inflammation has also been reported but still remains to be determined. Purpose We investigated clinical and coronary computed tomography angiographic (CCTA) features in patients with VSA diagnosed by spasm provocation test (SPT). Methods We retrospectively studied patients with clinically suspected VSA who underwent both SPT with intracoronary acetylcholine administration and CCTA within three months before SPT at Tsuchiura Kyodo General Hospital. PCAT inflammation was evaluated on CCTA images by fat attenuation index (FAI) which has been recently used as a novel biomarker of coronary inflammation. In FAI analysis, we measured FAI of the proximal segments not only for 4mm (FAI4mm) but also for the inner and thinner 2mm pericoronary adipose tissue layer from the vessel wall (FAI2mm), since FAI2mm has been reported to provide better discriminating efficacy for VSA diagnosis than FAI4mm. We also evaluated the presence or absence of MB and its features including length, depth and location on CCTA images. Results A total of 172 patients were studied and VSA was diagnosed in 39.0% (67/172) of patients by SPT according to the latest guideline. Male (74.6% vs 49.5%, P=0.001), smoking history (74.6% vs 48.6%, P=0.001) were more frequent, and prevalence of CCTA-defined MB (47.8% vs 34.3%, P=0.082) and RCA-FAI2mm (-68.73 HU vs -73.35 HU, P<0.001) were higher in patients with versus without VSA. In multivariable analysis, presence of CCTA-defined MB (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.26-5.19, P=0.0095), RCA-FAI2mm (OR 1.05, 95% CI 1.01-1.09, P=0.025), and smoking (OR 3.40, 95% CI 1.57-7.36, P=0.0019) were independently associated with VSA. A combination of high RCA-FAI2mm (≥-68.93HU, the best cut-off obtained by ROC analysis with AUC of 0.64, 95% CI 0.551 - 0.728), smoking history and existence of MB could predict VSA with 73.7% of probability, while an absence of all 3 covariates could exclude VSA with 85.3% of probability. Conclusion CCTA-defined MB, high RCA-FAI2mm and smoking were independently predictive of VSA.

Clinical Relevance of Specific IgE in Penicillin Allergy Investigation

Introduction: Patients with immediate type allergic reactions to penicillins are at risk of anaphylaxis on reexposure. Diagnostic gold standard is drug provocation test (DPT) if allergy is not diagnosed by other means, such as skin testing or in vitro testing with measurement of specific IgE. Specific IgE testing carries low risk for the patient and blood sampling can be performed in primary care, but it is reported to have low sensitivity. The aim of this study was to evaluate if clinical characteristics of patients with suspected allergic reactions to penicillin and elevated specific IgE to penicillins, differed from patients without specific IgE, to identify predictors for elevated specific IgE to penicillins. Methods: Levels of specific IgE to five penicillins (penicillin G, penicillin V, amoxicillin, ampicillin, and penicillin minor determinants) were available for 9,100 patients. Using multiple logistic regression, clinical data from 430 patients in this group who had elevated specific IgE to one or more penicillins were compared to data from 4,094 patients without specific IgE to penicillins, who had undergone DPT with a penicillin. Results: In total 5.2% of patients had elevated specific IgE to one or more penicillins. Significantly more patients with elevated specific IgE had a history of immediate type reactions (<2 h) (OR = 4.34, p < 0.001); circulatory symptoms (OR = 1.63, p = 0.03) or angioedema (OR = 1.46, p = 0.005). Also, significantly more patients with elevated specific IgE had been treated with adrenaline (OR = 2.21, p = 0.005), steroids (OR = 1.76, p < 0.001), or antihistamines (OR = 1.83, p < 0.001). Conclusion: A history of an immediate type reaction requiring treatment, combined with elevated specific IgE to one or more penicillins is suggestive of an IgE mediated penicillin allergy and further allergy investigations may not be needed. Specific IgE to penicillins may be used early in allergy investigation of patients with severe immediate type reactions to penicillins.

Allergic rhinitis: a brief overview of the etiopathogenesis and rehabilitation of patients

The article presents a brief overview of modern literature sources concerning the prevalence, etiopathogenetic approaches in the diagnosis and treatment of allergic rhinitis. The relevance of the problem under consideration is due to the high prevalence of this pathology, the variety of etiopathogenetic mechanisms and the variability of classifications. One of the most popular classifications is seasonal. When studying pathogenetic mechanisms, the following patterns were revealed: the nasal mucosa is the main air conditioner of the respiratory tract and the first line of defense against infectious agents transmitted by airborne droplets. These roles require maintaining and restoring epithelial integrity and the ability to initiate immune responses. When conditions or factors are present that compromise the integrity of the mucosa, the epithelium releases alarmins and other molecular patterns associated with damage that trigger repair mechanisms but can also cause protective inflammation. In allergic rhinitis, the same mechanisms can activate the development of the disease. Many authors consider various diagnostic methods for allergic rhinitis. Such as a detailed and competent collection of complaints and anamnesis, including family history, physical examination, endoscopic examination of the nasal cavity, rhinomanometry, skin prick tests, radiological studies, including computed tomography of the paranasal sinuses, intradermal tests, study of total and specific immunoglobulins E in blood serum, basophil activation test, nasal provocation test, nasal cytology and biopsy histology, acoustic rhinometry, nasal inspiratory peak flow testing, and nitric oxide measurements are used. Attention is also paid to laboratory and instrumental methods for the differential diagnosis of rhinitis of pseudoallergic origin; the following methods are used: ultrasound diagnostics of the hepatobiliary system, biochemical blood test, and immunological studies. Treatment of patients with allergic rhinitis requires an integrated and interdisciplinary approach and, of course, requires differential and personalized methods taking into account etiopathogenetic mechanisms.

Are pediatricians aware of the mysterious FPIES? Current diagnostic and treatment options. Case report

The prevalence of food allergies continues to grow steadily, and due to certain difficulties in diagnosing allergies not associated with immunoglobulin E, some conditions are little known. Such diagnosis-challenging diseases include food protein-induced enterocolitis syndrome (FPIES), a relatively low-prevalence disease most commonly occurring in early childhood but, in some cases, affecting adults as well. The pathogenesis of FPIES has not been reliably studied. FPIES is associated with elevated serum tryptase and release of pro-inflammatory cytokines, including interleukin-17. A characteristic symptom of FPIES is uncontrollable vomiting, which is probably triggered by the serotonin secreted by enterochromaffin cells, which activates the vagus nerve and the vomiting reflex, determining a good response of vomiting relief with ondansetron, a serotonin receptor antagonist. Changes in gut microbiota composition were also reported in FPIES. FPIES can lead to severe complications such as hypovolemic shock due to the rapid progression of symptoms and rapid dehydration, which often requires hospitalization of patients with acute FPIES. The provoking factors usually include products from the "big nine" allergens: cow's milk, eggs, gluten, soy, nuts, peanuts, fish, seafood, and sesame. FPIES can be acute or chronic; the manifestations slightly differ depending on the disease form. Laboratory diagnosis is difficult due to the lack of reliable biomarkers, and the diagnosis is established clinically and confirmed with an oral provocation test. The key treatment for FPIES is to eliminate the trigger protein from the diet, and depending on the severity of the disease, some patients may be allowed to consume a heat-treated allergen. The prognosis of FPIES is favorable: tolerance to the trigger product in most cases is developed within two years. Further studies are required to clarify the pathogenesis, prevalence, and treatment methods, with prospective follow-up of patients with a history of FPIES and the analysis of concurrent and subsequent diseases, including allergic conditions. The article presents two clinical cases of children diagnosed with FPIES.

Postprandial Symptoms in a Mixed-Meal-Test after Bariatric Surgery: Clinical Experience and a Critical Review of Dumping Syndrome Definition and Management

Plain Language SummaryDumping syndrome (DS) is a set of symptoms, which may occur in patients after bariatric surgery (weight loss surgery). These symptoms occur after meals and are attributed to a fast passage of food through the surgically altered stomach and intestine. The symptoms of DS include fainting, the need to lie down, shortness of breath, and dizziness. Current recommendations suggest measuring heart rate, taking laboratory measurements and comparing these to diagnostic criteria during a provocation test with a glucose solution. We have been using a so-called Mixed-Meal Test to evaluate the patients’ symptoms at our clinic. Patients would eat a meal designed according to recommendations for patients after bariatric surgery, made of curd, oats, apple sauce, and walnuts. Then, their symptoms, blood pressure, and blood samples would be collected for 180 min. We looked at the data from all 56 tests, we had performed at our clinic, and compared the measurements, which we had obtained, to the diagnostic criteria and symptoms reported. While all patients reported symptoms at home, only 28% reported typical symptoms during the test. We did not find meaningful associations between measurements taken by us and symptoms reported by patients. This study shows that many patients do not display typical symptoms under controlled conditions. At the same time, the diagnostic criteria seem to be unrelated to symptoms. It is not the first study showing discrepancies between measurements, diagnostic criteria, and symptoms. The current tests used for diagnosing DS may not be clinically useful and the whole concept of DS after bariatric surgery may need to be reevaluated.

Differentiating the Structural and Functional Instability of the Craniocervical Junction.

This paper presents the anatomical and biomechanical aspects of chronic instability of the craniocervical junction (CCJ) with a discussion on clinical diagnostics based on mobility tests and provocative tests related to ligamentous system injuries, as well as radiological criteria for CCJ instability. In addition to the structural instability of the CCJ, the hypothesis of its functional form resulting from cervical proprioceptive system (CPS) damage is discussed. Clinical and neurophysiological studies have shown that functional disorders or organic changes in the CPS cause symptoms similar to those of vestibular system diseases: dizziness, nystagmus, and balance disorders. The underlying cause of the functional form of CCJ instability may be the increased activity of mechanoreceptors, leading to "informational noise" which causes vestibular system disorientation. Due to the disharmony of mutual stimulation and the inhibition of impulses between the centers controlling eye movements, the cerebellum, spinal motoneurons, and the vestibular system, inadequate vestibulospinal and vestibulo-ocular reactions occur, manifesting as postural instability, dizziness, and nystagmus. The hyperactivity of craniocervical mechanoreceptors also leads to disturbances in the reflex regulation of postural muscle tone, manifesting as "general instability". Understanding this form of CCJ instability as a distinct clinical entity is important both diagnostically and therapeutically as it requires different management strategies compared to true instability. Chronic CCJ instability significantly impacts the quality of life (QOL) of affected patients, contributing to chronic pain, psychological distress, and functional impairments. Addressing both structural and functional instability is essential for improving patient outcomes and enhancing their overall QOL.

Physiological provocation compared to acetazolamide in the assessment of cerebral hemodynamics: a case report

BackgroundSevere large vessel disease may lead to cerebral hemodynamic failure that critically impairs cerebral blood flow (CBF) regulation elevating the risk of ischemic events. Assessment of the condition is often based on changes in CBF during vasodilatation; however, pharmacologically induced vasodilation does not reflect the physiological condition during an ischemic event caused by hemodynamic failure. We compared a [15O]H2O PET brain scan during vasodilation to a [99mTc]HMPAO SPECT brain scan during an ongoing transient ischemic attack (TIA).Case presentationA single patient presenting with limb-shaking TIA underwent CT, Digital Subtraction Angiography, and two different modalities of cerebral perfusion scans: [15O]H2O PET and [99mTc]HMPAO SPECT. Acetazolamide was used in the PET scan to induce vasodilatation, and during the SPECT scan physiological stress, standing up rapidly, was used to induce limb-shaking TIA. CT-angiography and Digital Subtraction Angiography revealed an occlusion in the distal part of the right A2 segment of the anterior cerebral artery, with a corresponding infarction in the watershed area. Collaterals supplied the main vascular territory of the anterior cerebral artery. During rest, neither perfusion modalities demonstrated reduced perfusion outside of the ischemic core. However, we found a pronounced difference between the PET utilizing acetazolamide and the SPECT during the TIA. The PET scan demonstrated relative hypoperfusion in vascular territory supplied by collaterals, while the area around the ischemic core was not affected. Contrary, the SPECT had only minor relative hypoperfusion in the collateral-supplied area, whereas the watershed area proximal to the infarct core had pronounced relative hypoperfusion.ConclusionsThe observed discrepancy in compromised areas during physiological provocation compared to pharmacological induced vasodilation questions the use of an unphysiological stressor for assessment of cerebrovascular hemodynamics. A physiological provocation test may achieve more clinically relevant evaluation.

Sudden cardiac death due to adrenal insufficiency masquerading as Brugada syndrome. Case report

Sudden cardiac death in young people in 20% of cases is caused by cardiomyopathies and channelopathies. One of the forms of channelopathies is Brugada syndrome, a hereditary disease characterized by ST segment elevation in the right precordial leads (V1-V3) and an increased risk of sudden cardiac death in the absence of structural heart disease. Brugada phenocopies are also known – clinical situations that are manifested by electrocardiogram (ECG) patterns identical to true Brugada syndrome. They are caused by different clinical circumstances and form a group of heterogeneous conditions that are often difficult to distinguish from true congenital Brugada syndrome due to identical ECG patterns. The formation of Brugada phenocopy due to hyperkalemia is presented in the literature in various conditions: with renal failure, after extensive trauma, application of medications. The article presents a case report demonstrating a rare cause of sudden cardiac arrest in a young patient without a history of cardiovascular pathology: the occurrence of the Brugada pattern on the ECG due to severe hyperkalemia in adrenal insufficiency. The stages of the differential diagnostic search are described, which made it possible to verify the final diagnosis and prescribe effective hormone replacement therapy. Performing a provocative test with novocanamide allowed us to confirm that the patient had a phenocopy, and not Brugada syndrome. Differential diagnosis of phenocopies of Brugada syndrome – a series of often life-threatening cardiac and non-cardiac diseases and conditions, manifested by similar ECG changes in the form of a peculiar ST segment elevation in leads V1-V3, is often a difficult task. This case represents a phenocopy of Brugada in the setting of severe hyperkalemia with development of cardiac arrest due to adrenal insufficiency, which resolved with correction of electrolyte abnormalities and treatment of the underlying disease. Typical ECGs are presented: a graph of the Brugada phenomenon, hyperkalemia, a sinusoidal curve during cardiac arrest, recorded over time in a patient, and the pathogenetic mechanisms causing the formation of the Brugada pattern in adrenal insufficiency are explained.

Absolute coronary blood flow across different endotypes of ANOCA.

Intracoronary continuous thermodilution is a novel technique to quantify absolute true coronary flow and microvascular resistance. However, few data are available in patients with angina with non-obstructive coronary arteries (ANOCA). This study aimed to investigate the diagnostic potential of hyperaemic absolute coronary flow (Qmax) and absolute microvascular resistance (Rμ,hyper) among different ANOCA endotypes, and to determine the correlation between continuous - and bolus - thermodilution indexes. A total of 222 patients were scheduled for clinically indicated coronary function testing (CFT), of whom 120 patients were included in this analysis. These patients underwent CFT including acetylcholine (ACh) provocation testing and microvascular function assessment using both bolus and continuous thermodilution. CFT was negative (CFT-) in 32 (26.7%) patients. Endothelium-dependent dysfunction (ACh+) was present in 63 (52.5%) patients, and coronary microvascular dysfunction (CMD) identified at bolus thermodilution (CMD+) was present in 62 (51.7%) patients. Patients with a positive CFT (CFT+) showed significantly lower Qmax and higher Rμ,hyper values as compared to CFT-. Qmax was significantly lower in CMD+ versus CMD- patients (0.174 vs 0.222 L/min; p=0.04) but did not differ in patients with or without a positive ACh test (0.198 vs 0.219 L/min; p=0.86). The prevalence of a CFT+ is high in a selected ANOCA population. In our study, Qmax and Rμ,hyper were associated with a positive CFT. Qmax was associated with the presence of microvascular dysfunction but not with a positive acetylcholine test. The novel continuous thermodilution method can provide further insights into ANOCA endotypes.

Nasal allergen and methacholine provocation tests influence co‑expression patterns of TGF‑β/SMAD and MAPK signaling pathway genes in patients with asthma.

Asthma is characterized by chronic bronchial inflammation and is a highly heterogeneous disease strongly influenced by both specific and non-specific exogenous factors. The present study was performed to assess the effect of nasal allergen provocation tests and methacholine provocation tests on the mRNA co-expression patterns of genes (SMAD1/3/6/7, MPK1/3 and TGFB1/3) involved in SMAD and non-SMAD TGF-β signaling pathways in patients with asthma. Reverse transcription-quantitative PCR was performed on blood samples taken pre-provocation and 1 h post-provocation to assess gene expression changes. Of the 59 patients studied, allergen provocations were administered to 27 patients and methacholine provocations to 32 patients. Correlations between expression levels of studied genes were found to be influenced markedly by the challenge administered, challenge test result and time elapsed since challenge. Importantly, increases in expression levels for four gene pairs (MAPK1-SMAD3, MAPK3-SMAD3, SMAD1-SMAD3 and SMAD3-TGFB1) were found to correlate significantly with asthma occurrence in the allergen provocation cohort, but not in the methacholine provocation cohort. The present study allows us to draw the conclusion that both intranasal allergen and bronchial methacholine challenges influence mRNA co-expression patterns of the SMAD1/3/6/7, MPK1/3 and TGFB1/3 genes.

Five weeks of intermittent hand exposures to alternating cold and hot stimuli do not modify finger cold-induced vasodilatation response.

We tested the hypothesis that prolonged intermittent hand exposures to transient contrast thermal stimuli would enhance the finger cold-induced vasodilatation (CIVD) response during localized cooling. Eight healthy men participated in a 5-week regimen, during which they immersed, thrice per week, the non-dominant (EXP) hand in 8° and 43°C water, sequentially and at 3-min intervals, for a total period of 60min. The contralateral (i.e., dominant) hand served as the control (CON) hand. Before and after the regimen, subjects conducted two 30-min hand cold (8°C water) provocation trials, one with the EXP hand and the other with the CON hand. In addition, a flow-mediated dilatation test was performed in the brachial artery of the EXP arm. Regardless of the hand tested, the average finger skin temperature [CON hand: pre-trial=10.5 (1.2)°C, post-trial=10.8 (1.3)°C and EXP hand: pre-trial=10.7 (1.1)°C, post-trial 10.9 (1.1)°C; p=0.79], and the incidence of CIVD events [CON hand: pre-trial=1.1 (1.2) events, post-trial=1.2 (1.1) events and EXP hand: pre-trial=1.1 (0.8) events, post-trial=1.1 (0.8) events; p=0.88] were not affected by the 5-week regimen. The sensation of cold-induced pain was transiently alleviated following the regimen (p=0.02). The flow-mediated dilatation response of the EXP brachial artery remained unaltered [pre-trial=5.4 (3.2)%, post-trial=4.7 (3.6)%; p=0.51]. Therefore, five weeks of intermittent hand exposures to alternating cold and hot stimuli do not improve finger temperature responsiveness to sustained localized cold.

TCT-602 Association Between the Severity of Coronary Artery Stenosis and the Minimum Responsive Dose of Intracoronary Provocation Test

TCT-602 Association Between the Severity of Coronary Artery Stenosis and the Minimum Responsive Dose of Intracoronary Provocation Test

S834 Positive Provocative Testing and Symptom Evaluation for Objective Detection of Upper Extremity Repetitive Use Injuries Among Endoscopists

S834 Positive Provocative Testing and Symptom Evaluation for Objective Detection of Upper Extremity Repetitive Use Injuries Among Endoscopists

Cow's milk allergy treatment. An expert consensus

The treatment of cow's milk protein allergy is based on the complete elimination of cow's milk protein from the diet. To achieve remission of symptoms and future tolerance, exclusion must be total. In formula fed infants the extensively hydrolysed formula is the most appropriate option in mild or moderate forms, while those based on amino acids are reserved for the most severe cases. The treatment time, the acquisition of tolerance and the moment for the oral provocation test will vary according to the clinical picture, the immunological mechanism involved and the age of the patient. The aim of this consensus has been to reflect the updated knowledge together with the experience of neonatologists, pediatricians, experts in allergy, nutrition and gastroenterology.

Global differences and risk factors influencing drug hypersensitivity quality of life: A multicenter, multiethnic study of drug allergy across 3 continents

BackgroundPenicillin allergy labels are associated with many adverse outcomes. Fear and restriction of future medication use also impact health-related quality of life (HR-QoL). However, the impact of a drug allergy on HR-QoL and its associated factors remain unknown. ObjectiveTo investigate the impact of penicillin allergy labels and compare the factors associated with HR-QoL impairment among an international multi-center and multi-ethnic cohort. MethodsHR-QoL was measured using the 6-item Drug Hypersensitivity Quality of Life Questionnaire (DrHy-Q) and compared among patients labelled with penicillin allergy, before their allergy evaluation, from eight adult allergy/immunology clinics across Asia, Australasia, and North America. ResultsWe recruited 643 patients labelled with penicillin allergy (median age: 56 [IQR 39-67] years, male: female ratio: 1:2.2), with 273 (42.5%), 186 (28.9%) and 184 (28.6%) from Asia, North America and Australia; respectively. The median DrHy-Q score was 8.3 (IQR 0.0–29.2). All patients underwent penicillin allergy evaluation, and 96.0% (617/643) were delabelled following negative provocation tests. Patients who were female (8.3 vs. 4.2, p=0.003), had other concomitant antimicrobial allergy labels (20.8 vs. 4.2, p=0.004), and from Asia (33.3 vs. 4.2 [North America] vs. 0 [Australia], p<0.001) had significantly higher DrHy-Q scores, reflecting a reduced HR-QoL. Ethnicity, as well as other allergy variables, were not significant in multivariate analysis. ConclusionRegional differences, ethnicity, and other risk factors influence HR-QoL impairment among patients labelled with penicillin allergy. Future studies are needed to understand the contributions of regional socio-demographic factors and identify interventions to improve HR-QoL.

S801 Dose-Related Effects of Ricinoleic Acid (Castor Oil) on Gut Permeability in Healthy Participants: Provocative Test for Treatments Aimed at Restoring Barrier Function

S801 Dose-Related Effects of Ricinoleic Acid (Castor Oil) on Gut Permeability in Healthy Participants: Provocative Test for Treatments Aimed at Restoring Barrier Function

Validation of the Cholinergic Urticaria Activity Score (CholUAS)

BackgroundIn cholinergic urticaria (CholU), itchy wheal and flare-type skin reactions are triggered by sweat-inducing activities. The CholU activity score, CholUAS, is used to assess disease activity, but has not yet been validated.The aim of the study was to validate the CholUAS, develop an English version, and provide instructions for scoring. MethodsCognitive debriefing of CholUAS was performed. CholU patients (n =75) used the CholUAS on 7 consecutive days, underwent provocation testing, and completed additional anchor instrument questionnaires including global evaluation tools and established quality of life instruments. A scoring protocol for the calculation of the weekly CholUAS, the CholUAS7, was developed. The CholUAS7 was tested for validity, reliability, and influencing factors. An English version of the CholUAS was developed. ResultsThe final CholUAS contains 3 questions that are used for scoring as well as one global question. The weekly CholUAS, CholUAS7, showed excellent test-retest reliability and good correlations with anchor instruments. Statistical analysis showed no significant influence of age or duration of disease on CholUAS7 results. ConclusionThe validated CholUAS is ready for use in clinical trials and routine clinical practice.

Evaluation of the efficacy of low-level laser therapy in the treatment of ulnar neuropathy at the elbow in terms of symptoms and clinical and electrophysiological findings: a randomized, prospective, double-blind clinical trial.

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy and presents with symptoms such as pain, paresthesia, and weakness in the elbow. Provocative tests and electrophysiological examinations are helpful in the diagnosis of UNE. Low-level laser therapy is one of the conservative treatments of UNE however, limited results were reported on the effectiveness of low-level laser therapy (LLLT) in the treatment of UNE. In our study, we aimed to the efficacy of LLLT in reducing symptoms and providing clinical and electrophysiological improvement in patients with UNE. This study with a randomized-sham controlled, and double-blind design included 68 patients aged 18-60 years who were diagnosed with UNE. LLLT was applied to the first group, and sham laser was applied to the second group. The VAS pain, paresthesia, and weakness scores, grip strength, and provocative test positivity were evaluated in clinical examination. The QuickDASH questionnaire was administered to assess functional status. Electrophysiologically, motor distal latency (MDL) differences, sensory distal latency (SDL), motor and sensory nerve conduction velocity (NCV) were examined. Evaluations were performed before treatment and on the 15th day and at the third month after treatment. The LLLT group showed improvement in symptoms, clinical findings, motor NCV, and MDL at both post-treatment evaluations and sensory NCV on the post-treatment 15th day (p < 0.05). The comparison of post-treatment changes between the two groups revealed that the LLLT group had greater improvement in VAS day and night pain scores at both post-treatment evaluation times, QuickDASH scores at the third month, and sensory NCV on the 15th day (p < 0.05) compared to the SL group. There were no significant differences between the groups in terms of the post-treatment changes in VAS weakness scores, grip strength and electrophysiological findings (p > 0.05). It was observed that splinting alone was effective in UNE, but the addition of LLLT, one of the conservative treatment methods, enhanced treatment outcomes.