Reliability of skin test results when read at different time points.

Percutaneous skin testing to determine allergies is usually read 15-20 minutes after placement, but the time to reading may be prolonged because of clinic duties or emergencies. The objective of the study was to compare skin-prick testing (SPT) wheal and flare reactions at 10, 30, and 40 minutes with the standard 20 minutes to determine if extended time from placement to reading skin tests interferes with clinical significance. Fifty-three subjects undergoing routine aeroallergen SPT for allergy symptoms were tested with allergen extracts, histamine, and a negative control solution. Based on these results, SPTs can be read up to 40 minutes after placement but are more reliable when read between 20 and 30 minutes after placement. Skin testing to determine IgE-mediated or immediate hypersensitivity can be read up to 30 minutes without significant loss of reliability.

Frequency, timing, and type of prodromal symptoms associated with hereditary angioedema attacks.

Hereditary angioedema (HAE) types I and II are autosomal dominant conditions characterized by recurrent attacks of edema formation in the subcutaneous tissue of the body or walls of the upper respiratory or gastrointestinal tract. Frequently, prodromal symptoms occur before an HAE attack. If certain prodromal symptoms were determined to be both sensitive and specific in predicting an acute HAE attack, treatment at the time of the prodrome could prevent development of an attack and decrease morbidity and mortality associated with HAE. The goal is to determine the frequency and timing of prodromal symptoms occurring before HAE attacks. After Institutional Review Board approval, a four-page survey was produced, using a focus group of patients with HAE and was assessed by HAE patients and physicians with expertise in HAE for cognitive reliability. Once devised, the questionnaire was sent to 158 HAE patients. The survey focused on questions related to prodromal symptoms that patients developed before their last HAE attack. Forty-six patients returned the survey and 40 (87.0%) reported the presence of prodromal symptoms before their last HAE attack. Forty-four of 46 (95.7%) reported having had prodromal symptoms before HAE attacks in the past. The most commonly reported prodromal symptoms included unusual fatigue, rash, and muscle aches. Prodromes occur frequently before HAE attacks. This high frequency suggests that prodromal symptoms could be a reliable indication to begin treatment to prevent an acute HAE attack, thus decreasing the anxiety associated with having an HAE attack.

The effect of intranasal steroid budesonide on the congestion-related sleep disturbance and daytime somnolence in patients with perennial allergic rhinitis.

Patients with perennial allergic rhinitis (PAR) often present with nasal congestion, poor sleep, daytime fatigue, and daytime somnolence. Pharmacologic therapy that reduces nasal congestion should improve the PAR patients' sleep quality and reduce daytime somnolence and fatigue. Our hypothesis is that intranasal steroid budesonide (BUD), an effective topical anti-inflammatory agent, will reduce nasal congestion and improve the patients' quality of life. The objective of this study was to determine whether topical steroid BUD improves sleep, daytime somnolence, and fatigue in patients with PAR. Twenty-six subjects were enrolled in a double-blind, placebo-controlled, crossover study using Balaam's design. Patients were treated with intranasal steroid spray BUD or placebo. The Epworth Sleepiness Scale, daily diary, and questionnaires were used as tools for subjective data analysis, which focused on nasal symptoms, sleep quality, daytime somnolence, and fatigue. The results were summarized and compared by PROC MIXED in SAS. The daily diary data showed significant improvement in self-reported nasal congestion (p = 0.04) and daytime sleepiness (p = 0.01) and a trend in reduction of daytime fatigue (p = 0.08) in the BUD group compared with the placebo group. The sleep measures showed statistically significant improvement in total sleep measures score (p = 0.04), "sleep compared with absolute" (p = 0.01), and "refreshing and restorative" sleep (p = 0.04) in the active group. Nasal corticosteroid BUD is effective in reducing nasal congestion, daytime somnolence, and daytime fatigue, and improving sleep quality in PAR.

Effect of topical nasal corticosteroids on patients with chronic fatigue syndrome and rhinitis.

BACKGROUND: Chronic fatigue syndrome (CFS) is a disabling illness of persistent fatigue. Recent studies have shown that patients with CFS have an increased prevalence of nonallergic rhinitis. Inflammation of the nasal passages due to allergic rhinitis can cause nasal congestion resulting in an increased number of sleep disturbances and daytime fatigue. While topical nasal corticosteroids have been shown to alleviate nasal obstruction effectively in patients with rhinitis who do not have CFS, it is unknown whether topical nasal corticosteroids will reduce CFS symptoms. STUDY OBJECTIVE: The purpose of this study is to determine whether topical nasal corticosteroids will reduce daytime sleepiness in patients with CFS and rhinitis. METHODS: Twenty-eight of 31 subjects with rhinitis and a diagnosis of CFS completed the double-blind, randomized, placebo-controlled trial. Two subjects failed screening, and 3 subjects withdrew from the study prior to its completion. Subjects were randomized according to Balaam's crossover design, and one of the following interventions was used for each group in the study: 8-week treatment with a topical nasal corticosteroid, 8-week treatment with a placebo saline spray, 4-week treatment with a topical nasal corticosteroid followed by a 4-week treatment with a placebo saline spray, or a 4-week treatment with a placebo saline spray followed by a 4-week treatment with a topical nasal corticosteroid. Data focusing on rhinitis symptoms, severity of chronic fatigue symptoms, and quality of life were gathered at biweekly office visits and with daily diaries. RESULTS: The results indicated that daytime sleepiness was reduced when patients with rhinitis and CFS were treated with topical nasal corticosteroids. The severity of associated CFS symptoms, specifically fatigue, muscle pain, postexertional fatigue, and daily activity, did not improve with treatment. CONCLUSION: Treating the symptoms of rhinitis in patients with CFS does not appear to alleviate daytime fatigue or associated nasal, musculoskeletal, or cognitive complaints. Therefore, it is unlikely that aggressive treatment of such symptoms with topical nasal corticosteroids will provide significant benefit to patients with CFS who do not have allergic rhinitis. These results indicate that the nonallergic rhinitis seen in patients with CFS may arise from a mechanism other than chronic inflammation.

The effect of topical nasal fluticasone on objective sleep testing and the symptoms of rhinitis, sleep, and daytime somnolence in perennial allergic rhinitis.

Recent data suggested that daytime somnolence in patients with allergic rhinitis was secondary to disrupted sleep caused by nasal congestion. Medications, which decreased congestion, would be expected to improve sleep and daytime somnolence. Previously, we showed that nasal steroids improved all three symptoms. Presently, we have not performed objective sleep testing to determine if there is a correlation between subjective improvement of congestion, sleep, and daytime somnolence. The objective of this 8-week, double-blind, placebo-controlled study was to determine if topical nasal fluticasone is effective at decreasing subjective congestion and daytime somnolence and improving sleep and if this improvement correlated with a change in overnight sleep testing (polysomnography). We recruited 32 subjects with perennial allergic rhinitis and randomized them in a double-blinded, cross-over fashion, to receive placebo or fluticasone (50 micrograms a spray), 2 sprays each side everyday, using Balaam's design. Questionnaires, quality of life instruments, daily diary, Epworth Sleepiness Scale, and an overnight sleep test with polysomnograms were used as tools. The last 2 weeks of each 4-week treatment period were summarized, scored, and compared by PROC MIXED in SAS. Correlations between arousals on sleep tests and subjective tests were performed. Fluticasone improved subjective sleep when compared with placebo (p = 0.04); however, there was no difference in the apnea/hypopnea index in those that were treated. Daytime sleepiness and fatigue were decreased by > 10% in the treated group; however, this was not statistically significant. However, fluticasone used at approved doses improves subjective sleep in patients with perennial allergic rhinitis without a change in the apnea/hypopnea index.