The identification of multiple-input multiple-output (MIMO) systems is an important part of designing complex control systems. This paper studies an auxiliary model least squares iterative (AM-LSI) algorithm for MIMO systems. With the expansion of the system scale and limitations of the computer resources, there is an urgent need for an identification algorithm that provides higher computational efficiency. To address this issue, this paper further derives a hierarchical identification model and proposes a new auxiliary model hierarchical least squares iterative (AM-HLSI) algorithm for MIMO systems by applying the hierarchical identification principle. Through the analysis of the computational efficiency, the AM-HLSI algorithm has higher computational efficiency than the AM-LSI algorithm. Additionally, the feasibility of the AM-LSI and AM-HLSI algorithms is validated by a simulation example.

Chagas disease is caused by the Trypanosoma cruzi parasite and is transmitted by infected triatomine bugs. This infection affects approximately 8 million people in the Americas, and due to globalization and displacement, it is becoming increasingly common to find infected patients worldwide. Diagnosis of the disease in its acute form is relatively simple, as the parasite can be detected in peripheral blood smears, and symptoms are visible. However, in its chronic condition, the parasite is almost undetectable, and indirect tests are necessary to determine the presence of antibodies in infected patients. It is important to note that a single test is not enough to confirm the disease, as a second serological test should confirm the diagnosis. If the results are contradictory, a third test should be performed to solve the problem. Unfortunately, laboratories may not have access to all necessary tests in many rural areas where the disease is more frequent. Rapid tests to diagnose this disease present problems, such as significant variations in sensitivity and specificity in different countries. Therefore, searching for new biomarkers that allow for optimal correlation is essential. In this work, we have searched scientific literature from the last years for mentions of novel biomarkers for diagnosis, treatment follow-up, and prediction of cardiac complications in Chagas disease in its chronic phase.

Introduction and objectives：Traditional transcatheter closure of atrial septal defect (ASD) via the femoral vein carries risk of radiation damage. Transcutaneous closure of ASD under echocardiography guidance avoids radiation exposure and can be gradually applied. An alternative is to transcutaneous closure of ASD trans-jugular with an adjustable curved sheath under echocardiography guidance. Methods: We retrospectively studied all cases of trans-jugular transcutaneous closure of ASD with an adjustable curved sheath under echocardiography guidance in the Heart Center of Henan Province People’s Hospital between 2016 and December 2022. Results: 156 patients were included, 74 males and 82 females. Mean age was 6.9 ± 7.4 years and weight 23.7 ± 14.6 kg. Mean sizes of the ASD and occluder were (9.7 ± 4.7) mm and (14.1 ± 5.7) mm. The mean operation time was (49.6 ± 29.2) min. No complications such as atrioventricular block, reoperation, or pericardial effusion occurred. There are 3 patients had a residual shunt. All patients were followed-up for (38.7 ± 11.0)months. The 3 patients with residual shunt had self-closed at the 3-6-12months follow-up. There was no complication at follow-up. Conclusion: Trans-jugular transcutaneous closure of ASD with adjustable curved sheath under echocardiography guidance is safe, effective and minimally invasive.

Interdisciplinary teams are on the rise as scientists attempt to address complex environmental issues. While the benefits of Team Science approaches are clear, researchers often struggle with its implementation, particularly for new team members. The challenges of large projects often weigh on the most vulnerable members of a team: trainees, including undergraduate students, graduate students, and post-doctoral researchers. Trainees on big projects have to navigate their role on the team, with learning project policies, procedures, and goals, all while also training in key scientific tasks such as co-authoring papers. To address these challenges, we created and participated in a project-specific, graduate-level Team Science course. The purposes of this course were to: (1) introduce students to the goals of the project, (2) build trainees’ understanding of how big projects operate, and (3) allow trainees to explore how their research interests dovetailed with the overall project. Additionally, trainees received training regarding: (1) diversity, equity & inclusion, (2) giving and receiving feedback, and (3) effective communication. Onboarding through the Team Science course cultivated psychological safety and a collaborative student community across disciplines and institutions. Thus, we recommend a Team Science course for onboarding students to big projects to help students establish the skills necessary for collaborative research. Project-based Team Science classes can benefit student advancement, enhance the productivity of the project, and accelerate the discovery of solutions to ecological issues.

The Neretva dwarf goby Orsinigobius croaticus (Gobiiformes, Gobionellidae) is an endemic fish native to the freshwaters of the Adriatic Basin in Croatia and Bosnia and Herzegovina. Due to its limited distribution range, specific karst habitat and endangered status, laboratory studies on reproductive biology are scarce. We investigated the sound production and acoustic behaviour of this species during reproductive intersexual laboratory encounters. We performed dissection and micro-computed tomography (μCT) scanning of the pectoral girdle to explore the anatomy of its putative sound producing mechanism. To study interspecific acoustic differences and determine whether acoustic features can discriminate among species, comparative analysis was conducted on sounds produced by closely related soniferous sand gobies. Our results indicate that males of the O. croaticus emit pulsatile sounds composed of a variable number of short (~ 15 ms) consecutive pulses when interacting with females, usually during the pre-spawning phase in the nest, but also during courtship outside the nest. Pulsatile sounds were low-frequency and short pulse trains (~ 140 Hz, < 1000 ms), and spectro-temporal parameters were correlated with physical traits and water temperature. Male visual behaviour rate was higher when co-occurring with sounds and females entered the male’s nest significantly more frequently when sounds were present. Male sound production was accompanied by movements such as head thrust and fin spreading. μCT scans and dissections suggest that O. croaticus shares certain anatomical similarities of the pectoral girdle (osseous elements and arrangement of levator pectoralis muscles) to previously studied sand gobies. Multivariate comparisons, using sounds produced by eight soniferous European sand gobies, effectively distinguished soniferous (and sympatric) species based on acoustic properties. Discrimination success decreased when temperature-dependent features (sound duration and pulse repetition rate) were excluded from analysis. Therefore, we suggest both spectral and temporal features are important for acoustic differentiation of sand gobies.

The plants’ geographical distribution is affected by natural or human-induced climate change. Numerous studies at both the global and regional level currently focus on the potential changes in plant distribution areas. Ecological niche modeling can help predict the likely distribution of species according to environmental variables under different climate scenarios. In this study, we predicted the potential geographic distributions of Quercus ilex L. (holm oak), a keystone species of the Mediterranean ecosystem, for the Last Interglacial period (LIG: ~120 Ka), the Last Glacial Maximum (LGM: ~22 Ka), mid-Holocene (MH: ~6 Ka), and future climate scenarios (Representative Concentration Pathway (RCP) 4.5 and 8.5 scenarios) for years 2050-2070 obtained from CCSM4 and MIROC-ESM global climate scenarios respectively. The models were produced with algorithms from the R-package “biomod2” and assessed by AUC of the Receiver Operating Characteristic plot and True Skill Statistics. Apart from BIOCLIM (SRE), all model algorithms performed similarly and produced projections that are supported by good evaluation scores, although Random Forest (RF) slightly outperformed all the others. Additionally, distribution maps generated for the past period were validated through a comparison with pollen data acquired from the Neotoma Pollen Database. The results revealed that southern areas of the Mediterranean Basin, particularly coastal regions, served as long-term refugia for Q. ilex, which was supported by fossil pollen data. Furthermore, the models suggest long term refugia role for Anatolia and we argue that Anatolia may have served as a founding population for the species. Future climate scenarios indicated that Q. ilex distribution varied by region, with some areas experiencing range contractions and others range expands. This study provides significant insights into the vulnerability of the Q. ilex to future climate change in the Mediterranean ecosystem and highlights the crucial role of Anatolia in the species’ historical distribution.

with other laboratory and clinical investigations. Early and accurate diagnosis of inherited conditions generally leads to better medical care for patients and their families, with improved knowledge of the natural history of the condition and early intervention. It is therefore essential that equitable access to such testing is established for indigenous and isolated populations, in order to further narrow the health disparity gap. Although supported by funding from a few sources, this study signals a success for the Silent Genomes Project, with one of the cases having been identified by whole genome sequencing within that project, after negative whole exome sequencing. Furthermore the study has potential life-changing clinical consequences and provides starting points for possible interventions for respiratory medicine in the Inuit population. These include increased awareness of the possibility of PCD in patients presenting with neonatal respiratory distress, bronchiectasis or otitis media leading to early intervention; and in conjunction with Inuit organizations and public health officials, targeted analysis of the DNAH11 variant in the population with the possible introduction of newborn screening for PCD.

Introduction: Wearable Cardioverter Defibrillator (WCD) is utilized in patients with assumed but not yet confirmed risk for sudden cardiac death (SCD). Many of these patients also present with atrial fibrillation (AF). However, the rate of WCD-detected ventricular or atrial arrhythmia events in this specific high-risk cohort is not well understood. Methods: In WEARIT-II, the cumulative probability of any sustained or non-sustained VT/VF (WCD-treated and non-treated), and atrial/supraventricular arrhythmias during WCD use was assessed using the Kaplan-Meier method by prior AF, with comparisons by the log-rank test. The incidence of ventricular and atrial arrhythmia events were expressed as events per 100 patient-years, and were analyzed by prior AF using negative binomial regression. Results: WEARIT-II enrolled 2000 patients, 557 (28%) of whom had AF prior to enrollment. Cumulative probability of any sustained or non-sustained WCD-detected VT/VF during WCD use was significantly higher among patients with a history of AF than without AF (6% vs. 3%, p=0.001). Similarly, the recurrent rate of any sustained or non-sustained VT/VF was significantly higher in patients with prior AF vs. no prior AF (131.5 events per 100 patient-years vs. 22.7 events per 100 patient-years, p=0.001). Patients with prior AF also had a significantly higher burden of any WCD-detected atrial arrhythmias/SVT/inappropriate therapy (183.2 events per 100 patient-years vs. 74.8 events per 100 patient-years, p<0.001). Conclusion: Our results demonstrate that patients with a history of AF wearing the WCD for risk assessment have a higher incidence of ventricular arrhythmias that may facilitate the decision making for ICD implantation.

People with mpox are likely to be stigmatized because of analogies to other sexually transmitted infections. Stigma is driven by beliefs about the perceived severity of the condition and perceived responsibility for acquiring the condition, both in broader society and individual responsibility. We explored these beliefs and compared them across mpox, HIV, syphilis, gonorrhoea, and chlamydia in an online survey, conducted in July, 2022, with 394 men-who-have-sex-with-men (MSM) in the Netherlands. We compared mean scores between infections using repeated measures ANOVA and conducted hierarchical regression analyses to identify determinants of both mpox perceived responsibility endpoints. Results showed that participants expected that mpox would be seen as a ‘gay disease’ and will be used to blame gay men. Compared to other infections, mpox was considered less severe than HIV, but more severe than syphilis, gonorrhoea, and chlamydia. Perceived responsibility was comparable across infections, but, for each infection, participants perceived attributed responsibility for infection to be higher in society than individual responsibility. Both perceived responsibility endpoints were highly correlated with each other and with other stigma beliefs. These results provide insight on the underlying determinants of mpox stigma, and demonstrate that mpox stigma is present in the Netherlands.

Summary: This paper proposes a 1/f noise optimized correlated multiple sampling (NOCMS) technique based on differentiated sampling weights for CMOS image sensor. Transfer functions of standard CMS and NOCMS for analyzing the suppression effect of random noise respectively are derived based on the Fourier Transform theory. NOCMS shows a dramatic advantage in the suppression of 1/f noise. For implementing NOCMS, the ramp generator provides multiple sets of ramps with different slopes to quantize the reset and signal voltages. Sampling weights are increased with the decrease of ramp slopes. The last reset and first signal values are weighted more due to their potentially higher correlations. Simulation results under 110nm CMOS technology illustrate that the ADC achieves DNL of −0.80/+0.70LSB and INL of −0.70/+0.90LSB after the NOCMS operation. The input-referred random noise is 142.9µV rms under standard CMS and 120.9µV rms under NOCMS when the number of samples equals 8. The noise reduction effect is improved by 15%. NOCMS makes it possible to further reduce 1/f noise of CMOS image sensor.

Cardiovascular diseases (CVDs) are complex, encompassing many types of heart pathophysiologies and associated etiologies. It has been shown that fractionated radiation exposure at high doses (3-17 Gy) to the heart increases the incidence of CVD, as evident from radiotherapy studies. However, the effects of low doses of radiation on the cardiovascular system or the effects from space travel, where radiation and microgravity are important contributors to damage, are not clearly understood. Herein, the adverse outcome pathway (AOP) framework was applied to develop an AOP to vascular remodeling from the deposition of energy. Following the creation of a preliminary pathway with the guidance of field experts and authoritative reviews, a scoping review was conducted which informed final key event (KE) selection and facilitated evaluation Bradford Hill criteria of the key event relationships (KERs). The AOP begins with a molecular initiating event of deposition of energy; ionization events increase oxidative stress, which concurrently causes the release of pro-inflammatory mediators and alters signaling pathways. These KEs alter nitric oxide levels leading to endothelial dysfunction and subsequent vascular remodeling (the adverse outcome). The work identifies evidence needed to strengthen understanding of the causal associations for the KERs, emphasizing where there are knowledge gaps and uncertainties in both qualitative and quantitative understanding. The AOP is anticipated to direct future research to better understand the effects of space on the human body and potentially develop countermeasures to better protect future space travelers.

{The use of state estimation techniques offers a means of inferring rotor effective wind speed from standard measurements of wind turbines. Typical wind speed estimators rely upon a pre-computed quasi-steady aerodynamic mapping, which describes the relationship between pitch angle and tip-speed ratio and the power coefficient. In practice, the static mapping does not capture the influence of turbine structural dynamics and atmospheric turbulence, inevitably resulting in poor performance of the wind speed estimation. In addition, the turbine aerodynamic properties might not be easily accessible. Thus, this paper presents a rotor effective wind speed estimation method that obviates the requirement for prior knowledge of turbine power coefficients. Specifically, the proposed method exploits a simple actuator disc model, where the aerodynamic power and thrust coefficients can be characterised in terms of axial induction factors. Based on this insight and standard turbine measurements, real-time estimation of rotor effective wind speed and axial induction factors can then be achieved using a simplified turbine drive-train model and an extended Kalman filter. In addition, the actuator disc model can be updated easily over time by calibrating solely two correction factors. Thus, the proposed algorithm presents an alternative for estimating the rotor effective wind speed, which is valuable for numerous applications, for example, LiDAR-assisted control and coherence studies.

Delayed cerebellar ataxia induced by Plasmodium falciparum malaria: A rare complicationEmmanuel Edwar Siddig1,2,*, Sarah Misbah EL-Sadig3, Hala Fathi Eltigani1, Ahmed Mudawi Musa4, Nouh Saad Mohamed5, Ayman Ahmed4,6,71 Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan2 Faculty of Medical Laboratory Sciences, University of Khartoum, Khartoum, Sudan.3 Faculty of Medicine, University of Khartoum, Khartoum, Sudan4 Institute of Endemic Disease, University of Khartoum, Khartoum, Sudan5 Molecular Biology Unit, Sirius Training and Research Centre, Khartoum, Sudan6 Swiss Tropical and Public Health Institute (Swiss TPH), Allschwil 4123, Switzerland7 University of Basel, Petersplatz 1, Basel 4001, Switzerland* Correspondance: Emmanuel Edwar Siddig; University of Khartoum, Khartoum, Sudan.Email: [email protected]: 0000-0001-6314-7374

A document by Shyam Duvuru. Click on the document to view its contents.

Background: Sickle cell disease (SCD) is characterized by vaso-occlusive crises (VOCs), that impair the health-related quality of life (HRQoL). The aim of this study is to evaluate the impact of hospitalization for VOCs on HRQoL in children with SCD over time. Methods: In this longitudinal cohort study, children aged 8-18 years diagnosed with SCD at the Amsterdam UMC were included between 2012 and 2021. HRQoL was annually measured as part of standard care using the Pediatric Quality of Life Inventory. The impact of hospitalization for VOC on HRQoL was evaluated using linear mixed models 3, 6, 9 and 12 months after hospitalization. The effect of frequency of hospitalization for VOC on HRQoL was evaluated over the last 12 months. Results: In total , 94 children with SCD were included with a median age of 11.8 years (IQR 9-14). Thirty-seven patients (39%) had been hospitalized for a VOC. Hospitalization for VOC led to a decrease of 3.2-4.8 points in total HRQoL compared to patients without hospitalization, most pronounced 3 months after hospitalization. Recurrent admission for VOC in the last 12 months was associated with a decrease of 2.3 points in total HRQoL (p=0.04). The most affected subscale was physical functioning. Conclusion: The adverse effects of hospitalization for VOC in children with SCD persist up to 12 months after hospitalization. After hospitalization for VOC, extra attention and support for its negative impact on HRQoL are recommended. This study also underlines the importance of systematically measuring HRQoL allowing clinicians to intervene accordingly.

Mobile edge computing (MEC) seems to be highly efficient to process the generated data from IoT devices by providing computational resources locating in close range to network edge. MEC can be promising in reduction of latency and consumption of energy from data transmissions from offloading computational tasks from IoT devices to nearby edge servers. In this paper, a computation offloading optimization algorithm is proposed which is based on deep deterministic policy gradient for realistic Aurelia X6 Pro unmanned aerial vehicle (UAV)-assisted MEC systems. The proposed algorithm optimizes the offloading decision for UAVs by taking task characteristics and the communication environment into consideration. The simulation yields outcomes indicating that the suggested algorithm can considerably enhance the competency of MEC systems.

The spatiotemporal variability of groundwater level (GWL) is an important property of peatland hydrology that directly affects fluctuations of water storage. Nonetheless, current understanding of the variations of GWL in different time scales still remains unclear. In this study, two peatland watersheds (0.151 km 2 for W1 and 0.844 km 2 for W2) in the Zoige Basin in the Source Region of the Yellow River (SRYR) were selected for monitoring the temporal variability of GWL using self-recorded water loggers during 2017-2021. The main results demonstrate that: (1) GWL variations tended to be controlled by gully drainage in sites adjacent to the gully and be more synchronized with rainfall in sites distant from the gully. The GWL near the gully that cuts through the peat layer was lower than that near the gully without cutting through the peat layer, with a maximum difference between the former and the latter of 58.3 cm, indicating the effect of longitudinal attenuation of the GWL in W1. (2) Because rainfall had a lag effect on the GWL, the length of lag gradually decreased with increased rainfall intensity (i.e., the lag time of sites far away from the gully was about 18 min shorter than that of sites close to the gully in W1). (3) The peak values of the GWL occurred simultaneously with the maximum and minimum rainfall in W2, and the peak occurrence time was related to the ratio of precipitation to evaporation. In the downstream sites, GWL fluctuated more intensively than the upstream ones in W2. Moreover, the average GWL of the upstream sites was 14.3 cm higher than that of the middle ones, indicating a decreasing trend of water storage along the gully. (4) The GWL discrepancy between wet and dry seasons was explicit, but the difference was smaller in the upstream sites due to limited gully incision and higher water storage within the peat layer. Additionally, rainy days dominate the GWL change in wet and dry seasons, but the different rainfall intensity resulted in a stable GWL in the dry season and an oscillating GWL in the wet season in W2. This study uncovers the spatio-temporal variation of groundwater level in two peatland watersheds, which is of great significance for understanding runoff variation, ecohydrological processes, and wetland shrinkage in the SRYR.

Aspirin induced urticaria in a recently diagnosed ischemic stroke patient: A case report and literature review. Abhinav Dahal : Sukraraj Tropical and Infectious Disease Hospital, Teku, Kathmandu, Nepal Email: [email protected] gautam: Nepalgunj medical college, banke,Nepalemail: [email protected] Shakya : Manipal college of medical sciences, Pokhara, Nepalemail: [email protected] pant: Manipal college of medical sciences, Pokhara, Nepalemail: [email protected] Bhandari , Nepal Medical College, Jorpati, Kathmandu, Nepal [email protected] Babu Shrestha, M Abdur Rahim Medical College, Dinajpur, Bangladesh. [email protected] author:ABS; M Abdur Rahim Medical College, Dinajpur, Bangladesh. [email protected]: Aspirin and urticaria correlation has not been fully understood. The pharmacological inference is suspected to be the diversion of arachidonic acid metabolism. Aspirin sensitivity can aggravate pre-existing chronic urticaria and in some instances causes acute urticaria. We report a case of a 53-year old male, recently diagnosed with stroke, who presented with complaints of multiple rash over trunk and upper extremity with aspirin. NSAIDs induced urticarial are usually neglected by physicians during diagnosis. Keywords: Aspirin, urticarial, stroke, hemiplegiaIntroduction: Aspirin is a drug which is widely used to reduce the risk of stroke, transient ischemic attack, and cardiovascular events. This is due to its antithrombotic properties by irreversibly inhibiting the cyclooxygenase enzyme, reducing the synthesis of Thromboxane A2 and thus subsequently reducing platelet aggregation [1– 3]. Aspirin and NSAIDs’ pharmacological properties also result in adverse reactions like GI upset, renal toxicity, and hemorrhagic complications, as well as potentiate hypersensitivity reactions [4]. Aspirin Hypersensitivity is reported by 0.9 to 1.5% of the general population [5]. Hypersensitivity reactions to NSAIDs are classified on the basis of their involvement of the skin, like urticaria or angioedema, the airways or other organs, their acute or delayed onset, the presence of underlying diseases, and their cross reactivity[6]. In this report, we document a case of aspirin induced urticaria in a patient with a recent history of Ischaemic stroke and Hypertension.Case Description: A 53 years old male presented to the emergency department with a chief complaint of multiple rashes with burning and itching sensation over trunk and extremities. Figure 1 and 2. The patient was a known case of hypertension with recent diagnosis of left sided ischemic stroke with right sided hemiparesis 7 days back for which he was admitted for 3 days. There were no significant reactions to the treatment noticed during the hospital stay. He was discharged with a daily dose of aspirin 75 mg o.d., enalapril 10 mg o.d., atorvastatin 20 mg o.d., omeprazole 20 mg b.d. He was advised for proper bed rest with two hourly posture changes & physiotherapy. He was solely on prescribed medications for the past 4 days. On the next day, he was admitted following the appearance of cutaneous manifestations with no other associated symptoms such as angioedema or shortness of breath. He had no prior history of allergic reactions. On further enquiry, he denied any changes to diet or environmental stimuli including no exposure to any pets or animals. He also gave a negative history of family members having such allergic manifestations. On examination, multiple, pruritic, erythematous, blanching macules were present on bilateral upper extremities and trunk(Figure 1). His vital signs were within normal limits. Leukocytosis (wbc:12,000 cells/mm3) with higher eosinophil count ( 550 per ml of blood) was noted while other complete blood count and comprehensive metabolic panels were unremarkable. Medical history revealed he was taking enalapril 10 mg o.d. for the past 3 years for hypertension. As ACE inhibitors are commonly responsible for causing the side effects such as allergies, drug rash & even angioedema, it was replaced with amlodipine 5 mg o.d. He was started on histacin 4 mg b.d for symptomatic management. However, there was no significant improvement in his condition. Therefore, we decided to stop the current medication one at a time to identify the culprit drug. Aspirin was replaced with clopidogrel 75 mg o.d. & given daily. He was kept under observation & followed up the next day with improvement. Patient told that his itching and the degree of rash spread throught his body were diminished. Three days later, the rashes almost fully subsided & he was advised to continue histacin for 1 more week without stopping clopidogrel intake. Aspirin was identified as the sole cause for the rashes. He was discharged following complete recovery of cutaneous symptoms after 3 days with proper counselling regarding his condition and precaution to be taken for future aspirin use.Discussion: Aspirin and other NSAID are known to cause hypersensitivity reactions. One of the manifestation of such reactions is urticaria. The prevalence of aspirin induced urticaria is estimated to be around 0.3% excluding individuals with recurrent urticaria, hay fever and chronic chest disease [7]. Aspirin induced Urticaria(AIU) can be classified into two types as aspirin intolerant acute urticaria(AIAU) and aspirin intolerant chronic urticaria(AICU). The symptoms develop within minutes to 24 hour in AIAU and lasts for less than 6 weeks whereas, in AICU symptoms typically last for more than 6 weeks.[8] Elevated IgE levels and atopy are suggested as a common predisposingfactors for AIU according to a genetic study done in Korean population[8]. In addition, HLA-DRB1 * 1302 - DQB1*0609 also has been identified as a genetic marker[9]. Besides this, various genetic studies have reported that high affinity IgE receptor[10] , histamine N‐methyltransferase[11] and adenosine A3 receptor[12] are other genetic determinants for AIU. These findings allude that, causes leading to the release of inflammatory mediators either by increased histamine release, faulty histamine degradation or augmented mast cell signalling, contributes to the manifestation of AIU. NSAIDs and Aspirin are known to be one of the common drugs causing hypersensitivity drug reactions.(13) Drug Hypersensitivity Reactions constitute about one third of all adverse drug reactions and affects 10-20% of hospitalized patients and 7% of outpatients.[14] Depending on the type of hypersensitivity reaction, patient can develop an array of cutaneous manifestations ranging from urticaria/ angioedema, fixed drug eruption, maculopapular exanthem to more severe manifestations such as DRESS or SJS/TEN.[15] We have previously encountered a case of Stevens Johnson Syndrome, Type III Hypersensitivity Reaction due to an antibiotic namely Cefixime.[16] In this case, we have encountered a case of Single NSAID Induced Urticaria/ Angioedema or Anaphylaxis, a Type I Hypersensitivity Reaction. Figure 3.To date, there are only few case reports published in pubmed highlighting the association of aspirin with urticaria. This may be due to the fact that aspirin sensitivity is often neglected because of the cross reaction with NSAIDs. One case report has documented urticaria in three patients caused by aspirin where pharmaceutical excipients present in the formulation of drug was found to be the sole cause for the hypersensitivity reaction in two of those patients.[17]However, acute urticaria is not uncommon and when patients present with an urticarial reaction clinicians do not consider NSAIDs as the cause, as the reaction occurs in context of different triggers and is thus difficult to establish.Beyond drug induced urticaria, differential diagnosis of acute urticaria includes urticaria attributed to infections, foodstuffs, contact dermatitis, solar urticaria, cholinergic urticaria, arthropod bite reactions, autoimmune disorders, small vessel vasculitis. Diagnostic workup for many of these etiologies rely on laboratory parameters and histological evidence in addition to history. Initial laboratory investigations revealed lekocytosis with a predominance of eosinophils. However, access to further testing was limited due to patient’s refusal and unfortunately no blood investigations or skin biopsy was taken at presentation. Management of NSAID induced urticaria includes strict culprit NSAID avoidance along with symptomatic management of acute urticaria.[18] Antihistamines are the first line treatment for management of acute urticaria. In severe cases, corticosteroids can be added to control symptoms.[19,20] Some types of NSAID hypersensitivity are known to exhibit cross reactivity thus strict NSAID avoidance should be done until potential of cross-intolerance is ruled out. If patient has history suggesting selective NSAID induced urticaria, challenge to chemically unrelated strong COX-1 inhibitor may be done to rule out crossreactivity type hypersensitivity.[21] Once diagnosis of SNIUAA is established, use of drug allergy passport and patient education help both the medical provider and the patient know about the NSAID hypersensitivity status, avoidance of the culprit NSAID as well as use of chemically unrelated NSAIDs as safe alternatives. In this entity, alternative drug to aspirin must be sought.[18,21] Therefore our clinical reasoning is composed from detailed patient’s history, physical examination and clinical course. Our patient did not have any history of multisystem involvement, recent infection, past medical history of atopy, inducible urticaria due to heat, cold or stress, recent contact with common irritants or insect bite. The patient had been taking Aspirin, Enalapril and Atorvastatin following the diagnosis of Ischemic Stroke with Right Sided Hemiparesis. The urticaria and pruritus should not be caused by Enalapril, since the patient was tolerating the medication well for the past 3 years and the patient’s symptoms worsened even after withdrawing of the drug. The temporal correlation between the appearance of urticarial rash and aspirin intake, and the resolution of urticarial rash and pruritus following aspirin discontinuation suggests the possibility of Aspirin Induced Urticaria. The causality assessment of the adverse drug reaction (ADR) was carried out using the Naranjo Scale, a method for estimating the probability of adverse drug reactions. The assessment revealed the ADR to be ‘Probable’(+6) to be associated with Aspirin.[22]The patient’s history notably lacked presence of chronic urticaria. While the drug provocation test for cross intolerance was not done, the patient’s history reveals previous tolerance to other NSAIDs like ibuprofen and paracetamol.