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Aim: We investigated whether individuals varied in their satisfaction with being randomized to an extension of early intervention (EI) for psychosis or regular care after 2 years of EI, and whether satisfaction was associated with service engagement 3 years later., Methods: Following randomization, patients (N = 220) indicated if they were happy with, unhappy or indifferent to their group assignment. Follow-up with service providers was recorded monthly., Results: Patients randomized to extended EI were more likely to express satisfaction with their group assignment than those in the regular care group (88.2% vs 31.5%, χ 2 = 49.96, P < .001). In the extended EI group, those happy with their assigned group were likelier to continue seeing their case manager for the entire five-year period than those who were unhappy/indifferent (χ 2 = 5.61, P = .030)., Conclusions: Perceptions about EI, indicated by satisfaction with being assigned to extended EI, may have lasting effects on service engagement., (© 2020 John Wiley & Sons Australia, Ltd.)

Objective: We aimed to investigate whether individuals with first-episode psychosis (FEP) receiving extended early intervention (EI) were less likely to experience suicidal ideation and behaviors than those transferred to regular care after 2 years of EI. Another objective was to examine the 5-year course of suicidality in FEP., Methods: We conducted a secondary analysis of a randomized controlled trial where 220 patients were randomized after 2 years of EI to receive extended EI or regular care for the subsequent 3 years. Suicidality was rated using the Brief Psychiatric Rating Scale. Linear mixed model analysis was used to study time and group effects on suicidality., Results: Extended EI and regular care groups did not differ on suicidality. There was a small decrease in suicidality over time, F (7, 1038) = 1.84, P = 0.077, with an immediate sharp decline within a month of treatment, followed by stability over the remaining 5 years. Patients who endorsed suicidality at entry (46.6%) had higher baseline positive, negative, and depressive symptoms. The 5-year course fell in 3 groups: never endorsed suicidality (33.9%), endorsed suicidality at low-risk levels (43.1%), and endorsed high-risk levels (23.0%). The high-risk group had a higher proportion of affective versus nonaffective psychosis diagnosis; higher baseline positive and depressive symptoms; higher 5-year mean depression scores, and fewer weeks of positive symptom remission over the 5-year course., Conclusions: The first month of treatment is a critical period for suicide risk in FEP. Although early reductions in suicidality are often maintained, our findings make the case for sustained monitoring for suicide risk management.

Background: The SarsCoV2, novel coronavirus (COVID-19) pandemic necessitated a rapid transition from in-person evaluations to remote delivery of care, including both video and telephone visits, in allergy/immunology practices., Objective: To evaluate patient satisfaction, patient and physician impression of encounter completeness, and reimbursement between in-person, video, and telephone encounters. This study also assessed factors influencing patient satisfaction, perception of completeness, and choice of future evaluation type., Methods: This was a prospective study of all encounters at a health care-system owned practice. Encounter type, encounter modality, patient demographics, primary diagnoses, reimbursement data, and physician assessment of encounter completeness were tracked. Patient satisfaction was assessed via standardized questions., Results: There were 447 encounters, with 303 in-person (67.8%), 98 video (21.9%), and 46 telephone (10.3%). Patient satisfaction data was obtained from 251 patients. There was similar patient satisfaction among all encounter modalities. Both patients and physicians were more likely to deem an in-person encounter as complete. Physicians were more likely to report an in-person encounter to be complete for food allergy (P < .001) and chronic rhinitis (P = .001) compared with video or telephone, whereas patients reported in-person encounters for food allergy to be complete compared with other modalities (P = .002). Patients reported that future encounter types should depend on the clinical situation., Conclusions: There was similar patient satisfaction with in-person, video, and telephone encounters in an allergy/immunology practice during the COVID-19 pandemic. Chronic rhinitis and food allergy are more likely to call for an in-person evaluation. New patient visits are likely to be the highest yield to focus on for in-person evaluations., (Copyright © 2021 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Aspirin-exacerbated respiratory disease (AERD) affects 7% of asthmatics. Usual therapies are inadequate for asthma and/or nasal polyposis, leading to decreased quality of life., Objective: Our objective was to evaluate the efficacy of dupilumab in AERD patients with uncontrolled, chronic rhinosinusitis with nasal polyposis (CRSwNP)., Methods: Patients 18 years and older with a physician diagnosis of AERD and sino-nasal outcome test 22 (SNOT 22) score ≥19 despite standard medical therapy were eligible for the study. Patients received one month of placebo dosing, followed by 6 months of dupilumab. Patients were blinded to the order of therapy. Wilcoxon-paired rank sum test was used to compare study outcomes at baseline and the completion of the study., Results: Ten patients completed the study. The median baseline SNOT 22 score improved from 46 [IQR: 34 to 64.8] to 9.5 [IQR: 2.5 to 19] after 6 months of therapy (p = 0.0050). The median baseline Lund MacKay score improved from 21.5 [IQR: 17 to 23.3] to 4 [IQR: 1.2 to 6] after 6 months of therapy (p = 0.0050). There was also improvement in the following secondary outcomes: asthma control test (ACT), mini asthma quality of life questionnaire (AQLQ), and University of Pennsylvania Smell Identification test (UPSIT). Exhaled nitric oxide (FeNO), total serum IgE, 24-hour urinary leukotriene E 4 , and serum thymus and activation regulated cytokine (TARC) also decreased. There were no significant study-related adverse events., Conclusion: Dupilumab was highly effective as add-on therapy for CRSwNP in AERD, improving patient-reported outcomes, sinus opacification, and markers of T2 inflammation.

This paper has three main objectives related to the neutronic and burnup analysis of the BWR (Boiling Water Reactor) Four-Lattice. The first objective is to provide partial validation of the MCNPX code for this lattice by comparing its results with Scale-5.1 results. Validation of the MCNPX to calculate effective multiplication factor and reactivity rod worth for the F-Lattice is provided. This is carried out in case of instantly removing the control blade and replacing it with a graphite moderator. Moreover, spatial neutron flux distributions using F-mesh card over the bundle and the control blade are investigated at inserting and withdrawing the B 4 C. The second objective is to perform parametric design studies of the F-Lattice. Areas of particular interest are the effect of increased or decreased blade width on the neutron flux throughout the bundle. It is found that the presence of carbon in the control blade at withdrawing the B 4 C makes the reactor supercritical, (K-eff = 1.22206). On the other hand, the use of B 4 C blade presents (K-eff = 0.93521). Consequently, the reactivity of 10% B 4 C thinner case is higher that of 10% B 4 C thicker. The simulation also showed that the B 4 C blade had an effective role in decreasing the thermal flux at the periphery of the bundle. This is contrast to the effect of carbon that moderates fast to thermal neutrons. The third part of this work aims at studying the burnup calculations using MCNPX code for 30 days burn with 1 day time step then for 20 months burn with 2 week time steps for the lattice. At the end of the work, it is very important to determine the most proper bundle model that achieves a prolonged fuel burn and flatting thermal flux distribution. For reaching this goal, three cases (B 4 C, 10% thinner of B 4 C and 10% thicker) are simulated by MCNPX code till 70 GWd/ton. It is found that the B 4 C and 10% thicker are the appropriate models that can satisfy the safety considerations of the Compact Modular Boiling Water Reactor.

Purpose of Review: To summarize the impact of the COVID-19 pandemic on the practice of paediatric allergy., Recent Findings: Given significant overlap in symptoms, care must be taken to differentiate routine allergic conditions from COVID-19 infection but it appears that most allergic diseases are not risk factors for a severe COVID-19 course. The full impact of restricted allergy/immunology ambulatory services will take months to years to fully understand. One benefit of having to adapt practice style is greater awareness and acceptance of shared decision-making and recognition of preference-sensitive care options in food allergy, in particular for approaches towards allergy prevention, treatment, and anaphylaxis care. Social distancing and masks have helped reduce spread of common respiratory viruses, which may be helping to lower the incidence of viral-associated wheezing episodes, enhancing evidence of the effects of preventing exposure of young children to respiratory viruses on asthma pathogenesis, as well as on allergic rhinitis. There has been a revolution in the rise of telemedicine to increase access to high-quality allergy/immunology specialty care., Summary: Although the field has adapted to remain operational in the face of a significant challenge, it is important to apply lessons learned to evolve patient care and optimize treatment in the aftermath of the pandemic., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the safety and tolerability of subcutaneous IgPro20 (Hizentra ® , CSL Behring, King of Prussia, PA, USA) administered at high infusion parameters (> 25 mL and > 25 mL/h per injection site) in patients with primary immunodeficiency., Methods: The Hizentra ® Label Optimization (HILO) study was an open-label, parallel-arm, non-randomized study (NCT03033745) of IgPro20 using a forced upward titration design for infusion parameters. Patients experienced with pump-assisted IgPro20 infusions received weekly IgPro20 infusions at a stable dose in the Pump-Assisted Volume Cohort (N = 15; 25-50 mL per injection site) and in the Pump-Assisted Flow Rate Cohort (N = 18; 25-100 mL/h per injection site). Responder rates (percentage of patients who successfully completed ≥ 75% of planned infusions), safety outcomes, and serum immunoglobulin G (IgG) trough levels were evaluated., Results: Responder rates were 86.7% (13/15, 25 mL) and 73.3% (11/15, 40 and 50 mL) in the Volume Cohort, and 77.8% (14/18, 25 and 50 mL/h), 66.7% (12/18, 75 mL/h), and 61.1% (11/18, 100 mL/h) in the Flow Rate Cohort. Infusion compliance was ≥ 90% in all patients in the Volume Cohort and in 83.3% of patients in the Flow Rate Cohort. The number of injection sites (Volume Cohort) and the infusion duration (Flow Rate Cohort) decreased with increasing infusion parameters. The rate of treatment-emergent adverse events per infusion was low (0.138 [Volume Cohort] and 0.216 [Flow Rate Cohort]). Serum IgG levels remained stable during the study., Conclusion: Pump-assisted IgPro20 infusions are feasible at 50 mL and 100 mL/h per injection site in treatment-experienced patients, which may result in fewer injection sites and shorter infusion times., Trial Registration: NCT03033745 ; registered January 27, 2017.

Background: Electronic consultations (e-consults) are asynchronous clinician-to-clinician exchanges within the electronic health record (EHR)., Objective: We sought to demonstrate the utility of e-consults in allergy/immunology (A/I) inpatient consultations., Methods: Inpatients ≥18 years of age for whom an A/I consultation was requested were eligible for an e-consult. An e-consult was completed if considered appropriate by the A/I physician with recommendations made in the EHR. In-person consultation was performed for inpatients if deemed necessary. Likert scale satisfaction data were collected from requesting providers after the e-consultation. Cost was calculated using time-based billing codes plus the cost of penicillin allergy evaluation, if appropriate., Results: Of the 109 inpatient consults, 78 (71.6%) were completed through an e-consult and 31 (28.4%) were completed by an in-person consult. The most common indication for an inpatient consult was evaluation of penicillin allergy in 73 (67%) patients. The most common reason to complete an in-person consult was the need to complete penicillin skin testing in 17 of the 31 (55%) patients. E-consults were completed in less time than in-person consults (15 minutes, interquartile range [IQR]: 10-15 vs 60 minutes, IQR: 45-60, P < .001) and had a shorter turnaround time (1 hour, IQR: 0.5-2 vs 7 hours, IQR: 3-19, P < .001). Management recommendations were followed at a similar rate regardless of type of consult (88% of e-consults vs 96% of in-person consults, P = .162). A total of 97% of requesting providers reported an "excellent" or "good" impression of e-consults. E-consults were less costly than in-person consults., Conclusions: E-consults have utility in providing inpatient A/I consultation and may have advantages over in-person evaluation, while adequately maintaining provider satisfaction., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Rituximab is an anti-CD20 chimeric antibody used to treat autoimmune conditions and B cell neoplasms. We characterized immunoglobulin (Ig) levels and vaccine responses in rituximab-treated B cell non-Hodgkin lymphoma (NHL) patients. Patients with impaired vaccine responses were offered therapy with 20% subcutaneous (subq) Ig., Patients and Methods: Patients with a biopsy-proven diagnosis of B cell NHL who had received rituximab within the past 24 months were eligible for the study and underwent the following immune evaluation: serum IgG, IgM, IgA, IgE, T/B cell lymphocyte panel, and pre/post vaccine IgG titers to diphtheria, tetanus, and streptococcus pneumoniae. Patients were vaccinated with tetanus, diphtheria and pneumococcal polysaccharide vaccine. Patients with abnormal vaccine responses were offered prophylactic subq Ig for 52 weeks., Results: Fifteen patients with NHL were enrolled in the study. The median IgG was 628 mg/dL [interquartile range, 489-718 mg/dL]. Three (20%) of 15 patients responded to diphtheria vaccination, 1 (6.7%) of 15 responded to tetanus vaccination, and 3 (20%) of 15 responded to vaccination to streptococcus pneumoniae. Thirteen (86.7%) of 15 met criteria for humoral immunodeficiency. Ten patients received subq Ig, and experienced a significant increase in serum IgG (P = .008). There were no serious adverse events, and there was a decrease in nonneutropenic infections while on subq Ig therapy., Conclusions: Patients with NHL treated with rituximab may have significant humoral immunodeficiency as defined by abnormal vaccine responses even in the setting of relatively normal IgG levels. For these patients, subq Ig replacement therapy is well-tolerated and efficacious in improving serum IgG, and may decrease reliance on antibiotics for the treatment of nonneutropenic infections., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Direct challenge (DC) is an emerging safe and effective alternative to penicillin skin testing (PST) in patients reporting a low-risk reaction history, but limited data exist for the inpatient setting., Objective: To demonstrate the safety and efficacy of DC of penicillin-based antibiotics in the inpatient setting in patients with low-risk, cutaneous-only reaction histories more than 20 years ago., Methods: Adult inpatients reporting penicillin allergy and receiving antibiotics were screened by an infectious disease PharmD for appropriateness for penicillin allergy delabeling. Patients with low-risk, cutaneous-only reaction histories (rash, hives, itching) more than 20 years ago were offered a 3-step DC. Patients with a cutaneous reaction history less than 20 years ago, a history of angioedema, or reactions involving multiple body systems underwent PST followed by a 1-time observed dose of amoxicillin., Results: A total of 372 patients were screened during the study period, with 100 of these patients undergoing further evaluation, 52 with histories appropriate for PST and 48 with histories appropriate for DC. In the PST group, 44 of 52 (84.6%) patients were PST negative. In the DC group, 47 of 48 (97.9%) patients initially tolerated the DC, with 2 of 48 (4.2%) experiencing a delayed reaction. The sole patient with an immediate DC reaction was treated with an antihistamine alone. Beta-lactam antibiotics were subsequently used in 56 of the 100 total patients. Total direct antibiotic savings was $23,375.27. DC was less costly than PST, at $206.18/patient versus $419.63/patient., Conclusions: DC is a safe, effective, and less expensive method for penicillin delabeling in adult inpatients with a low-risk, cutaneous-only reaction history more than 20 years ago., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Individuals with peanut allergy often avoid tree nuts, yet true rates of tree nut allergy in peanut-allergic individuals are as low as 7%., Objective: To examine tree nut sensitization patterns in peanut-allergic individuals, patient and family choice regarding tree nut consumption, and factors that influence consumption of tree nuts., Methods: All patients presenting for peanut allergy evaluation to an outpatient allergy office were included during a 4-month period. In addition to demographic information, sensitization to tree nuts and tree nut consumption were collected. Logistic regression was performed to generate odds ratios with 95% CIs in univariate and multivariate analyses for variables that predict tree nut consumption., Results: A total of 258 individuals with peanut allergy were enrolled. Ninety-five (36.8%) consumed all tree nuts ad libitum, 63 (24.4%) consumed some but not all tree nuts, and 100 (38.8%) consumed no tree nuts. Of the 100 electively avoiding all tree nuts, the most commonly reported reason was fear of cross-contact (50%). Although there was no difference between rates of sensitization between individual tree nuts (P = .056), cashew and pistachio had higher serum specific IgE levels compared with other tree nuts (P < .001). The tree nut most commonly consumed by peanut-allergic individuals was almond (P < .001). Consumption of foods with precautionary labeling was the strongest predictor of tree nut consumption in peanut allergic individuals (P < .001) CONCLUSION: Our data highlight the potential for safe introduction of tree nuts in peanut-allergic individuals and indicate that peanut-allergic individuals who consume foods with precautionary labeling are most likely to consume tree nuts., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Although local reactions (LR) to subcutaneous immunotherapy (SCIT) occur in 26-86% of patients, there are no well-studied strategies to manage LRs. Objective: To complete a prospective, randomized, single-blind, controlled trial that compared pre-rinsing SCIT syringes with diphenhydramine, epinephrine, or placebo in patients who were receiving aeroallergen SCIT and experiencing LRs despite pretreatment with an antihistamine. Methods: Patients ages ≥5 years who were receiving aeroallergen SCIT per a conventional dosing schedule and who were experiencing LRs despite premedicating with an oral antihistamine were randomized to diphenhydramine, epinephrine, or placebo rinse, and were followed up for three subsequent visits. At each visit, the patients were asked (yes or no) if LRs improved. Results: A total of 490 patients were enrolled in the study. Seventy-four of the 490 patients (15.1%) experienced an LR despite pretreatment with an oral antihistamine and were randomized into an intervention group. At visit 1, an epinephrine rinse was strongly associated with decreasing LR compared with both diphenhydramine rinse and placebo (p < 0.001). There was no difference among the intervention groups at visits 2 and 3. In patients who reported a consistent outcome at all three visits, the epinephrine rinse was significantly associated with a decrease in LR compared with both diphenhydramine rinse and placebo rinse (p = 0.05). Conclusion: In patients who received aeroallergen SCIT per a conventional dosing schedule, an epinephrine rinse significantly decreased LR at the first visit, and also within a population that reported a consistent outcome at all three study visits. In patients already premedicating with an oral antihistamine, adding an epinephrine rinse is a safe and effective strategy to decrease LRs to aeroallergen SCIT.

Thorium-plutonium mixed oxide, (Th,Pu)OX, is currently used as an alternative fuel in the light water reactors in the world. The main objective of this paper is not only to show the benefits of using the thorium, but mainly to study how the way thorium is introduced in the fuel affects the neutron parameters. Among these benefits is the possibility of extending the operating cycle length and the reduction of the increasing stockpiles of plutonium. The first investigated method is introducing thorium as (Th,Pu)OX. The second one is a homogeneous model of thorium plutonium oxide. It is carried out by adding an amount of plutonium separated from the uranium oxide cycle at 50 GWd/ton of heavy metal to the same amount of thorium. Thus, we studied three assemblies; the reference assembly is uranium oxide of 4.2% enrichment containing borated water as a moderator of concentration 500 ppm (part per million) of B-10. The second is a (Th,Pu)OX and the third one is an assembly with homogenized thorium plutonium. All three assemblies are modeled using MCNPX. A comparison is held between the results of the three lattices. The factors compared are the effective multiplication factor, the inventory of plutonium and uranium isotopes, and the depletion of B-10, the pin by pin power distribution at 0 and 60 GWd/ton and the relative pin radial power for the three lattices. The comparison is aimed to show the effect on the cycle length, the reduction in the Pu content and the power flattening across the assembly. It is found that the evolution of the multiplication factors shows a similar behaviour using (Th-Pu)OX fuel in the assembly as UOX cycle inspite of lowering the K-eff of fresh (Th-Pu)OX fuel (1.19847). The power flattening which is favorable in reactor operation is clearer in (Th,Pu)OX fuel. It is noticed that the mass of Pu-239 decreases by 1.07% from its initial value at the end of life. For homogeneous (Th,Pu)OX, the mass decreases by 0.0832%. The high power peaking factor for (Th,Pu)OX is not expected to cause significant effects during reactor operation but it can be reduced by adding burnable poisons.

Our current recommendations for diagnosing and treating primary mast cell (MC) activation syndrome make use of the latest studies and consensus guidelines for clinically recognizing systemic anaphylaxis in real time, regardless of whether allergen-triggered or other pathways are involved; our current understanding of the biomarkers secreted by activated MCs that best discriminate this disorder from other conditions; and the therapeutic drugs that might selectively affect those mediators or MCs themselves. Finding familial or somatic mutations of genes that cause MCs to be hyperactivatable would extend our diagnostic tools and potentially indicate new therapeutic interventions, targeting either the mutated gene product or the associated molecular pathway. In conclusion, we trust that the clinical, laboratory, and therapeutic criteria for primary MC activation syndromes described herein will provide clinicians with practical criteria of sufficient sensitivity and specificity to diagnose most cases without overdiagnosing the disorder in patients who likely have other conditions., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Background: Direct challenge (DC) may be a safe and effective alternative to penicillin skin testing (PST) in low-risk patients., Objective: To complete a prospective, randomized, controlled trial comparing PST followed by a challenge to amoxicillin versus a 2-step DC to amoxicillin without preceding skin testing in a predefined low-risk patient population., Methods: Penicillin allergy histories were reviewed in patients presenting to an outpatient allergy/immunology practice from April 2018 to August 2018. Patients 5 years or older with a cutaneous-only or unknown reaction (>1 year ago for those aged 5-17 years, >10 years ago for those 18 years or older) were randomized 1:1 to PST or 2-step DC. All children younger than 5 years underwent DC, and patients with extracutaneous reaction histories underwent PST. All groups were monitored 30 minutes after administration of amoxicillin., Results: Penicillin allergy was reported in 363 of 2465 (14.7%) patients, of which 185 consented to further evaluation. Thirteen patients younger than 5 years underwent DC; all were negative. Thirteen patients with angioedema and/or extracutaneous symptoms underwent PST; 2 of 13 patients had positive PST result. A total of 159 patients were randomized to DC (49.7%) or PST (50.3%). PST result was negative in 70 of 80 (87.5%) patients. All 70 patients had a negative amoxicillin challenge. DC was negative in 76 of 79 (96.2%) patients; positive DC reactions were minor. Average time for patients undergoing PST was 72.7 ± 5.3 minutes and for patients undergoing DC was 66.7 ± 4.8 minutes., Conclusions: In low-risk patients, DC provided a safe and effective alternative to PST in delabeling penicillin allergy. Compared with PST, DC may also take less time, cost less money, and lead to fewer penicillin allergy evaluations with false-positive results., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Systemic reactions are a known risk of subcutaneous immunotherapy (SCIT) for aeroallergens., Objective: To identify the dose of SCIT that results in the most systemic reactions to SCIT (SCITSRs) and other risk factors for SCITSRs., Methods: We performed a retrospective review of all SCIT encounters from 2013 to 2017 at a multisite allergy/immunology practice. SCITSRs were identified from the electronic health record through immunotherapy encounters in which epinephrine was administered. Collected data included patient demographics, the dose of immunotherapy at the time of the SCITSR, the presence or absence of asthma, and aeroallergen content. The control group was generated randomly from the same cohort during the same period., Results: There were 86,949 SCIT visits, with 81 SCITSRs (0.9 per 1000 injections). A total of 77.8% of reactions occurred at a dose of 1:1 0.1 mL and above. The presence of cat (81.5% vs 63.0%, P = .01), dog (67.9% vs 37.0%, P < .001), and grass extracts (85.2% vs 67.5%, P = .01) were associated with SCITSRs. Asthma was not significantly associated with SCITSRs. The presence of dust mites, trees, weeds, and molds was not associated with SCITSRs. There were no months or seasons where SCITSRs were more likely to occur. Individuals who experienced SCITSRs had a mean (SD) higher number of included aeroallergenic groups compared with controls (5.86 [1.88] vs 5.00 [1.92], P < .001)., Conclusion: Risk factors for SCITSRs in a multisite allergy/immunology practice included administration of the highest immunotherapy doses; inclusion of cat, dog, and grass extracts; and the number of aeroallergenic groups included in the extract. This information helps further characterize risk for patients receiving SCIT., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Immunodeficiency is an underrecognized risk factor for infections, such as community-acquired pneumonia (CAP)., Objective: We evaluated patients admitted with CAP for humoral immunodeficiency., Design: Prospective Cohort Study., Setting: Inpatients., Patients, Intervention, and Measurements: We enrolled 100 consecutive patients admitted with a diagnosis of CAP from February 2017 to April 2017. Serum IgG, IgM, IgA, and IgE levels were obtained within the first 24 hours of admission. CURB-65 score and length of hospital stay were calculated. The Wilcoxon rank-sum test, Kruskal-Wallis test, and simple linear regression analysis were used in data analysis., Results: The prevalence of hypogammaglobinemia in patients with CAP was 38% (95% confidence interval: 28.47% to 48.25%). Twenty-seven of 100 patients had IgG hypogammaglobinemia (median: 598 mg/dL, IQ range: 459-654), 23 of 100 had IgM hypogammaglobinemia (median: 38 mg/dL, IQ range: 25-43), and 6 of 100 had IgA hypogammaglobinemia (median: 36 mg/dL, IQ range: 18-50). The median hospital length of stay for patients with IgG hypogammaglobinemia was significantly higher when compared to patients with normal IgG levels (five days, IQ range [3-10] vs three days, IQ range [2-5], P = .0085). Fourteen patients underwent further immune evaluation, resulting in one diagnosis of multiple myeloma, three patients diagnosed with specific antibody deficiency, and one patient diagnosed with selective IgA deficiency., Conclusion: There is a high prevalence of hypogammaglobinemia in patients hospitalized with CAP, with IgG and IgM being the most commonly affected classes. IgG hypogammaglobinemia was associated with an increased length of hospitalization. Screening immunoglobulin levels in CAP patients may also uncover underlying humoral immunodeficiency or immunoproliferative disorders., (© 2018 Society of Hospital Medicine.)

Infections are a major cause of morbidity and mortality in individuals with multiple myeloma (MM). These individuals exhibit humoral dysfunction and show a suboptimal response to pneumococcal polysaccharide vaccine (PPV23). Since pneumococcal conjugate vaccine (PCV13) elicits a T cell dependent response, it is recommended in patients with multiple myeloma. This study compares the initial response to PCV13 and durability of the response at 6 months in patients with multiple myeloma versus normal controls. Seven patients with multiple myeloma and 18 control patients were enrolled in the study. Streptococcal pneumonia serotype IgG titers were drawn at baseline, day 30, and day 180 after MM patients and controls received PCV13. Although vaccination with PCV13 produced a similar initial response in patients with multiple myeloma compared to control subjects, the duration of response may have waned in patients with multiple myeloma as compared to control subjects.

Background: Food allergy affects up to 8% of children in the U.S. There is minimal research to date on food allergy policies that are currently in place in schools and the opinions of parents of children with food allergy on the effectiveness of or need for these policies., Methods: An electronic survey was disseminated to parents of children with food allergy. Frequencies were calculated to describe respondent characteristics and responses. Chi-square tests were performed to examine associations between school and child characteristics and outcomes., Results: Of the 289 parent respondents, 27.4% were unsure or felt school was unsafe for their child with food allergy. While the majority felt that the polices in their child's school were helpful, most also believed that implementation of additional polices was necessary, including availability of stock epinephrine (94.2%), lunch menus with allergen information (86%), ingredient labels on food items (81%), and direct food allergy education for students (86%). There were significant differences in school food allergy policy depending on the age of the student body, private versus public school, and geographic location., Conclusions: While most schools reportedly have one or more food allergy policies in place, many parents have concerns over the safety of their child at school and feel that additional policies are necessary to improve the safety of the school environment for children with food allergy. The availability of stock epinephrine, improved allergen labeling of food and menus and increased food allergy education may be key policy areas on which to focus.

Purpose of Study: Immune-mediated adverse drug reactions occur commonly in clinical practice and include mild, self-limited cutaneous eruptions, IgE-mediated hypersensitivity, and severe cutaneous adverse drug reactions (SCAR). SCARs represent an uncommon but potentially life-threatening form of delayed T cell-mediated reaction. The spectrum of illness ranges from acute generalized exanthematous pustulosis (AGEP) to drug reaction with eosinophilia with systemic symptoms (DRESS), to the most severe form of illness, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)., Recent Findings: There is emerging literature on the efficacy of cyclosporine in decreasing mortality in SJS/TEN. The purpose of our review is to discuss the typical presentations of these conditions, with a special focus on identifying the culprit medication. We review risk factors for developing SCAR, including HLA alleles strongly associated with drug hypersensitivity. We conclude by discussing current strategies for the management of these conditions.

Background: Although school health care professionals are integral to the management of students with food allergy, their views on school food allergy policies have not yet been reported., Objective: To characterize food allergy policies currently being used in schools and their utility and potential barriers to implementation from the perspective of school health care professionals., Methods: An electronic survey was disseminated to school nurses at the 2016 National Association of School Nurses meeting and through the Allergy and Asthma Network listserv. Frequencies were calculated to describe participant characteristics and responses. Unadjusted associations were examined using χ 2 tests; adjusted associations were examined using multiple logistic regression models., Results: A total of 242 completed surveys were included in the analysis. Thirty-two percent of nurses reported an allergic reaction in their school in the past year. Most schools used a variety of policies, including anaphylaxis training for staff (96.7%), stock epinephrine availability (81.7%), designated lunch areas (62.2%), and food guidelines for classrooms (61.8%). Barriers to implementation included financial, time, and attitudinal considerations. Schools with pre-K or kindergarten students had higher odds of having designated lunch areas (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0-4.1; P < .05). The odds of having emergency epinephrine available were higher in schools with a full-time nurse (OR, 2.6; 95% CI, 1.1-6.3; P < .05) and in schools reporting at least 1 severe reaction in the past year (OR, 3.2; 95% CI, 1.2-8.5; P < .05)., Conclusion: With one-third of school nurses reporting an allergic reaction in the past year, schools use many strategies to minimize allergen exposures and increase anaphylaxis preparedness. Most school nurses favor these policies and acknowledge barriers to implementation., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: One reason for worldwide interest in the clinical high-risk (CHR) state for psychosis is its potential as a target for prevention. However, the feasibility and utility of early intervention initiatives that are focused on this stage involve an untested assumption: that most patients with a first episode of psychosis (FEP) experience earlier CHR symptoms. The objective of this study was to identify and characterize the proportion of FEP patients who had experienced such symptoms prior to the onset of their psychosis., Methods: Semistructured interviews of 351 patients and families with the Circumstances of Onset and Relapse Schedule were supplemented by chart reviews in a catchment area-based sample of FEP patients. Information was extracted regarding pathways to care and psychiatric and behavioral changes over time. Experts (N=30) working in FEP and CHR settings identified which of 27 early signs and symptoms constitute attenuated positive or subthreshold psychotic symptoms (APSPS) if they appear prior to a syndromal-level psychotic episode., Results: Nine early signs and symptoms were endorsed by the experts as representing APSPS. More than half of consenting patients, and two-thirds (68%) of those who completed all assessments, had experienced at least one such sign or symptom prior to their FEP. The groups with and without APSPS were similar in social, demographic, and clinical characteristics., Conclusions: Most consenting patients with an FEP had experienced previous signs and symptoms consistent with a CHR state prior to the onset of threshold-level psychotic symptoms, although a substantial minority had not. This finding validates the viability of the CHR construct as a potential target for early case identification and preventive and therapeutic interventions.

This paper describes neutronic analysis for fresh fuelled IRIS (International Reactor Innovative and Secure) reactor by MCNPX code. The analysis included criticality calculations, radial power and axial power distribution, nuclear peaking factor and axial offset percent at the beginning of fuel cycle. The effective multiplication factor obtained by MCNPX code is compared with previous calculations by HELIOS/NESTLE, CASMO/SIMULATE, modified CORD-2 nodal calculations and SAS2H/KENO-V code systems. It is found that k-eff value obtained by MCNPX is closer to CORD-2 value. The radial and axial powers are compared with other published results carried out using SAS2H/KENO-V code. Moreover, the WIMS-D5 code is used for studying the effect of enriched boron in form of ZrB2 on the effective multiplication factor (K-eff) of the fuel pin. In this part of calculation, K-eff is calculated at different concentrations of Boron-10 in mg/cm at different stages of burnup of unit cell. The results of this part are compared with published results performed by HELIOS code., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The caregiving process accompanying inflammatory arthritis can be stressful to both caregivers and care recipients. In this study, we examined how caregiving involvement and caregiving appraisal as perceived by both patients and their caregiving spouses relate to disease activity and mental health of patients in early inflammatory arthritis., Methods: Patients in the early phase (> 6 weeks, <18 months duration) of inflammatory arthritis were recruited from a larger early inflammatory arthritis registry, which recorded sociodemographic data and disease characteristics. Disease activity was measured with the Disease Activity Score in 28 joints (DAS28). Current depressive symptoms were measured using the Center for Epidemiologic Studies - Depression Mood Scale. Patient and spouse perceived caregiving involvement and caregiving appraisal were assessed using the Caregiving Involvement Questionnaire and Caregiving Appraisal Scale, respectively., Results: The study sample consisted of 73 patients living with spouse. Mean age was 54 years, 64.4% were women and mean illness duration was 7.48 months. Patients' positive caregiving appraisal was associated with less disease activity (DAS28) (p = 0.003) and less total depressive mood (p < 0.001). In multivariate analysis, patients' appraisal of the caregiving context was negatively associated with disease activity (DAS28) after controlling for caregiving involvement and depression (p = 0.035)., Conclusion: This study indicates that, in early inflammatory arthritis, patients' caregiving appraisal might be important to consider when assessing disease activity. Clinicians are encouraged to include both patients and their spouse caregivers in interventions., (© 2012 The Authors. Scandinavian Journal of Caring Sciences © 2012 Nordic College of Caring Science.)

Introduction: Our study examines the association between the disease characteristics of inflammatory arthritis and patients' self-perception of mental health, parenting disability, parenting stress and child behaviour in early inflammatory arthritis (EIA)., Methods: Patients in the early phase (more than 6 weeks, less than 18 months) of inflammatory arthritis were recruited from a larger EIA registry that recorded sociodemographic data and measures of pain, physical functioning and disease activity. Patient-perceived parenting disability, parenting stress, depression and children's behaviour problems were assessed using the Parenting Disability Index, Parenting Stress Index, Center for Epidemiologic Studies--Depression Mood Scale and Child Behavior Checklist, respectively., Results: Pain, physical dysfunction, number of tender joints and physician global assessment of disease activity were associated with parenting disability. Self-report measures of parenting disability were associated with those of depression and parenting stress. Parenting stress was associated with children internalizing and externalizing behaviour problems while parenting disability was associated with children externalizing behaviour problems., Conclusion: This study suggests a possible reciprocal relationship among physical aspects of disease activity, parenting disability and parent and child distress in EIA.

Objective: Inflammatory arthritis is associated with a high degree of work instability and financial burden. In this study, we examine the extent of work instability and financial loss as well as their association with disease characteristics during the first 18 months of inflammatory arthritis., Method: One hundred and four patients in the early phase (more than 6 weeks, < 18 months) of inflammatory arthritis were recruited from a larger early inflammatory arthritis registry. Questionnaires recorded sociodemographic data and disease characteristics, including pain assessed using the Short Form McGill Pain Questionnaire (MPQ) and physical functioning measured with the Medical Outcomes Study Short Form 36 (SF-36) physical functioning score. The Rheumatoid Arthritis Work Instability Scale (RA-WIS) was used to measure patient-perceived functioning in the workplace and the Financial Loss Questionnaire (FLQ) measured the impact on family finances., Results: Participants' mean age was 56 years, 70.2% were female and 49.0% were working. Average yearly household income was < 60 000 Canadian dollars (CAD) for 38.5% of the sample. Of our working patients, 43% had a medium or high risk of work loss as measured by the RA-WIS and 35% reported a financial loss. On multivariate analysis, MPQ and SF-36 contributed to the dependent variable work instability, while age and SF-36 contributed to financial loss., Conclusion: This study identifies pain and physical dysfunction as potential modifiable risk factors for negative socioeconomic repercussions of illness in early inflammatory arthritis., (© 2012 The Authors International Journal of Rheumatic Diseases © 2012 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Background: Inflammatory arthritis impairs participation in societal roles. Role overload arises when the demands by a given role set exceed the resources; time and energy, to carry out the required tasks. The present study examines the association between role overload and disease outcomes in early inflammatory arthritis (EIA)., Methods: Patients (n = 104) of 7.61 months mean duration of inflammatory arthritis completed self-report questionnaires on sociodemographics, disease characteristics and role overload. Pain was assessed using the Short Form McGill Pain Questionnaire (MPQ) and physical functioning was measured with the Medical Outcomes Study Short Form 36 (SF-36) physical functioning score. Role overload was measured by the Role Overload Scale. Patients indicated the number of social roles they occupied from a total of the three typical roles; marital, parental and paid work., Results: Participants' mean age was 56 years and 70.2% were female. Role overload was not correlated to the number of social roles, however, it was positively associated with pain (p = 0.004) and negatively associated with physical functioning (p = 0.001). On multivariate analysis, role overload was negatively associated with physical functioning after controlling for the relevant sociodemographic variables., Conclusion: This study identifies a possible reciprocal relationship between role overload and physical functioning in patients with EIA.

We enrolled 53 peanut-allergic subjects and 64 peanut-tolerant full siblings, measured peanut-specific IgG and IgE, determined HLA class II at high resolution, and analyzed DRB1 alleles by supertypes. Peanut-specific IgG and IgE were elevated in the peanut-allergic subjects (p<0.0001) but did not stratify with HLA alleles, haplotypes, or supertypes. There were no significant differences in HLA class II between the peanut-allergic and peanut-tolerant siblings but there was an increased frequency of DRB1*0803 in both sets of siblings compared to unrelated controls (p(c)=4.5×10⁻⁹). Furthermore, we identified 14 sibling pairs in which the peanut-allergic and the peanut-tolerant siblings have identical HLA class II and again found an elevation of anti-peanut IgG in the peanut-allergic subjects (p<0.0001). In conclusion, although DRB1*0803 may identify a subset of families with increased risk of peanut allergy, differences in peanut-specific immunoglobulin production between peanut-allergic subjects and their peanut-tolerant siblings are independent of HLA class II., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Ethanol extract of roots of Sida cordifolia was evaluated for antistress, adaptogenic activity using cold restraint stress and swim endurance in mice. Mice pretreated with extract of Sida cordifolia showed significant improvement in the swim duration and reduced the elevated WBC, blood glucose and plasma cortisone.

A selective, accurate and reproducible high-performance liquid chromatographic (HPLC) method for the separation of individual enantiomers of DRF 2725 [R(+)-DRF 2725 and S(-)-DRF 2725 or ragaglitazar] was obtained on a chiral HPLC column (Chiralpak). During method optimization, the separation of enantiomers of DRF 2725 was investigated to determine whether mobile phase composition, flow-rate and column temperature could be varied to yield the base line separation of the enantiomers. Following liquid-liquid extraction, separation of enantiomers of DRF 2725 and internal standard (I.S., desmethyl diazepam) was achieved using an amylose based chiral column (Chiralpak AD) with the mobile phase, n-hexane-propanol-ethanol-trifluoro acetic acid (TFA) in the ratio of 89.5:4:6:0.5 (v/v). Baseline separation of DRF 2725 enantiomers and I.S., free from endogenous interferences, was achieved in less than 25 min. The eluate was monitored using an UV detector set at 240 nm. Ratio of peak area of each enantiomer to I.S. was used for quantification of plasma samples. Nominal retention times of R(+)-DRF 2725, S(-)-DRF 2725 and I.S. were 15.8, 17.7 and 22.4 min, respectively. The standard curves for DRF 2725 enantiomers were linear (R(2) > 0.999) in the concentration range 0.3-50 microg/ml for each enantiomer. Absolute recovery, when compared to neat standards, was 70-85% for DRF 2725 enantiomers and 96% for I.S. from rat plasma. The lower limit of quantification (LLOQ) for each enantiomers of DRF 2725 was 0.3 microg/ml. The inter-day precisions were in the range of 1.71-4.60% and 3.77-5.91% for R(+)-DRF 2725, S(-)-DRF 2725, respectively. The intra-day precisions were in the range of 1.06-11.5% and 0.58-12.7% for R(+)-DRF 2725, S(-)-DRF 2725, respectively. Accuracy in the measurement of quality control (QC) samples was in the range 83.4-113% and 83.3-113% for R(+)-DRF 2725, S(-)-DRF 2725, respectively. Both enantiomers and I.S. were stable in the battery of stability studies viz., bench-top (up to 6 h), auto-sampler (up to 12 h) and freeze/thaw cycles (n = 3). Stability of DRF 2725 enantiomers was established for 15 days at -20 degrees C. The application of the assay to a pharmacokinetic study of ragaglitazar [S(-)-DRF 2725] in rats is described. It was unequivocally demonstrated that ragaglitazar does not undergo chiral inversion to its antipode in vivo in rat plasma.

Background: The purpose of this study was to determine the effects of systemic infusions of nitroglycerin and sodium nitroprusside on flow distribution and wall shear stress in the microcirculation., Methods: With university approval, the cremaster muscle of 28 anesthetized (70 mg/kg pentobarbital given intraperitoneally) hamsters (Harlan Sprague Dawley: Syrian; weight, 121+/-11 g [mean +/- SDD) was observed using in vivo fluorescence microscopy. Arteriolar diameter, erythrocyte flux, and velocity were measured for a feed arteriole and its sequential branches. Observations were made during control (mean arterial pressure, 88+/-4 mm Hg) and after 30 min of intravenous delivery of sodium nitroprusside or nitroglycerin, titrated to decrease mean arterial pressure by 20 mm Hg., Results: Sodium nitroprusside significantly dilated select upstream portions of the network (23+/-2.6 to 29+/-2.6 microm); no arterioles were dilated with nitroglycerin. Erythrocyte flux into the feed (i.e., inflow into the arteriolar network) and into the sequential branches (i.e., distribution within the network) were evaluated. With nitroglycerin, inflow decreased significantly from 1,560+/-335 to 855+/-171 cells/s, and flux into the branches decreased evenly. With sodium nitroprusside, inflow increased significantly to 2,600+/-918 cells/s, yet cells were "stolen" from upstream branches (a decrease from 425+/-67 to 309+/-87 cells/s in the first branch). Excess flow passed into a downstream "thorough-fare channel," significantly increasing flux from 347+/-111 to 761+/-246 cells/s. Wall shear stress decreased uniformly with nitroglycerin infusion, with a decrease in the feed from 8.8+/-2.5 to 6+/-1.7 dyn/cm2. With sodium nitroprusside, variable changes occurred that were location specific within the network. For instance, at the inflow point to the network, wall shear stress changed from 8.3+/-2.5 to 4.2+/-3.3 dyn/cm2., Conclusions: Nitroglycerin infusion promoted homogeneity of flow. Sodium nitroprusside significantly increased the heterogeneity of flow within this arteriolar network; an anatomic location for steal induced by sodium nitroprusside is identified.