Cost assessment of allergy procedures to improve high-value care implementation.

Background: Oral challenges and desensitizations are regularly performed by allergy/immunology physicians. However, there is limited research that has evaluated their cost-effectiveness and overall health-care-related value. Objective: The objective was to analyze the costs of oral challenges and desensitizations by clinician type (including allergy/immunology physicians, other physicians, and certified registered nurse practitioners [CRNP] and physician assistants [PA]), and by geographic distribution in the United States. Methods: By using a de-identified commercial database of medical encounters, we identified all claims for outpatient oral challenges and desensitizations in 2017 and grouped them separately by clinician type and by U.S. Census region. We used analysis of variance to test for cost differences between these two groupings. Results: Allergy/immunology physicians performed the majority of oral challenges (74.36%) with a mean cost of $161, significantly less than that of other physicians ($280). Allergy/immunology physicians also performed the majority of desensitizations (84.48%) with a mean cost of $335, significantly higher than that of CRNPs/PAs ($280); other physicians were reimbursed significantly more than both groups ($410). By geographic region, the mean costs of oral challenges in the Northeast ($212) and the West ($210) were significantly higher than those of other regions, whereas the mean cost of desensitizations was significantly highest in the West ($381). Conclusion: Allergy/immunology physicians and CRNPs/PAs cost the least with respect to oral challenges, whereas CRNPs/PAs cost the least with respect to desensitizations. The Northeast and the West regions provided the highest cost for oral challenges, whereas the West was most expensive in terms of desensitizations. Further knowledge and examination of these reimbursement patterns are crucial in understanding their relative value and the impact on delivery of high-value care.

Vitamin D Is Required for ILC3 Derived IL-22 and Protection From Citrobacter rodentium Infection.

Citrobacter rodentium is a gastrointestinal infection that requires early IL-22 from group 3 innate lymphoid cells (ILC3) for resistance. The role of vitamin D in the clearance of C. rodentium infection was tested in vitamin D sufficient (D+) and vitamin D deficient (D-) wildtype (WT) and Cyp27B1 (Cyp) KO mice (unable to produce the high affinity vitamin D ligand 1,25(OH)2D, 1,25D). Feeding Cyp KO mice D- diets reduced vitamin D levels and prevented synthesis of 1,25D. D- (WT and Cyp KO) mice had fewer ILC3 cells and less IL-22 than D+ mice. D- Cyp KO mice developed a severe infection that resulted in the lethality of the mice by d14 post-infection. T and B cell deficient D- Rag KO mice also developed a severe and lethal infection with C. rodentium compared to D+ Rag KO mice. D- WT mice survived the infection but took significantly longer to clear the C. rodentium infection than D+ WT or D+ Cyp KO mice. Treating infected D- Cyp KO mice with IL-22 protected the mice from lethality. Treating the D- WT mice with 1,25D reconstituted the ILC3 cells in the colon and protected the mice from C. rodentium. IL-22 treatment of D- WT mice eliminated the need for vitamin D to clear the C. rodentium infection. Vitamin D is required for early IL-22 production from ILC3 cells and protection from enteric infection with C. rodentium.

PET/CT in primary hepatic lymphoma with hepatic vein thrombus that extended into the inferior vena cava.

Primary hepatic lymphoma (PHL) is an extremely rare manifestation of extranodal non-Hodgkin's lymphoma (0.016% of all cases). Presented are CT, MRI, ultrasound, and (18)F fluoro-2-deoxy-D-glucose (FDG) PET/CT images, which characterized PHL and demonstrated hepatic vein thrombus that extended into the inferior vena cava--a feature not previously described. Recognition of this imaging pattern may help in the differential diagnosis of future such cases. FDG PET/CT was critical in confirming the diagnosis, staging, and demonstrating response to treatment.