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The enhanced choice model of skill-based treatment (ECM-SBT; Rajaraman et al., 2021) is a package of behavioral treatment procedures with modifications designed to reduce risks associated with extinction of problem behavior. The skill-based treatment component of this package (Hanley et al., 2014) has been investigated thoroughly in clinical settings, though fewer studies have been conducted in public schools. In this investigation, we systematically replicated Rajaraman et al.'s (2021) demonstration of the ECM-SBT with 3 children enrolled in a public special day school for students with emotional and behavioral disorders. Intervention procedures were associated with increases in targeted alternative responses (i.e., communicative response, tolerance response, and cooperation with instructions) and decreased precursor behavior relative to baseline. Severe problem behavior was rare in both assessment and treatment. Participants chose to spend most appointment time participating in ECM-SBT, indicating preference for treatment procedures over alternative contexts (i.e., free access to a break area with preferred activities; regular classroom instruction). These outcomes suggest ECM-SBT has promise for safely teaching alternatives to problem behavior to children with emotional and behavioral disorders in school settings.

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To evaluate effects of psychotropic medication for children with disabilities, direct assessments may offer a valuable supplement to caregiver reports. Relative to indirect assessment, direct measures of behavior can increase objectivity and sensitivity, and some have potential to isolate distinct behavioral and learning processes. We conducted a systematic, narrative literature review to identify and describe the types and qualities of direct assessment methods that have been used to evaluate effects of non-stimulant psychotropic medication for children with disabilities. We identified 50 studies and 78 direct assessments, which we organized and described using seven assessment categories. Only one study met all three direct assessment quality indicators. We use our descriptive results to highlight research trends and gaps that warrant further study.

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The purpose of the current study was to explore the scientific utility of two behavior analytic assessments (i.e., progressive ratio and demand assessments) for psychotropic medication evaluation. For a sample of 23 children with disabilities who were prescribed medication, we conducted a series of generalizability and optimization studies to identify sources of score variance and conditions in which stable estimates of behavior can be obtained. To inform construct validity, we calculated correlations between scores from each assessment and those from a standardized behavior rating scale (Aberrant Behavior Checklist-Second Edition; ABC-2). Results offer initial support for the scientific utility of progressive ratio scores. More research is needed to evaluate sensitivity to change and construct validity of scores from these and other behavior analytic assessments.

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The association between asthma and sinusitis was recognized more than a century ago. Since 1980, several studies have documented that severe asthma improved after coexisting sinusitis was effectively treated either medically or surgically. Because the mechanism relating sinusitis to asthma is not known, several theories have been proposed: 1) aspiration of infected sinus secretions into the lungs during sleep, 2) enhanced vagal stimulation in the infected sinus producing direct bronchospasm, 3) bronchospasm from excessive airway drying from mouth breathing, 4) production of bacterial toxins that induce partial beta blockade, and 5) production in the infected sinus of cytokines and bronchoconstrictive mediators. There are data to support each of these hypotheses, and any or all of them may be operative. In view of recent demonstrations of activated lymphocytes and eosinophils in asthmatic airways, it is intriguing that biopsies of chronic hypertrophic sinusitis have revealed increased numbers of eosinophils and increased levels of granulocyte-macrophage colony stimulating factor, interleukin-3, and interleukin-5 compared to control tissue. These findings suggest that sinusitis might induce asthma by stimulating eosinophil production and activation and thereby supplying peptidoleukotrienes (LTC4 and LTD4) and other asthmagenic eosinophil products.

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The mast cell, equipped with enzymes, chemotactic factors, a vasoactive amine, an anticoagulant, and lipid-derived proinflammatory products, may be essential in tissue modeling as well as in defense. Its primarily perivascular location in skin and the mucosa of the respiratory tract and the gut assures its availability to counter parasites. By the same token, the mast cell is responsible for interactions with inhaled, ingested, and injected antigens that comprise IgE-mediated allergic reactions. Abnormally high numbers of mast cells in the skin, either localized or generalized, result in urticaria pigmentosa or generalized cutaneous mastocytosis, respectively. Tissue infiltration by excessive mast cells, primarily in gut, bone, liver, and spleen, results in systemic mastocytosis; this may be accompanied by myelodysplasia or lymphoma and may eventuate in mast cell leukemia. Until the etiology of mastocytosis is understood, the treatment is symptomatic: histamine antagonism by H1 +/- H2 blockade for flushing, itching, and gastric distress; cyclooxygenase inhibition to prevent prostaglandin D2 (PGD2)-induced hypotension when indicated; and oral cromolyn to prevent gastrointestinal symptoms and bone pain.

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Allergen-stimulated release of a cyclooxygenase product (thromboxane [TX] A2) and a 5-lipoxygenase product (leukotriene [LT] E4) into the urine was measured in 10 atopic asthmatics undergoing allergen inhalation. Because indomethacin has been reported to increase allergic-stimulated 5-lipoxygenase product formation and to inhibit the late asthmatic response, we determined the effect of indomethacin (50 mg 3 times a day) or placebo on airway and biochemical responses to inhaled allergen in a randomized, blinded study. Urinary levels of the enzymatic metabolite of TXB2, 11-dehydro-TXB2, increased from 585 +/- 330 to 1,500 +/- 250 pg/mg creatinine (mean +/- SEM, p less than 0.05) 2 h after allergen. Urinary LTE4 increased from 190 +/- 37 to 1,100 +/- 400 (p less than 0.05) 2 h after challenge. The urinary levels of these eicosanoids were not elevated during the late response. Indomethacin significantly reduced urinary 11-dehydro-TXB2 levels without affecting the excretion of LTE4 or pulmonary function. Thus, we failed to obtain evidence for enhanced leukotriene formation during allergic stimulation in vivo in the presence of cyclooxygenase inhibition. Furthermore, we conclude that cyclooxygenase products are likely to play only a marginal role in allergic bronchoconstriction.

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Repeat A-scans of 45 patients who had silicone intraocular lens (IOL) implantation indicated an apparent increase in the axial length of the eyes. The average increase of 1.045 mm over the original axial length was noted when using the pseudophakic mode for the axial length determination. The actual velocity of sound in eyes with a silicone IOL is 1,486 M/sec compared to 1,548 M/sec in an eye with a polymethylmethacrylate implant. This finding is clinically significant when one is comparing the axial length of two eyes, one of which is pseudophakic. A 1 mm difference in axial length can cause serious doubts about the validity of one or the other of the scans if the type of implant is not known. The velocity of RMX-3 silicone was determined to be 1,049 M/sec.

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The diagnosis of systemic mastocytosis without urticaria pigmentosa has been made with increasing frequency since modern methods of histamine assay have been used clinically. We examined the incidence of urticaria-angioedema and mastocytosis over a recent 12-month period. Of 490 new patients we saw, 52 had urticaria-angioedema, and ten had evidence of excess histamine +/- PGD2, with at least ten mast cells per high-power field on skin biopsy. The average age was approximately 35 years; the male:female ratio was 1:4 for urticaria-angioedema and 1:2 for mastocytosis. Symptoms of mastocytosis included flushing, abdominal cramping/diarrhea, syncope, urticaria-angioedema, pruritus, and headache. Symptoms have typically been prevented by a combination of H1 and H2 antagonists, with addition of a cyclo-oxygenase inhibitor in syncopal cases. Acute hypotension has responded to epinephrine.

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We have previously reported that flushing associated with a gastric carcinoid tumor can be provoked by pentagastrin and inhibited by either somatostatin or combined histamine H1- and H2-receptor blockade. In this report, the effects of pentagastrin and somatostatin on histamine release in a patient with a metastatic gastric carcinoid tumor were examined. Small doses of intravenous pentagastrin (0.1-0.4 micrograms) produced a dose-dependent increase in the level of circulating plasma histamine. Graded infusions of somatostatin suppressed both basal and pentagastrin-stimulated plasma histamine levels in a dose-dependent fashion. A close correlation was found between circulating plasma histamine levels and attendant changes in blood pressure and pulse rate. This study documents that pentagastrin directly evokes the release of histamine from this patient's gastric carcinoid tumor and that the release of histamine is inhibited by somatostatin. In addition, this study provides additional evidence that the primary mediator of the flushing in this patient with foregut carcinoid syndrome is histamine.

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In this report we describe the characteristics of human anti-LRH antibodies detected in the serum of a male patient with isolated gonadotropin deficiency. He had received 90 days of therapy with LRH (1 mg, sc, three times daily) and was then placed on three cycles of intermittent therapy (3 weeks of LRH daily, followed by hCG every 3 days for 15 days). At the start of the fourth cycle of therapy with LRH, he developed urticaria at the site of injection, at sites of previous LRH injections, and at distant sites. Upon direct skin testing, the patient reacted positively to 0.02 ng LRH intradermally. A positive intradermal reaction was induced in a normal adult male by preparing his skin with 0.1 ml of the patient's serum and, 24 h later, injecting 0.2 microgram LRH at that site. A binding factor for LRH was detected in the patient's serum by incubation with [125I]LRH. The serum bound 33% of tracer compared to 6% in control serum. We have detected both immunoglobulin G and immunoglobulin E antibodies against LRH in the patient's serum. We have compared displacement of tracer by synthetic LRH with displacement achieved by a series of analogs. Displacements of tracer by LRH, [Lys8]LRH, [D-Trp6,Pro9-NEt]LRH, [des-Gly10]LRH, and [Phe2]LRH were similar, whereas the potencies of Ac-LRH5-10 and AcLRH2-10 were 0.1% or less.

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Seven patients with bronchial asthma underwent bronchial inhalation challenge with aerosolized allergen extracts and methacholine. Simultaneously, venous blood samples were collected and histamine was measured. Each patient was challenged on successive days with an allergen extract to which he had no skin-sensitizing antibody (skin test-negative allergen), followed by methacholine and skin test-positive allergen. Bronchospasm was not induced by inhalation of skin test-negative allergens but was observed in all patients after methacholine and in the majority of patients after skin test-positive allergens. No changes in plasma histamine were detected after challenges with methacholine and skin test-negative allergens. After challenge with skin test-positive allergens, significant rises in plasma histamine were detected in 5 of 7 patients. Plasma histamine was elevated within the first 5 min after inhalation of aerosolized allergen, and elevations persisted as long as 30 min. These studies showing that histamine increases significantly in the plasma during allergen-induced asthma in man suggest that histamine should be considered as at least one of the mediators of bronchospasm in allergic asthma. Bronchospasm induced by the cholinergic drug methacholine, unlike allergen-induced bronchospasm, is not associated with changes in plasma histamine.

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Although the serum bactericidal test is commonly used in the management of infective endocarditis, little has been written about its validity or limitations. We report three cases of gram-negative bacillary endocarditis (Pseudomonas aeruginosa, Vibrio fetus and Serratia marcescens) encountered in 1 year at a Veterans Administration hospital. Serum bactericidal titers were considered necessary to identify inadequate antibiotic regimens or to avoid unnecessary drug toxicity. The limitations of the test, particularly those pertaining to gram-negative infections, are reviewed. Misleading results during treatment with aminoglycoside antibiotics could be due to the tendency of serum to become alkaline on standing. A detailed study of the interaction of the complement-dependent bactericidal system of serum with eight antibiotics is presented. In the context of the serum bactericidal test, the interaction was additive or synergistic in 15 of 16 determinations, indicating the need to include a control study of serum sensitivity of the infecting microorganism in each case.

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The present studies investigated patterns of rabbit platelet aggregation and release of 5-hydroxytryptamine (5HT) utilizing nine variables: three different types of challenge, soluble antigen and antibody (AG-AB), zymosan (Z), an agent known to activate the alternate complement pathway (ACP), and Z preincubated in lightly heparinized plasma so as to become coated with complement (ZC); three different types of platelet-rich plasma (PRP), lightly heparinized PRP in which both complement pathways are active, ethylene glycol tetraacetic acid-PRP (EGTA-PRP) in which only the ACP is active, and ethylene diamine tetraacetic acid PRP (EDTA-PRP), which inhibits both complement pathways; three different types of inhibitors, cobra venom factor (CoF), which causes activation of C3 proactivator (C3PA) to C3 activator (C3A) and fluid phase decomplementation of C3 and C5 through C9, adenosine monophosphate (AMP), a specific antagonist of ADP, and tosyl arginine methyl ester (TAME), an inhibitor thought to act not only on the first component of complement, but also on a platelet membrane site of mediating complement-induced platelet injury as well as on C3PAse. In heparinized PRP, both AG-AB and Z produced biphasic aggregation and prompt and extensive 5HT release. A brief lag period noted with both AG-AB and Z challenge was not observed with ZC challenge, indicating that this lag period represented time required for generation of the necessary complement-dependent membrane-injuring activity. Prior decomplementation by CoF entirely prevented both aggregation and release by either AG-AB or Z but by ZC, indicating first that fluid-phase ACP activation did not produce platelet injury, and second that ZC had on its surface an activity capable of producing immediate biphasic aggregation and prompt 5HT release without the further participation of later acting complement components. Both AMP and TAME eliminated the second phase of aggregation and diminished or eliminated 5HT release with all three challenges, suggesting that both inhibitors might be operative on similar or identical platelet membrane receptors mediating complement-dependent platelet injury. In EGTA-PRP, AG-AB and Z produced delayed monophasic aggregation and delayed and diminished 5HT release, whereas ZC produced immediate although monophasic aggregation but delayed and diminished 5HT release. This suggested that all three challenges were capable of producing ACP-mediated platelet injury.

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A new example of complement-mediated platelet injury has been described. Staphylococcal protein A (SPA) causes rabbit platelet injury as manifested by release of platelet 5-hydroxytryptamine (5HT). This reaction is complement-dependent and occurs over a very small range of SPA concentration, larger amounts being inhibitory. Complement fixation by SPA demonstrates the same narrow SPA concentration requirement whereas precipitation of IgG by SPA is roughly proportional to SPA concentration over a wide concentration range. The reaction can be separated into a sensitization step which requires SPA and plasma but not complement, and a release step which does require complement. Complement-mediated platelet damage induced by SPA is a new biologic property of this common component of the cell wall of pathogenic staphylococci which may contribute to the development of inflammatory and thromboembolic reactions complicating intravascular staphylococcal infection.

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