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Content » Vol 93, Issue 5
Management of Childhood Urticaria: Current Knowledge and Practical Recommendations
Helena Pite1–3, Bettina Wedi1, Luís Miguel Borrego2,4, Alexander Kapp1 and Ulrike Raap1
1Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany, 2Department of Immunoallergy, Centro Hospitalar de Lisboa Central, 3Department of Pharmacology, and 4Department of Immunology, CEDOC, Faculty of Medical Sciences, Lisbon, Portugal
Urticaria, defined by the presence of wheals and/or angioedema, is a common condition in children, prompting parents to consult physicians. For its successful management, paediatric-specific features must be taken into account, regarding the identification of eliciting triggers and pharmacological therapy. This review systematically discusses the current best-available evidence on spontaneous acute and chronic urticaria as well as physical and other urticaria types in children. Potential underlying causes, namely infections, food and drug hypersensitivity, autoreactivity and autoimmune or other conditions, and eliciting stimuli are considered, with practical recommendations for specific diagnostic approaches. Second-generation antihistamines are the mainstay of pharmacological treatment aimed at relief of symptoms, which require dose adjustment for paediatric use. Other therapeutic interventions are also discussed. In addition, unmet needs are highlighted, aiming to promote research into the paediatric population, ultimately aiming at the effective management of childhood urticaria. Key words: antihistamines; children; diagnosis; disease management; pruritus; therapy; urticaria.
Accepted Nov 17, 2012; Epub ahead of print Apr 2, 2013
Acta Derm Venereol 2013; 93: XX–XX.
Helena Pite, Department of Immunoallergy, Hospital Dona Estefania, Centro Hospitalar Lisboa Central, Rua Jacinta Marto, 1169-045 Lisbon, Portugal. E-mail: helenampite@gmail.com
Urticaria is subjectively recognized as a common problem in children. However, population-based studies are scarce. In a non-interventional birth cohort study, 5.4% of 404 participating 6-year-old children were reported to have had at least one episode of urticaria during the last year (1). Despite the fact that only half of the urticaria episodes were diagnosed by doctors, the authors report that this figure is in accordance with previously published data estimating overall urticaria frequency in children between 2.1% and 6.7%.
Childhood urticaria management is currently suggested to be the same as in adults (2). However, there are paediatric-specific features that must be taken into account regarding eliciting triggers and pharmacological therapy. This review systematically considers and discusses the currently best-available evidence on childhood urticaria addressing the diagnostic and therapeutic management. It also highlights unmet needs, aiming to promote research in this specific population.
Accurate diagnosis is an essential prerequisite to a successful management approach. Urticaria is defined by the presence of wheals and/or angioedema (3). A wheal comprises a central swelling, pruritus or burning sensation, disappearing within a maximum of 24 h, without residual lesion (3). Angioedema is characterized by a swelling of the lower dermis and subcutis, associated with a tingling sensation or pain, its resolution taking up to 72 h (3). Other diseases, including cutaneous mastocytosis, urticarial vasculitis or C1 esterase inhibitor deficiency, not fulfilling the aforementioned criteria for wheals and angioedema, are not considered in this review.
So far, no concise pathogenic mechanism has been identified for all cases of urticaria, although the activation and degranulation of basophils and/or mast cells leading to histamine release is a central feature suggested to explain this troubling disease.
Urticaria management comprises 2 essential steps: the identification and elimination of eliciting triggers and/or underlying causes and treatment aimed at providing symptom relief (2).
ELICITING TRIGGERS AND UNDERLYING CAUSES IN CHILDHOOD URTICARIA
The avoidance/elimination of urticaria triggers or underlying causes is the only potentially curative therapy. Therefore, it is the first concept in urticaria management in children (Table I). Comprehensive anamnesis and physical examination is the key for the identification of relevant eliciting factors. All extended diagnostic tests should be patient-tailored. Before ordering a test, especially regarding children, physicians must carefully consider the usefulness of its result. This should have a practical effect, ultimately allowing better disease management for the particular child.
Table I. Key concepts in urticaria management in children
• Avoidance/elimination of underlying causes and/or eliciting triggers is important.
• Second-generation H1-antihistamines are the mainstay of pharmacological treatment aimed at providing symptom relief. Up-dosing has not been validated in children. First-generation H1-antihistamines should be avoided, mostly due to relevant side-effects.
• Difficult cases may require other therapeutic interventions, the risk–benefit ratio being carefully analysed as there is hardly any evidence supporting it in children.
• Corticosteroids should be avoided whenever possible and strictly used for short periods only (3–7 days), given the unacceptable side-effects from long-term use.
Urticaria is classified into 4 main types according to its precipitants and duration: spontaneous acute urticaria, spontaneous chronic urticaria, physical urticaria, and other urticaria types (3). These different types display distinct underlying aetiologies, involving specific management approaches.
Spontaneous acute urticaria
By definition, acute urticaria lasts less than 6 weeks (3). It is the most common type of urticaria in children (1, 4–6). In many cases of urticaria, no specific cause is found. Overall, success in identifying a cause in paediatric acute urticaria varies widely in literature, from approximately 20% to 90% (7, 8). This is mainly justified by different patient recruitment (e.g. from emergency departments, hospitalized or specialized units/departments), diagnostic testing performed, and criteria used for establishing a cause. The possibility that a specific combination of several triggers is required to elicit acute urticaria could be one explanation for why symptoms may never reappear.
Infections, drug and food hypersensitivity have been reported as common potential triggers of acute urticaria in children.
Infections have been found to be the most frequently associated potential triggers in several studies (4, 8–11). Although the exact role and pathogenesis of mast cell activation by infectious processes remains unclear (12), there is no doubt for a causal relationship to infections in acute urticaria (13). Usually these are upper respiratory tract infections, but gastrointestinal and urinary infections have also been implied (4, 7–11, 13). Viruses, such as adenovirus, enterovirus, rotavirus, respiratory syncytial virus, Epstein-Barr virus and cytomegalovirus have been reported to cause acute urticaria in children (8, 11, 13). Seasonalities of several acute respiratory viral infections and acute urticaria coincide, which underlines the significance of these infections as a potential cause of acute urticaria in children (7, 13).
Bacteria, such as streptococcus, as well as Mycoplasma pneumoniae may induce urticaria in children (11, 13, 14). Parasitic infections, including Blastocystis hominis, Plasmodium falciparum and Anisakis simplex, may also induce urticaria (13, 15). Regarding the Anisakis nematode, its role in recurrent acute urticaria is controversial (13). However, a paediatric case-control study involving 200 patients has found a significantly higher risk for relapsing acute urticaria in sensitized children (16). Fungi have not been stated as a cause of acute urticaria (13).
Infections are a potentially treatable cause of urticaria. However, the role of clinically silent infections in childhood urticaria is debatable. This issue requires case-control studies and follow-up of urticaria remission in response to infection-directed therapy.
Drug hypersensitivity
Drug hypersensitivity is the second main suspected cause in childhood acute urticaria (7, 8, 10, 11). The most commonly reported drugs are antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs), which are often prescribed during infections. True drug hypersensitivity can be a cause of urticaria, implying drug suspension and, if necessary, the prescription of an alternative drug without cross-reactivity to the former. However, its role in acute urticaria in children may be overestimated. Studies evaluating > 40 children with a plausible history of drug allergy have demonstrated that > 90% of them were able to tolerate the suspected drug after a proper diagnostic work-up (17, 18). The confirmation of a drug hypersensitivity diagnosis may involve in vitro assays and/or skin tests and ultimately drug provocation tests, if not contraindicated, according to the patient's history and implicated drug.
Despite the fact that acute urticaria is the main clinical manifestation in immunoglobulin E (IgE)-mediated food allergy, food allergens have been documented as a cause of less than 7% of all cases of urticaria in several studies (7, 10, 11). Nevertheless, food allergy was still the most frequent cause of acute urticaria in children referred to Allergology Departments in Spain. This probably did not reflect its frequency in the general population, due to paediatricians not referring those urticaria cases suspected of having an infectious cause to the specialists (5).
Food allergy may occur after direct skin contact (a form of contact urticaria), inhalation or ingestion. The prominent pathophysiological mechanism is IgE-mediated, symptoms occurring immediately (in less than 1 h), most commonly after food ingestion. The diagnostic work-up mainly consists of allergen-specific IgE quantification with total IgE and/or skin-prick testing regarding the suspected food allergens. Oral food challenges are the gold standard for diagnosis (19).
If identified, the specific-food allergens need to be eliminated from the child's diet. Avoidance of type I allergens is expected to induce remission of urticaria within less than 48 h (2).
Practical recommendation: An extended diagnostic work-up is not needed in childhood acute urticaria. Specific testing should be performed only if strongly suggested by the patient's history (Table II).
Table II. Underlying causes/eliciting triggers and general testing recommendations in childhood urticaria
Urticaria type
Underlying causes/eliciting triggers/urticaria subtype
General testing recommendations
Infections (viral, bacterial or parasitic infections)
Hypersensitivity (e.g. foods, drugs)
Other (e.g. insect stings, inhalant allergens)
None recommended
Should be based upon strongly-suggestive history (e.g. suspected IgE-mediated allergy)
Spontaneous chronic urticaria
Autoimmune conditions (e.g. thyroid autoimmunity, celiac disease, connective tissue disorders)
Other (e.g. hypersensitivity to foods, additives, drugs; malignancy)
Guided by suspected causes from anamnesis and physical examination
Consider complete blood count with differential and erythrocyte sedimentation rate/C-reactive protein
Physical urticaria
Dermographic
Cold contact
Other (heat contact, solar, delayed pressure, vibratory)
Perform physical urticaria subtype identification test with suspected eliciting trigger. If positive, determine the stimulation threshold
In dermographic and cold contact urticaria consider complete blood count with differential and erythrocyte sedimentation rate/C-reactive protein. Rule out other diseases, if suspected
Other urticaria types
Cholinergic
Other (exercise-induced, aquagenic)
Perform urticaria subtype identification test with suspected eliciting trigger. If positive, determine the stimulation threshold for cholinergic and exercise-induced urticaria
See text for details.
N.B. Different urticaria subtypes may coexist in the same child.
Chronic urticaria has a duration of > 6 weeks (3). Population-based studies are needed to estimate the frequency of chronic urticaria in children. In a nationwide Spanish study, including patients treated by allergology specialists, urticaria was diagnosed in 66 out of 917 children, of whom 12 (18%) were chronic (5). In another prospective study addressing all different childhood urticaria types evaluated in an Allergy Unit, chronic urticaria was diagnosed in 17 of 54 (32%) children (11).
Many suspected causes have been considered in childhood chronic spontaneous urticaria, including infections, autoreactivity, autoimmunity, food hypersensitivity; and other precipitants.
Several pathogens have been associated with paediatric chronic urticaria, including viruses (e.g. Epstein-Barr virus), bacteria (mostly streptococci, staphylococci, Helicobacter pylori and Escherichia coli) and parasites (11, 13, 20–22).
In a study published more than 40 years ago, recurrent upper respiratory tract infections were described in 15 out of 16 children with chronic urticaria (23). These data are in accordance with the current clinical experience of some working groups (13). Sackesen et al. (11) have documented infections in 6/17 (35%) children with chronic urticaria. This is in clear contrast with the study by Kilic et al. (24), who found infections in none of the 40 children with chronic urticaria, who were examined thoroughly for infectious diseases.
Besides documenting infections, it is important to evaluate urticaria improvement or remission with the treatment of infections, which has been reported for respiratory and urinary infections (11, 13, 23). Gastrointestinal disease caused by H. pylori has also been linked to paediatric urticaria. Sackesen et al. (11) documented H. pylori infection in 3/17 (18%) children, all without gastrointestinal symptoms. One patient had urticaria remission after an eradication treatment. Other studies addressing childhood chronic urticaria have found 3/31 (10%), 2/93 (2%), and none out of 40 children infected with H. pylori (20, 22, 24). A case-control study regarding H. pylori infection in 167 children in Brazil found urticaria to be an independent variable associated with this bacterial infection (25).
Regarding parasites, a recent study including children has reported urticaria remission after the successful eradication of Blastocystis hominis infection with no recurrence of symptoms in 1-year follow-up (15). Another study also found urticaria remission in 2/5 children with chronic urticaria after treatment for parasitic infestations, which was nevertheless not higher than the rate of urticaria remission in the remaining patients (57%) (21).
In order to estimate the role of different infections, and compare urticaria remission rates, a larger number of children should be evaluated in randomized controlled trials. Moreover, data on this regard have to be carefully analysed, since the pathogenesis of chronic urticaria in a particular patient may be multifactorial and not only infectious (13).
Practical recommendation: Infectious symptoms and signs should be carefully assessed during anamnesis and physical examination and treated appropriately in all children with chronic urticaria. In addition, a more thorough search for infectious agents may be advisable in those children with refractory chronic urticaria. Guidelines recommend a complete blood count with differential and erythrocyte sedimentation rate or C-reactive protein as useful for a diagnostic approach in chronic spontaneous urticaria, which may highlight suspicion for underlying infections (Table II).
Autoreactivity
Recent publications have highlighted the role of autoreactivity in childhood chronic spontaneous urticaria. Autoreactivity can be assessed in vivo by the autologous serum skin test (ASST). This test does not define, per se, autoimmune urticaria, which should include clinical, immunological and other laboratory criteria, currently a matter for analysis to be formally defined (26). Positive ASST indicates the presence of factors (which may include autoantibodies or others) in the patient's own serum, responsible for the development of wheals. In order to demonstrate functional autoantibodies and their specificity, a basophil histamine release assay and an immunoassay (Western blot or enzyme linked immunosorbent assay), respectively, should be performed (26).
Data analysis from some of the largest studies concerning results of ASST in childhood chronic spontaneous urticaria, each testing >40 children, shows a frequency of positive ASST in 38–47% of these patients (20–22, 27). These children with positive ASST had similar clinical characteristics to those with negative ASST. There were no differences in medication requirements or chronic urticaria remission between children with positive and negative ASST (20–22, 27).
The study conducted by Du Toit et al. (27) also detected autoantibodies to the IgE receptor in 37 of 78 (47%) tested children with chronic urticaria. This was similar to the previously published study by Brunetti et al. (20) (40%) testing a total of 52 children. Furthermore, Brunetti et al. demonstrated a positive correlation between a positive ASST result and histamine release. However, Du Toit et al. (27) could not find a significant correlation between the ASST result and the presence of histamine-releasing factors or of autoantibodies to the IgE receptor.
Overall, the role of autoreactivity deserves additional analysis.
Practical recommendation: Current data do not support the routine use of the ASST in children with chronic urticaria, since, to date, it has not been proven to enhance the identification of an underlying cause or disease or to be useful in predicting urticaria severity, duration or the best therapeutic approach.
Thyroid autoimmunity
Additional evidence supporting an autoimmune basis in chronic urticaria comes from its association with other autoimmune conditions, namely thyroid autoimmunity (3). In a study by Caminiti et al. (28) conducted in Italy, 9 out of 95 (9.5%) children with chronic urticaria had anti-thyroid autoantibodies, 4 of them with Hashimoto's disease. In contrast, Brunetti et al. (20) reported that none of the 93 studied children with chronic urticaria, also recruited from Italy, showed signs of thyroid autoimmunity. The reason for this difference may rely on the severity of urticaria, as all the patients included in the study by Caminiti et al. (28) had antihistamine-resistant chronic urticaria, with the need for frequent oral steroids for disease control. Thus, it is hypothesized that children with more severe or unresponsive to standard treatment chronic urticaria may have associated autoimmune conditions more frequently.
Other studies, each involving > 80 children with chronic urticaria, have found increased levels of anti-thyroid antibodies in 1.1–4.3% of these patients (21, 22, 29).
Thyroid abnormalities in childhood chronic urticaria deserve more investigation in future studies, also regarding the fact that thyroid autoimmunity prevalence differs in different populations.
Practical recommendation: For the present, it is consensual that laboratory examinations for thyroid hormones or antibodies should not be performed on a routine basis, but only if the child's personal or family history suggests thyroid dysfunction (Table II).
Other autoimmune conditions
Other autoimmune conditions have been reported in children with chronic urticaria, namely juvenile idiopathic arthritis, systemic lupus erythematosus, type 1 diabetes and coeliac disease. From these, the role of coeliac disease is stressed, as it may be subclinical and has been suggested to cause chronic urticaria in some children rather than being simply an associated disease. This was supported by a study comparing 79 children with refractory chronic spontaneous urticaria with 2,545 children with a negative clinical history for urticaria (28). Coeliac disease was found in 4 out of 79 (5%) children with chronic spontaneous urticaria, significantly more than in controls (0.67%). All 4 children had complete remission of urticaria within 5–10 weeks on a gluten-free diet. Other reports associating chronic urticaria with coeliac disease in children have been found. The vast majority of these children had urticaria remission after a gluten-free diet (30–32). This finding is worthy of further investigation, since it might suggest screening for coeliac disease in children with chronic urticaria, especially in refractory cases.
Practical recommendation: Coeliac disease and other autoimmune conditions should be considered, if suggested by the patient's history.
Food hypersensitivity
IgE-mediated food allergy is very rarely the cause of chronic urticaria in children (21, 22, 27). Regarding food additives, a study conducted more than 10 years ago showed that 12/16 (75%) children with chronic urticaria went into remission under a stringently controlled low-pseudoallergen diet for 3 weeks. Urticaria reappeared when the prohibited foods were reintroduced. Reactions occurred mainly to colouring agents and preservatives, but also to monosodium glutamate and a sweetener (saccharin/cyclamate) (33). Martino et al. (34) previously studied a total of 120 children with intermittent or recurrent urticaria. After a diet devoid of food additives and during a symptom-free period without medication intake, children were orally challenged with 7 food additives. None reacted to placebo, while 56 (46%) children had one or more positive challenges to food additives, evidencing urticaria. Colouring agents and preservatives were also relevant to the majority.
The so-called pseudoallergen-free diets may be beneficial to some patients. However, special care is required as these diets are usually very strict, many essential foods being forbidden, and therefore potentially harmful for the child and consequently not advisable.
Practical recommendation: Suspected hypersensitivity to foods and food additives must be documented in a patient-tailored way in selected cases, guided by history. Ultimately, it should be confirmed by a supervised elimination diet for at least 3 weeks (preferably dietician-supervised to avoid dietary deficiencies) followed by oral challenge tests (adapted to the particular patient and suspected food/additive).
Other precipitants
Recurrence of urticaria has also been described after drug intake in children with chronic urticaria, although this is not a commonly suspected precipitant in paediatric studies (11, 22).
Occasional reports of paediatric malignancy associated with chronic urticaria in literature stress the need for a thorough history, physical examination and follow-up (35, 36). There is no evidence supporting a screen for malignancies in children with chronic spontaneous urticaria (3).
Practical recommendation: Other possible triggers for urticaria should be carefully considered during anamnesis and physical examination. Extended testing is recommended, if suspected by history (Table II).
Physical triggers are the most commonly identified aetiology in childhood chronic urticaria (5, 6, 11, 37). Physical urticaria subtypes are described according to the eliciting trigger: cold contact, heat contact, solar, dermographic, delayed-pressure and vibratory urticaria (3). Dermographic and cold urticaria are highlighted mainly due to its frequency and potential severity, respectively.
Dermographic urticaria
Dermographic urticaria is elicited by mechanical shearing forces (rubbing/scratching rapidly inducing wheals, typically without angioedema). Khakoo et al. (6) studied 53 children with physical and other inducible urticaria types. Dermographic urticaria alone was diagnosed in 38% of all cases. Together with cholinergic urticaria, alone or in mixed forms, it accounted for > 70% of all cases. Regarding a more general paediatric population, a study randomly selecting children from a healthcare centre in Spain has estimated a prevalence of 10% of dermographic urticaria among children (38).
It is important to clearly distinguish this condition from simple dermographism (i.e. wheal upon minimal friction without pruritus), which is more frequent and requires no investigation or treatment (39).
Dermographic urticaria is usually considered idiopathic. However, it has also been described as secondary to infections, infestations, drugs or related to systemic mastocytosis.
Cold urticaria
This subtype is considered when cold (objects, air or fluids) induces immediate urticaria. Anaphylaxis due to cold exposure has been reported in up to 50% of children with this condition (40–42). While, in the vast majority, cold urticaria is idiopathic, there are secondary forms (43). These are more frequent due to infections (mostly documented association to viral infections) or cryoglobulinaemia (40, 42–44). Atypical cold urticaria forms have also been described, with immediate negative or uncharacteristic responses (such as systemic or prolonged reactions) to cold-stimulation testing, being either hereditary or acquired (43, 45).
Practical recommendation: Each physical urticaria subtype is diagnosed by performing specific testing (Table II) (3, 39). Specific tools have been validated for cold (Peltier element-based provocation device TempTest®) and dermographic (calibrated dermographometer) urticaria, which have also been tested on children (3, 39, 46, 47). In dermographic and cold urticaria, extended testing for suspected causes or for differential diagnosis may be considered, according to history (Table II) (3).
When physical urticaria is diagnosed, avoidance of physical stimuli is crucial. Simple measures, such as avoiding tight-fitting or woollen clothing next to the skin of children with dermographic urticaria, may be useful. Exposure to cold environment or ingestion of cold foods, such as drinks or ice-cream, should be considered to prevent cold urticaria. Taking into account the risk for anaphylaxis and for drowning, aquatic activities should be banned in cold-induced systemic reactions (42, 48).
Other inducible types of urticaria are taken into account: cholinergic, exercise-induced, contact, and aquagenic urticaria.
Cholinergic vs. exercise-induced urticaria
In the study by Khakoo et al. (6), the cholinergic subtype was found to be the second most common form. Cholinergic urticaria must be differentiated from the far less frequent exercise-induced urticaria. The former occurs within minutes after the elevation of the body temperature, regardless whether passive (hot shower) or active (exercise), whereas hot bath testing will not elicit exercise-induced urticaria (39, 49). Besides, in cholinergic urticaria, wheals typically have a diameter of less than 5 mm. Those associated with exercise-induced urticaria are substantially larger, the evolution to anaphylaxis being frequent. Classic exercise-induced anaphylaxis has been predominantly described in young adults and adolescents, usually occurring within 30 min of exercising. It is typically preceded by cutaneous manifestations with a rapid progression to severe systemic reaction (50–52). In some cases, symptoms only occur when exercise is preceded by food intake. This entity is designated as food-dependent exercise-induced anaphylaxis (FDEIA). FDEIA is usually associated with IgE-mediated hypersensitivity to food (52). Wheat is the most frequently associated culprit. Other foods such as distinct cereals, shellfish, nuts, vegetables, fresh fruits, milk and egg have been implicated (52). The intake of these foods is tolerated in the absence of exercise, distinguishing this syndrome from food allergy. The diagnostic approach includes an isolated suspected oral food challenge, an isolated exercise test (without food intake in the previous 4 h) and an exercise test after suspected food intake. The high risk of severe reactions must be carefully considered, the sensitivity of this combined test being only 70% (53). Specific-IgE to omega-5 gliadin, a major allergen in wheat-dependant exercise-induced anaphylaxis, has been shown to be useful for the diagnosis of this condition, possibly avoiding the need for a provocation test (54).
Contact urticaria
Contact urticaria involves immediate hypersensitivity reactions to exogenous proteins and chemicals (3, 55). Studies systematically addressing contact urticaria in children are scarce. Latex has been one of the main causes of immunological contact urticaria. It was an important issue in children with spina bifida or other conditions involving multiple chirurgical procedures with latex contact since early life. Fortunately, a decreased prevalence has been observed due to primary preventive measures (56). Oral and perioral urticaria occurring after the direct contact of the oral mucosa with food is a frequent manifestation of food allergy in children (19). A clinically-relevant cross-reactivity to pollen is common (pollen-fruit syndrome) (19). Contact urticaria may progress to systemic symptoms, which could be severe and life-threatening (55).
Aquagenic urticaria
Urticaria elicited by contact with water independent of temperature is a rarity, especially in children and is not discussed further.
Practical recommendation: In this category, each urticaria subtype implies specific testing according to the eliciting factor (Table II) (3, 39). Avoidance of triggers is essential. Regulating the bathing temperature is important in cholinergic urticaria. Exercise-induced urticaria/anaphylaxis may imply the avoidance of physical exercise or the ingestion of suspected food >4–6 h before exercise (53).
TREATMENT AIMED AT PROVIDING SYMPTOM RELIEF
Antihistamines: second generation
Antihistamines are used to inhibit the effect of mast cell and basophil mediators on the target tissue and to induce symptom relief. The use of second-generation H1-antihistamines (2ndGAH) at a standard dose in spontaneous and cold urticaria is the only therapeutic option with a strong recommendation from current guidelines (Table I) (2).
Cetirizine and its active enantiomer levocetirizine are the most comprehensively studied 2ndGAH in children with urticaria. Both drugs have been reported to significantly reduce urticaria episodes, while being safe for children as young as 1–2 years old, evaluated in randomized double-blind placebo-controlled trials lasting 18 months (57–59). Additional evidence supports the use of other 2ndGAH, namely desloratadine, fexofenadine and loratadine, approved for children in both Europe and the USA (60–64). However, randomized, double-blind, placebo-controlled studies evaluating 2ndGAH in childhood acute and chronic urticaria are scarce, especially regarding children under the age of 12 years. Dosage adjustments are required for the use of licensed antihistamine in children (Table III).
Guidelines for chronic urticaria recommend increasing the dose of 2ndGAH up to 4-fold, as needed, to provide symptom relief (2). However, this approach has not yet been validated in children (Table I) (60).
Given inter-patient variability as well as the possibility of dissimilar in vivo H1-receptor antagonist potency of each antihistamine, the change to an alternative 2ndGAH may result in enhanced symptom relief (2, 65–68).
Practical recommendation: Antihistamines (2ndGAH) are the mainstay of pharmacological treatment aimed at providing symptom relief (Table I). Posology adjustments are required for the use of 2ndGAH in children (Table III).
Table III. Oral second-generation H1-antihistamines licensed for paediatric use (alphabetical order)a
Daily dose for children
Daily dose for adults
Bilastineb
≥ 12 years: 20 mg once a day
20 mg once a day
Cetirizinec
S, T
2–5 year: 2.5 mg twice a day
6–11 years: 5 mg twice a day
Desloratadinec
S, LYO, T
1–5 years: 1.25 mg once a day
6–11 years: 2.5 mg once a day
≥ 12 years: 5 mg once a day
2–5 years: 2.5 mg once a day
6–11 years: 5 mg once a day
20 mg once a dayd
Fexofenadinec
6–11 years: 30 mg twice a dayd
≥ 12 years: 120 mgd or 180 mg once a day
120 mgd or 180 mg once a day
Levocetirizinec
2–5 years: 1.25 mg twice a day
≥ 6 years: 5 mg once a day
Rupatadineb
aTopical antihistamines are not recommended for the treatment of urticaria, according to current guidelines. bAccepted European Medicines Agency paediatric investigation plan. cIn some countries, approved for the treatment of chronic idiopathic urticaria in infants >6 months. dLicensed only for allergic rhinitis both in Germany and Portugal.
T: tablet; S: solution; LYO: lyophilisate/orodispersible tablet.
(N.B. This table is a summary based upon European Medicines Agency marketing authorization as well as that from authors' national health authorities by May 2012. For country-specific information, national health authority recommendations should be observed.)
Antihistamines: first generation
Contrary to recommendations, first-generation H1-antihistamines (1stGAH) are used in children despite their known adverse effects and the absence of satisfactory randomized, placebo-controlled trials to support their efficacy. Indeed, information on pharmacokinetics and pharmacodynamics in children is scarce for most of 1stGAH (60). Unlike 2ndGAH, the unfavourable therapeutic index of 1stGAH has been well documented in children and must be considered. After standard doses of 1stGAH, there is potential sedation and impairment of alertness, cognition, learning, memory as well as psychomotor performance and behavioural changes (60, 69). Infants and young children may show paradoxical excitation, irritability, hyperactivity, hallucinations and seizures, usually in overdose, which may be followed by coma and respiratory depression (60). Other adverse effects include sleep disruption, arrhythmias, dry mouth, constipation, urinary retention, increased appetite and weight gain. Furthermore, 1stGAH have been causally linked with deaths from accidental overdose and with homicide (60, 69).
Practical recommendation: The use of 1stGAH in children is strongly discouraged (Table I) (2, 69).
Further therapeutic options
There is a very significant lack of studies addressing the efficacy and safety of other pharmacological therapeutic approaches in severe, refractory childhood urticaria cases.
Montelukast is licensed for paediatric use, but there are very few studies assessing the effectiveness of adding montelukast systemic therapy to antihistamine treatment of urticaria in children (70).
Although there are successful case reports, greater studies to support the recommendation of other therapeutic options, including cyclosporine, immunoglobulin or omalizumab, in childhood refractory urticaria are missing (48, 71–75).
Corticosteroids can control urticaria effectively. However, the potential side-effects of chronic use restrict its application (2, 48).
Other potentially relevant therapeutic options in selected cases include the induction of tolerance, which may be considered in some urticaria types such as cold and cholinergic urticaria (2). Cold tolerance treatment has been reported to be effective and well-tolerated by some motivated children (48). The risk of severe reactions due to cold exposure must, however, be considered.
Practical recommendation: In refractory cases, the physician must carefully assess the best therapeutic risk-benefit ratio of other therapeutic approaches for the particular child (Table I). Corticosteroids should be used only in selected severe cases and exacerbations and only for short periods (Table I). A poor response to therapy should also enforce a differential diagnosis.
FOLLOW-UP AND PROGNOSIS
The monitoring of the physical, cholinergic and exercise-induced urticaria includes the threshold determination of the eliciting factors, since specific testing allows the estimation of disease activity (3, 39). For spontaneous urticaria, the Urticaria Activity Score based on the assessment of key urticaria symptoms (wheals and pruritus) is simple and suitable for disease activity evaluation in adult chronic urticaria patients (3, 76). Such a validated tool is missing for paediatric patients and would be very desirable.
Likewise, an urticaria-specific quality of life questionnaire for children and caregivers would be useful. Using Children's Life Quality Index©, quality of life impairment in children with chronic urticaria has been considered higher than that experienced in the case of children with asthma or epilepsy (77). Chronic urticaria is known to significantly affect school performance, causing school absenteeism and parents taking days off work (78).
Regarding prognosis, acute urticaria is transient, resolving without any sequels in the vast majority of cases.
Chronic spontaneous urticaria has usually been considered to have an overall long-term favourable prognosis. It is rarely associated with severe or life-threatening diseases or the development of serious illness. Sahiner et al. (22) reported urticaria remission in 16.5% of the 82 evaluated children after 1 year. After 3 years, 38.8% of the children were urticaria-free and after 5 years, it had resolved in half of the cases, without any relapse or identified sequel. In univariate analysis, the coexistence of female gender and being older than 10 years predicted an unfavourable prognosis. However, in multivariate analysis, age, gender, the presence of angioedema or other allergic diseases, autoimmunity family history, ASST positivity or abnormal laboratory results did not predict the prognosis.
Physical and other urticaria types may have a worse prognosis. In the study by Khakoo et al. (6), the number of children becoming urticaria free was 11.6% after 1 year and 38.4% after 5 years. In a univariate analysis, a history of other allergic conditions in the child and more frequent urticaria episodes were associated with having a greater risk of non-remission. No significant difference in the age of onset of urticaria and duration of individual bouts was noted between the remission and non-remission groups.
Urticaria is common in children, being a frequent reason for doctors' visits. Most paediatric cases of urticaria are acute, i.e. transient by definition, and resolve without sequel. In these cases, after an accurate clinical diagnosis, symptom relief therapy with 2ndGAH and no extended testing are recommended.
In chronic urticaria forms, appropriate testing should be guided by the child's medical history. In these cases, especially in refractory urticaria, the important gap in medical knowledge regarding documented causes needs to be addressed.
Another unmet need relates to formal evidence supporting current therapeutic approaches in children with urticaria. The first-line antihistamine therapy lacks randomized controlled trials and the need for research addressing further therapeutic options in children with refractory urticaria is imperative.
Current knowledge on childhood urticaria requires the physician to be focused. A thorough anamnesis and a systematic, comprehensive physical examination are of utmost importance for an appropriate diagnosis. Furthermore, reasonable testing and subsequent effective and safe therapeutic decisions are required, aiming at the desirable goal of the child's wellbeing.
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Q: Array object in array object I have an array of objects and that objects also have an array of objects. I'm getting it with an ajax request and want to make a select with that JSON data. Cant solve this problem) i've tried a lot of examples.
Object service_problems:
   Array[3]
     0: Object
       id: 2
       name: "bla bla"
        problems: Array[2]
          0: Object
            id: 3,
            name: 'blab bla'

          1: Object
             id: 4,
             name: 'bla blae'

From this data i want to make a select with optgroup and options:
<select>
    <optgroup label="service_problems.name">
        <option value="3">blab bla</option>
        <option value="4">bla blae</option>
    </optgroup>
</select>

Also my PHP code:
if ($request->ajax()) {
            $services = DeviceType::find($request->type_id);
            $services = $services->services;

            $service_with_problems = [];

            function findServiceProblems($id) {
                $service = Service::find($id);
                return $service->serviceProblems;
            }

            foreach ($services as $service) {
                $service_problems = findServiceProblems($service->id);

                array_push($service_with_problems, [
                    'id' => $service->id,
                    'name' => $service->name,
                    'service_problems' => $service_problems
                ]);
            }

            return response()->json(['service_problems' => $service_with_problems]);
        }

help pls)

A: Solved problem)
jQuery.map(data['service_problems'], function (problem) {

    options += '<optgroup label="'+ problem.name +'">';

    jQuery.map(problem.problems, function (data) {
        options += '<option>'+ data.name +'</option>';
    });

    options += '</optgroup>';
});

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Clash Of The Titans: Sindhu Vs Saina
November 8, 2017 November 8, 2017 hilnews	Leave a comment
Delhi is caught in the haze, yet again. Tax base has widened as more e-returns were filed this year until October, versus the same period last year. Air passengers have piled up complaints against IndiGo, but that number is still lowest amongst the airlines. In clash of the badminton titans, its PV Sindhu vs Saina Nehwal this time.
What is it? The air quality index pertaining to PM 2.5 (fine solid and liquid hazardous particles suspended in air) at RK Puram, a locality in Delhi, at 10 pm on Tuesday, according to the US Embassy.
Why is it important? This falls in the 'hazardous' category, the worst among six. By comparison, a score between 0 and 50 qualifies as 'good' while 51-100 translates to 'moderate'. The Indian Medical Association said the national capital was witnessing a public health emergency and warned people against stepping out. The National Green Tribunal pulled up the governments of Delhi, Haryana and Uttar Pradesh, and asked them why steps were not taken to prevent deterioration in air quality.
Tell me more: The Environment Pollution Control Authority has recommended the following measures: parking fees in Delhi-NCR region be quadrupled, Delhi Metro reduce fares during off-peak hours for at least 10 days and introduce more coaches, road construction agencies violating pollution norms be fined Rs 50,000, and the Delhi government start preparing for measures such as the odd-even scheme and ban on construction activities.
What is it? The increase in e-returns filed until October in 2017-18 (37.8 million), up from 32.2 million filed in the corresponding period in 2016-17.
Why is it important? Today marks a year since the shock announcement of withdrawal of high-value currency notes, which the government defended as part of its efforts against black money and corruption. The increase in e-returns is one of the data points released by the government to demonstrate impact. Other data points include a widening of the tax base, amount deposited and withdrawn by companies, and striking off of firms from the Registrar of Companies and disqualification of directors.
Tell me more: The number of individual e-filers (who use form ITR-1) increased by 23.3% to 20.8 million between April-October this year, from 16.9 million.
What is it? The percentage of passengers per 10,000 who filed complaints against IndiGo in September, according to the airline regulator. Among major domestic airlines, this is the lowest.
Why is it important? Yesterday, India's largest airline came under flak when an IndiGo staffer was seen manhandling a passenger. IndiGo has since suspended the staffer and its CEO Aditya Ghosh has tendered an apology. Earlier in the week, Indian badminton player PV Sindhu had accused the airline's staff of rude behaviour, which the airline contested.
Tell me more: Among domestic airlines, Air India had the highest complaint rate (1.6% per 10,000 passengers carried), followed by Jet Airways and JetLite (1.3%).
What is it? The loss posted by Denmark's AP Moller Maersk in the July-September quarter, against a profit of $429 million in the corresponding year-ago period, despite an increase in revenues from $7 billion to $8 billion.
Why is it important? The world's largest shipping company, also an oil producer, has partly attributed this loss to the cost of a cyber-attack in June—of $250-300 million—that primarily affected its shipping unit. This makes a persuasive case for businesses to bolster their IT systems to thwart cyber-attacks.
Tell me more: According to a recent report by Lloyd's of London, a major, global cyber-attack could cause economic losses to the tune of $53 billion, which would be equivalent to the losses due to a catastrophic natural disaster such as the US super-storm Sandy in 2012.
What is it? The head-to-head record between Indian badminton players PV Sindhu and Saina Nehwal in the international sphere.
Why is it important? The two women, who put India on the world badminton map, yesterday reached the finals of the Senior Badminton National Championship. This summit clash will be a rare encounter between the two who are referred to in a similar vein but whose tenures at the very top have coincided little.
Tell me more: Nehwal won her first international encounter in January 2014, while Sindhu won in March 2017. Saina is 27, while Sindhu is 22.
air pollution AP Moller Maersk badminton e-filings Indigo Airlines PV Sindhu Saina Nehwal
News in Numbers, Aug 19, 2016: SBI board approves merger, Sindhu aims for the gold…
August 19, 2016 hilnews	Leave a comment
What is it? The number of jobs technology companies in the US have shed so far this year, according to an outplacement agency.
Why is it important? Automation is replacing jobs, and analysts say that this trend is likely to continue. Hardware engineers are the most hit with firms such as Cisco making the shift to more profitable software-oriented services. Cisco laid off 5,500 employees recently and it may affect its research and development centre in India.
Tell me more: Other companies that are likely to lay off employees are IBM Corp, Oracle Corp, Dell Inc and Hewlett Packard Enterprise, according to analysts. A Global Equities Research analyst said the tech industry is likely to shed 370,000 jobs this year.
Rs 37 lakh crore
What is it? The balance sheet size of State Bank of India (SBI) and its five associate banks post merger. This proposal was cleared by its board on Thursday.
Why is it important? The announcement was made in May and this is the first step in what is believed to lead to a major consolidation phase in the banking sector after many years. This, despite the fact that bank unions have been opposing the move and have gone on strikes in the recent past.
Tell me more: The SBI has announced swap ratios (acquiring company offers its shares in exchange for the target company's shares) for three of its associate banks (State Bank of Bikaner and Jaipur, State Bank of Mysore and State Bank of Travancore), in addition to that for Bharatiya Mahila Bank. It is yet to announce the swap ratios for State Bank of Hyderabad and State Bank of Patiala.
What is it? The number of pellets fired by the Central Reserve Police Force (CRPF) between July 8 and August 11 to control violent mobs in Kashmir, as per its admission to the Jammu and Kashmir High Court on Thursday.
Why is it important? The use of pellet guns, which caused eye injuries (including loss of vision) to many, has come under sharp criticism by human rights organisations and political parties. After Home Minister Rajnath Singh's announcement in July that the government would form an expert panel to consider other non-lethal alternatives for crowd control measures, the court had said this meant that pellet guns are not non-lethal weapons and this is enough reason to discontinue its usage.
Tell me more: The protests erupted after separatist militant, also the head of a terrorist group called Hijb-ul Mujahideen, Burhan Wani was killed in July. The CRPF told the court that pellet guns were introduced in 2010 as an accepted form of riot control and if these are withdrawn, then it would have no option but to open fire with rifles in extreme situations, which could be fatal.
What is it? The gap between the actual number of toilets built under the Swachh Bharat Mission and the official numbers as put up by the sanitation ministry in Arunachal Pradesh and Manipur, as per a field survey report of select districts.
Why is it important? Such a mismatch raises concerns about the real progress of the programme. India has set a target to eliminate open defecation by 2019. In some states such as Jharkhand, Gujarat, Karnataka and Rajasthan, the gaps between the actual numbers and those reported to the central government are 19%, 23%, 27% and 28% respectively. The field survey numbers for Sikkim, which became the first to achieve the open defecation free status, are the only ones that match with those with the ministry of sanitation.
Tell me more: Retired civil and defence services officers and non-government institutions with rural development experience are empanelled by the rural development ministry as individual and institutional National Level Monitors. These monitors covered 24.22 lakh random households in some districts across states.
What is it? The duration of the semi-final match between Indian shuttler PV Sindhu and World Number 6 Nozomi Okuhara from Japan on Thursday. Sindhu smashed her way into the finals.
Why is it important? With her Thursday's win, Sindhu has assured India of at least a silver medal – the second one after Sakshi Malik won a bronze in the 58 kg women's freestyle wrestling category on Wednesday, and the fifth Indian female athlete to get a medal overall. All eyes are on the 21-year-old athlete from Hyderabad who would face World Number 1 Carolina Marin from Spain this evening and if Sindhu defeats Marin, she would be the second Indian sportsperson to win the gold after ace shooter's Abhinav Bindra's victory at the 2008 Beijing Olympic Games.
Tell me more: This was Sindhu's debut at the Olympics. She trains under Pullela Gopichand at his academy in Hyderabad.
2016 Rio Olympics badminton Carolina Marin Cisco CRPF Jammu and Kashmir jobs merger pellet guns pellets PV Sindhu SBI Swachh Bharat tech companies toilets
Update: Live election results; How India Lives moving out of beta October 19, 2019
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Marathas Rally For Reservation July 25, 2018
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News Energy & Power Energy Efficiency Energy Storage Generation Renewables
July 28, 2020 – The Government of Canada announced a $5.1-million investment in London Hydro to develop and deploy a smart microgrid in the West 5 net zero energy (NZE) community in London, Ont.
According to NRCan, this will involve the following:
• Microgeneration
• Renewable sources of energy
• Tighter building envelopes
• Smarter heating and cooling systems
• Direct current (DC) generation, distribution and energy storage
• System monitoring
• Vehicle-to-grid storage
• Improved electric vehicle (EV) charging infrastructure
"The overarching objective of the project is to successfully construct Canada's first large-scale, fully integrated, [NZE] community, to demonstrate [NZE's] feasibility, deploy it at the community level, and to inspire and inform widespread change across Canada's construction industry towards net zero energy," explains NRCan in its Project Brief.
NRCan adds this project will allow a municipal utility to build its "capacity for innovative projects and experiment with new business and technical models that can be scaled up" while setting an example for other Canadian communities.
Local partners also contributing to the West 5 project include S2e Technologies, Sifton Properties and Western University, for a combined investment of $10.99 million.
Funding for this project is provided by Natural Resources Canada's Smart Grid Program, which allows utilities to reduce pollution and optimize electricity use while encouraging innovation.
Feds invest $150K toward Clean Energy SME Capacity Building Program in the West
Feds on clean-energy spending spree through EcoEnergy Innovation Initiative
The Feds invest 78 million in job creation through energy efficiency and clean energy technology
S&C Canada and utility partner deploying microgrid at North Bay Community Energy Park
ebergy storage
net zero energy
NRCan
NZE
S2e Technologies
Sifton Properties
Edmonton unveils fleet of electric buses and purpose-built garages


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A symbol of purity and grace, the unicorn has captivated people throughout the ages. Legend has it that this mythical creature appears only to a rare few and approaches those who are pure and virtuous.
Get your free drawing now and let this enchanting creature guide your creative spirit!


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redpajama_set_name: RedPajamaGithub


We are a funny lot when it comes to things that potentially break with what we find as 'traditional'. When something new does come along which is a little less usual we have a tendency to look at it with either love and fascination, or a questioning 'why'?
In this case, the new Cymbal Tuners (or 'magnets' for the more cynical among us) have the potential for either liking and using them, or thinking they're a silly idea.
Either way, the Cymbal Tuners are basically rubber covered magnets which you apply in pairs (one top, one bottom) as desired on a cymbal to 'tune' it. In the pack you get one pair of lighter magnets and a pair of thicker, heavier magnets. Given that, you have three obvious combinations available.
'Tuner', in this context really means 'dampen' more than anything else, but in more broad terms this also means controlling the sustain and adjusting the volume as well.
So, do they work or are they just a gimmick? Well, yes they do work and noticeably too.
As you might expect, placement is key with the Cymbal Tuners, which is something I will come to later.
What I found was that depending on the type of sound and use I was going for, this dictated the positioning of the magnet. That's probably a bit evident really.
I didn't try using any splash cymbals as that seemed a little pointless to me. However, I did use hihats, a crash and a ride from Benny Greb's signature line, which seemed appropriate since he helped develop the Cymbal Tuners. These cymbals aren't too thick, nor are they that thin.
In the video, I put the tuners in different positions across the bow and bell of the crash and ride cymbals. Clearly, as you'll see, one or two of the positions don't work on certain cymbals, but that was what I was expecting, I tried these positions for effect and demonstration more than anything else. I only did the bow for the hihats.
Having the magnets on the cymbals was noticeable in relation to the weight/balance aspect, but that varied on where they were placed and I got used to it very quickly. All it takes is a little experimentation of the placement of the magnets to get the desired sound or effect.
However, all that said, I have a very big complaint about them and one which Meinl – I am politely asking here – really should address I think.
That complaint is this – small, round, all black items have a real tendency to get lost on floors very easily, especially when playing live. No one likes to lose things they've bought. Both Mike and I lost pairs of the Tuners, in fact, the pair I lost was actually doing the video for this review. Upon review, it was quite amusing watching the top Tuner flying off the ride cymbal in slow motion to disappear to wherever, but that's not cool. I still haven't found them yet either, but that's why there is no clip of the lighter Tuners on the ride cymbal. Basically, they came off in style.
To me, the obvious solution to this is to offer the Cymbal Tuners in colours, preferably bright ones at that. They may look a little strange to begin with, but the bigger picture is that you won't lose them quite as easily.
In terms of why the lighter version came off, I think it was just that I may have put the Tuners too near the edge before crashing on it (although they weren't that near) so it may have been my bad. All the same, it does emphasis the point, and I didn't strike the cymbal that hard to begin with. If you're not going to crash on your ride, then putting them near the edge won't be an issue.
As I said, the Cymbals Tuners aren't gimmicks and they do really work. They won't be for everyone obviously, but they are a viable alternative to tape, they look a lot cleaner in that respect too, and are more flexible as well. I've never liked putting tape on cymbals so this really is a nice option to have.
Also which I found was useful was that if you're only using two of the tuners, the container with the other two in it will stick to a hihat or cymbal stand if you want to keep them to hand without using the attached hook.


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text:
London Marathon
Posted by: RaceGrader on April, 17 2013
Race organisers of the London Marathon which involves around 36,000 runners, were quick to react on Monday night to the reports from Boston, immediately beginning a dialogue with the Met.
Speaking to BBC Radio 5 Live, Nick Bitel, chief executive for the London Marathon, said: "We will not be cancelling, what we are doing, we are reviewing.
"You look at what has occurred, if there are steps we can take to increase security and all sorts of measures one could deploy.
"We run through the city, when you have an event of any nature, a marathon, parade, it's only as safe as the city itself, if it's not held in a stadium you can't do a lockdown like you may do in a building."
In an earlier statement, Bitel said: "We are deeply saddened and shocked by the news from Boston. Our immediate thoughts are with the people there and their families. It is a very sad day for athletics and for our friends and colleagues in marathon running.
"Our security plan is developed jointly with the Metropolitan Police and we were in contact with them as soon as we heard the news."
Met Police Chief Superintendent Julia Pendry said: "A security plan is in place for the London Marathon. We will be reviewing our security arrangements in partnership with London Marathon."
CATEGORIES: Running


Don't expect a film of depth or lasting artistic merit. Prom does deliver some wholesome family-oriented themes, like believing in yourself and accepting yourself as you are.Prom kind of played like a senior yearbook. Full of moments that will make everyone who has gone to high school sigh or smirk, the film is a sweet romance that will reach out to more than the adolescents.


A Tough Decision - Frances Southwick, D.O.
Decisions can be arrived at quickly or through pains-taking processes. Sometimes, I am internally conflicted. Often, really. What to eat, what time to wake up, which mug to use. And so - small decisions - I try to allow them to be small. And when decisions are larger, sometimes it is more challenging.
For example, my decision to choose medicine took some time, but it's not something I currently consider up for discussion. My choice to be out instead of closeted took time and was difficult, but I am not going back. Other choices are more difficult, still.
I'm being vague and clinical.
What I mean is...I struggle with estrangement from my immediate family.
I have been shown many times and in many ways that I am not important to them. The lessons on emotions and relationships they have tried to impart - When it counts, pretend everything is fine. When stressed, act nonchalant. When in pain, don't allow anyone to see this. Don't let them see you sweat. And no one wants to hear your problems.
In other words, for my family, the appearance of stability and lack of vulnerability of any Southwick is more important than my feelings, my dignity, and even my life.
I have an urge to make a case to you, my void, that I am right in my decision. And sometimes when I make the case, I feel better. Sometimes, I obsess more.
To tolerate or passively bystand an abusive cycle is to participate in the abuse.
It's 3 against 1 (in more ways than one), and the underdog (my integrity) is winning. It is exhausting holding this line, but I'm doing it, because I am working hard to love myself, and have respect for myself, first.
Mutual respect must underpin a real, functioning relationship. Each party must be able to be his/her/their full selves.
But pretending is no longer an option for me. I have nothing if I have no integrity. If I don't have myself, I'm not even a real person.


text:
Q: why can not find exactly one wifi while all other are visible in `available wifi`? I am trying to use wifi(HOME_WIFI) created using mobile hotspot(xiaomi). My OS is windows 10, at first i successfully connected and used smoothly. Then suddenly can not find the HOME_WIFI anymore. That same wifi(HOME_WIFI) is visible to all other mobile and laptop.
Also my laptop can find all other available wifi except HOME_WIFI.
I tried the following solutions

*

*Turn off firewall to check if firewall is blocking the wifi

*Manage known network -> HOME_WIFI  -> Forget

*Restart everything

*Recreate mobile hotspot

*Tried to change frequency from mobile but it only supports 2.4 GHz

A: If a Wifi is not visible on one or two devices of a large pool this usually means that the Wifi is running on a channel that is not available world wide (for 2.4GHz channels 12-14 are not available in every country of the world).
If you have a second Android device running max Android 9 you can use Wifi Analyzer app and check which channel is used.
If you have verified that a channel higher than 11 is used there two options:

*

*Configure the hotspot to use a lower channel (1-11). For Android before 10 there is usually the possibility to configure the channel in the advanced options of the mobile hotspot. By default the channel should be set to auto. See also this question on the hotspot channel

*You can check the device(s) that do not see the Wifi with a high channel if they have been correctly set-up for your country (assuming you are in a country using the channel used by the mobile hotspot is allowed). For smartphones this usually means that a SIM card of your country is inserted and at least connected once after reboot. Linux and Windows devices can also be configured for a specific country: See for example this topic for Ubuntu.


text:
Q: Implementing RSA in C# when Public Key is Known I'm trying to implement an RSA encryption function, but I'm new to cryptography. I know the public key and have data to encrypt, but I can't get the implementation correct in C#. I've tried using:
private byte[] RSAEncrypt(byte[] data, byte[] publicKey)
{
    using (RSACryptoServiceProvider RSA = new RSACryptoServiceProvider())
    {
        RSAParameters RSAKeyInfo = RSA.ExportParameters(false);
        RSAKeyInfo.Modulus = publicKey;
        RSA.ImportParameters(RSAKeyInfo);
        data = RSA.Encrypt(data, false);
    }

    return data;
}

But this keeps giving me the error "Bad Length". The public key is 8 bytes long. The data is 254 bytes long. The similar questions about that error say that it occurs when the data is too long. Does an 8 byte long public key sound correct to encrypt 254 bytes?


If these walls could talk, they would sing.
Since it was built in 1908, year after year, decade after decade, and now into a new century Washington Hall has been a welcoming place where people gather, create, entertain and celebrate. The Hall has been a cultural home to many communities and art forms, and for a long time embodied the soul of Seattle's Central Area.


text:
Q: Configure React Dev Server within an ASP.NET Core Application I have an existing ASP.NET Core application (that uses razor pages) and I am trying to convert it, one component at a time, to React until I can completely make it a SPA. The idea is to create an entry point for each of my razor pages until I can combine them all into one SPA. I have most of this working except for the use of webpack-dev-server to serve my bundles. The problem I am having is the ASP.NET app runs on port 44321 and the dev server runs on port 8080 so the script tags in my .cshtml files cannot see the bundles that are being hosted from webpack.
I can temporarily change them from:
<script src="./dist/[name].bundle.js"></script>

To something like:
<script src="http://localhost:8080/[name].bundle.js"></script>

To get around this, but this is not long term solution.
I have created a sample application to showcase what I am trying to accomplish here: https://github.com/jkruse24/AspNetReact.
Is there any way to either get my ASP.Net application to listen on the port that webpack-dev-server is serving to (without changing my script tags) or to have my webpack-dev-server serve to the port that my ASP.Net app is running on?
I have tried to use the .NET CORE SPA middleware (Microsoft.AspNetCore.SpaProxy) but either I have not configured it correctly or I am misunderstanding what it is used for. Upon adding in the below code (which is commented out in my github sample) my application still looks at the .\dist directory for my bundles (which are still there from running actual builds).
    if (env.IsDevelopment())
    {
        app.UseSpa(spa =>
        {
            spa.Options.SourcePath = "./ClientApp";
            spa.UseReactDevelopmentServer(npmScript: "start");
            spa.UseProxyToSpaDevelopmentServer("http://localhost:8080");
        });
    }

A: I ended up getting this working using the .NET Core SPA Middleware. When I originally tried to used the middleware, it was working fine, but I didn't have my webpack dev server configured to serve my bundles to the correct location.
As you can see above, I was serving them to
http://localhost:8080/[name].bundle.js

when they needed to be served to
http://localhost:8080/dist/[name].bundle.js

My problem was that my webpack publicPath was not set correctly. I made an update commit on my repository here. More specifically, this was the file diff that solved my problem.


Colourful magnet clips for home, office, storage, school, workshop, etc.
The set contains magnet clips in six different colours: blue, red, green, yellow, white and black. The embedded ferrite magnets feature a much lower adhesive force than neodymium magnets of the same size, but they provide a low-cost alternative when adhesive force is not crucial.


Identifying different types of websites still remains to be a mystery to many. Throughout our consulting sessions we have learned that some confusions still exists amongst the business owners or even marketing and PR people who often play the role of educators to their clients.
A lot of today's successful websites are powered by software and developed by software developers and not by static pages published by web designers and web design companies. That might be the clue to why your last website project that was put together by your favorite design and marketing firm looked so visually stunning but failed to perform as it should have!
Understanding the nature of your Internet project and knowing the evolutionary stage that it is standing in, will put you in the right direction in choosing the type of talents and teams that you will be involving with your next website project.
This diagram shows the evolution of Internet websites from static HTML pages all the way up to the social web. Charles Darwin would have been so proud of this!


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text:
Q: Azure DevOps + Docker : 'apt-get' is not recognized as an internal or external command I'm a newbie in Azure DevOps and trying to build my first full pipeline, but I have issues when building the docker image.
A line from the Docker file make the pipeline fail, the one with apt-get !
Do you have any idea to fix this?
Here is the error I got (the log):
Step 11/25 : RUN apt-get update && apt-get install -y libgdiplus libc6-dev && dotnet dev-certs https;     dotnet publish --self-contained --runtime linux-x64 -c Debug -o out src/${PROJECT};
 ---> Running in 29ada69fe569
'apt-get' is not recognized as an internal or external command,
operable program or batch file.
The command 'cmd /S /C apt-get update && apt-get install -y libgdiplus libc6-dev && dotnet dev-certs https;     dotnet publish --self-contained --runtime linux-x64 -c Debug -o out src/${PROJECT};' returned a non-zero code: 1
'displayName:' is not recognized as an internal or external command,
operable program or batch file.
'failOnStderr:' is not recognized as an internal or external command,
operable program or batch file.
##[error]Cmd.exe exited with code '1'.

Here is my pipeline file:
- script: |
    docker image build --no-cache --tag=registry.gitlab.com/iznogood/myproject/iznogood.myproject.httpapi:1.0.0 -f .\src\Iznogood.Myproject\Dockerfile .
    displayName: 'Build image'
    failOnStderr: true

And here is the Docker file:
### >>> GLOBALS
ARG ENVIRONMENT="Production"
ARG PROJECT="Iznogood.MyProject.HttpApi"
### <<<

FROM mcr.microsoft.com/dotnet/core/sdk:3.1 AS build

### >>> IMPORTS
ARG ENVIRONMENT
ARG PROJECT
### <<<

ARG NUGET_CACHE=https://api.nuget.org/v3/index.json
ARG NUGET_FEED=https://api.nuget.org/v3/index.json

# Copy sources
COPY src/ /app/src
ADD common.props /app

WORKDIR /app

RUN apt-get update && apt-get install -y libgdiplus libc6-dev && dotnet dev-certs https; \
    dotnet publish --self-contained --runtime linux-x64 -c Debug -o out src/${PROJECT};

# Start a new image from aspnet runtime image
#FROM mcr.microsoft.com/dotnet/core/aspnet:3.1 AS runtime
FROM mcr.microsoft.com/dotnet/core/sdk:3.1 AS runtime

### >>> IMPORTS
ARG ENVIRONMENT
ARG PROJECT
### <<<

ENV ASPNETCORE_ENVIRONMENT=${ENVIRONMENT}
ENV ASPNETCORE_URLS="http://+:80;https://+:443;https://+:44359"
#ENV ASPNETCORE_URLS="http://+:80"
ENV PROJECT="${PROJECT}.dll"

# Make logs a volume for persistence
VOLUME /app/Logs

# App directory
WORKDIR /app

# Copy our build from the previous stage in /app
COPY --from=build /app/out ./

RUN apt-get update && apt-get install -y ffmpeg libgdiplus libc6-dev

# Ports
EXPOSE 80
EXPOSE 443
EXPOSE 44359

ENTRYPOINT dotnet ${PROJECT}

A: Can you add a suffix to specify which machine you want ?
For debian buster: FROM mcr.microsoft.com/dotnet/core/sdk:3.1.201-buster AS build
The tag as been founded in "Full Tag Listing" section:
Docker Hub Repo

A: Check the pipeline and verify the OS that you're running on. If it's a Windows image, apt-get isn't going to work. Change your pipeline to use a Linux machine.


text:
Q: Putting a struct member inside of a separate variable to clean up code and helping me understand how the code would look formatted differently In C, instead of just listing out a struct variable such as ((struct listing*)p), what kind of primitive type should my variable be in order to hold this and how would it look?
For example, I currently have this function inside of my program:
int price_comparator(const void* p, const void *q){

    float price1 = ((struct listing*)p)->price;
    float price2 = ((struct listing*)q)->price;

    return (price1 - price2);
}

This does work, however, I would like to format this function in different ways. One way I would like to clean this up a bit would be to put "((struct listing*)p)" into a variable before putting it into the price1 variable.
I'd like to try something like this:
struct structOne = ((listing*)p);

or
void structOne = ((listing*)p);

but neither of those are working from what I can tell. Also, the parenthesis are confusing me a little bit inside of:
 ((struct listing*)q)->price

I'd like to see it formatted differently, such as when it doesn't have the arrow pointing to "price" in order to see how it works more clearly.
My stuct has already been created at the beginning of my program as follows:
struct listing {
   float latitude, longitude, price;
};

But this is not needed to answer my question
Thanks!

A: You can use pointers to structure instead of void pointers:
int price_comparator (struct listing *p, struct listing *q)
{
    return (p->price - q->price);
}

A: From what i understand is that you want to access the struct without using the arrows and what data type to use.
First: your datatype should be of type struct listing * instead of void *.
Second: To make typing more easier you should declare your struct using typedef
typedef struct {
    float latitude, longitude, price;
} listing;

This will make using your struct easier like instead of using:
struct listing x = {2.3, 3.5, 11.0};

You can do this:
listing x = {2.3, 3.6, 11.5};

Third: To access a pointer to struct without the arrows from void * you can do this :
float price1 = (*((listing *) p)).price;
float price2 = (*((listing *) q)).price;
return price1 - price2;

I hope that answered your question.

A: You can make local pointers of the right type:
int price_comparator(const void* p, const void *q)
{
    struct listing const *p1 = p;
    struct listing const *q1 = q;

    return p1->price - q1->price;
}

Cast is not necessary here as we have specified the type for p1 and q1 already .


Essex Police's armed officers descended on a street in Canvey Island earlier today (March 4) after a report of a man in the street with a firearm.
The Firearms Support Unit tweeted to say that a man matching the description given to police was "quickly arrested" before they moved onto a house.
They shared the photo at the top of this story along with the tweet.
The photo shows that, including the car the picture was taken from, there were at least five Essex Police vehicles on the residential street.
One of the other police vehicles at the scene is an Essex Police dog unit car.
In the tweet the firearms unit said: "FSU Firearms team attended Canvey today as report of a male in the street with a firearm - officers quickly arrested a male matching the description and then moved onto a house. Enquiries are in hand to establish what has taken place."
The police vehicles that responded to the call completely blocked the residential street in Canvey with no way for cars to get back down the road in the direction the police arrived from.
In the picture it appears that the locals kept out of the way of the armed police as no one is visible on the pavements and curtains are drawn around the area.


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text:
Bobbi Gibb
Bobbi's Sculptures
London Publication Recognizes Bobbi
It's so nice getting recognition from "across the pond." In honor of International Women's Day, a London publication honored Bobbi by running a fun pictorial article on her. http://www.studionicholson.com/blogs/features/132407111-vital-women-bobbi-gibb#
The best part of the article may be the last sentence, though. After giving Bobbi's age and mentioning she still runs an hour a day, the article ends with, ". . . we think she's a real babe."
Thanks fellas!
Bobbi Raises Funds for ALS Research
Writer Gordon Vincent from Winchester, MA publication homenewshere.com has written a fabulous article about Bobbi's 50th anniversary running The Boston Marathon, highlighting Bobbi's running of the marathon in 1966 and her fundraising efforts on behalf of The Angel Fund for ALS Research.
You can see the full article at http://homenewshere.com/middlesex_east/article_95d36008-d71f-11e5-acc1-e310027f070c.html#.Vt-EkVtlwLw.email
Bobbi Gibb to serve as grand marshal at Boston Marathon
By Rachel G. Bowers, Boston Globe, March 15, 2016
The first woman to complete the Boston Marathon will serve as the grand marshal of this year's race, the Boston Athletic Association announced Tuesday.
Roberta "Bobbi" Gibb finished the race as an unregistered runner in 1966 when women were still barred competing in the race from Hopkinton to Boston. This year marks the 50th year of women participating in the marathon, though the BAA did not recognize women as official marathon competitors until 1972.
Source: https://www.bostonglobe.com/sports/2016/03/15/bobbi-gibb-serve-grand-mar
Bobbi Featured in New Book, "First Ladies of Running"
First Ladies Of Running
Fifty years ago, when Roberta Gibb wrote for a Boston Marathon application in 1966, she was told: Amateur Athletic Union rules prohibit women from racing more than 1.5 miles. Furthermore, women are physiologically incapable of covering 26.2 miles. Gibb ran Boston anyway, and finished in 3:21:29--ahead of 2/3rds of the male runners.
These and other stories of courage and tenacity are chronicled in First Ladies of Running: 22 Inspiring Profiles of the Rebels, Rule breakers and Visionaries who Changed the Sport Forever.
Author Amby Burfoot - an important member of Bobbi's 50th Anniversary Celebration Team - has been a Runner's World editor since 1978. He won the 1968 Boston Marathon, has run more than 110,000 miles in his life, and is the author or co-author of six previous books.
First Ladies of Running is available through Amazon.com.
National Women's History Museum Acknowledges Bobbi
The National Women's History Museum graciously acknowledged Bobbi for her contribution to women's sports in their Facebook post of December 13, 2015. Based on the number of "likes" and "shares," Bobbi's courage is as relevant today as it was 50 years ago. If you are on Facebook, search their page for Bobbi Gibb and you can join the over 99,000 people that have "liked" this post!
Montserrat "Artrageous" to Auction two of Bobbi Gibb's Mixed Media Prints
For the first time ever, Bobbi has donated two completely unique pieces to the Montserrat College of Art Auction in Beverly, MA. A rare chance to see her work and share in her love of nature and the universe. The pieces are entitled Purple & Gold Swirls and Cosmic Plan. The Auction is Saturday, April 2nd and always draws an exciting crowd!
Bobbi to be on Panel Discussion in LA
"First Ladies of Running" Panel Discussion
Friday, Feb. 12, 12:30 p.m.
At Skechers Performance Los Angeles Marathon Health & Fitness Expo
Los Angeles Convention Center, South Hall
1201 S. Figueroa St.
Roberta Gibb, first woman to run the Boston Marathon (50 years ago, 1966)
Jacqueline Hansen, LA native, Boston Marathon winner (1973), two-time world-record holder, and first woman to break 2:40 in the marathon
Cheryl Treworgy, mother of Olympic Marathon Trials favorite Shalane Flanagan, and first woman to break 2:50 in the marathon
Judy Ikenberry, 5th place finisher, 800 meters, 1960 Olympic Track Trials; winner first National Marathon Championship for women, 1974
Amby Burfoot, winner 1968 Boston Marathon, Runner's World editor at large, and author of new book First Ladies of Running: 22 Inspiring Profiles of the Rebels, Rule Breakers and Visionaries Who Changed the Sport Forever.