The Lights and the Shadows of Controlled Sting Challenge With Hymenoptera.

Hymenoptera venom immunotherapy (VIT) is effective for protecting individuals with systemic allergic reactions caused by Hymenoptera stings. The need for a tool that shows the degree of protection afforded by VIT and the lack of useful biomarkers have made the sting challenge test (SCT) the gold standard for this disorder, although its use has both lights and shadows. SCT with Hymenoptera involves causing a real sting in a patient diagnosed with allergy to the venom of the stinging insect and who is undergoing treatment with specific immunotherapy. In Spain, SCT is included in the list of services offered by some hospitals and forms part of their daily clinical practice. This review aims to analyze the strengths and weaknesses of this test and to describe the standardized procedure and necessary resources, based on the experience of a group of Spanish experts and a review of the literature.

Diversity in warning coloration is easily recognized by avian predators.

Warning coloration is a widespread strategy to alert predators about prey unprofitability. The success of this strategy partly depends on predators being able to learn and recognize certain signals as indicators of toxicity, and theory predicts that this is easier if signals converge on similar colours. However, the diversity in warning signal form is astonishing, contradicting predictions. Here, we quantified ladybird signal diversity with respect to avian vision, measuring how unique and discernible each signal is from one another. In addition, we measured signal conspicuousness against a series of backgrounds, namely an average green, average brown, and where we collected each species, to determine whether signals are more contrasting against the ladybirds' local substrates than compared to average ones. This allowed us to establish whether there are local adaptations in conspicuousness that promote signal diversity. We found that while ladybird signals are unique and recognizable, specialist species are more contrasting against the background they are most commonly found on. However, overall our study suggests that warning signals have evolved to be effective against a wide range of natural backgrounds, partly explaining the success of this strategy in nature.

Susceptibility of Diaphorina citri (Hemiptera: Liviidae) and Its Parasitoid Tamarixia radiata (Hymenoptera: Eulophidae) to Entomopathogenic Fungi under Laboratory Conditions.

Diaphorina citri (Kuwayama) is a global pest of citrus that transmits the bacteria associated with the disease, Huanglongbing. Entomopathogenic fungi and the parasitoid Tamarixia radiata (Waterston) are important biological control agents of this pest and likely to interact in D. citri populations. As a basis for interaction studies, we determined the susceptibility of nymphs and adults of D. citri and adults of the parasitoid T. radiata to six fungal isolates from the species Beauveria bassiana s.l. (Bals.-Criv.) Vuill. (isolates B1 and B3), Metarhizium anisopliae s.s. (Metsch.) (Ma129 and Ma65) and Isaria fumosorosea Wize (I2 and Pae). We conducted experiments evaluating infection levels in all three insect groups following inoculation with a series of conidial concentrations (1 × 104-1 × 108 conidia mL-1). Results showed that D. citri nymphs and T. radiata were more susceptible to fungal isolates than D. citri adults. Overall, B. bassiana and M. anisopliae isolates caused the greatest infection compared with I. fumosorosea isolates in all three groups of insects. Isolates B1 (B. bassiana) and Ma129 (M. anisopliae) infected a greater proportion of adults and nymphs of D. citri, respectively. Both isolates of B. bassiana caused greater infection in T. radiata compared with isolates of the other fungal species. We propose that isolates B1 and Ma129 are the strongest candidates for control of D. citri. Our results represent the first report of entomopathogenic fungi infecting T. radiata, and the basis for future studies to design a biological control programme that uses both agents more efficiently against D. citri populations.

Hypersensitivity to penicillin V with good tolerance to other beta-lactams.

A 24 year-old man developed an anaphylactic reaction within thirty minutes of an oral administration of penicillin V. He suffered from recurrent streptococal pharyngitis that was usually treated with penicillin V with good tolerance. Skin prick and intradermal tests with penicilloyl-polylysine, minor determinant mixture, amoxicillin, ampicillin and cefuroxima were negative. However, a skin prick test with penicillin V was positive in the patient and negative in 10 controls. Determination of specific (Immunogloblulin (Ig) E to penicillin V was 0.64 kU/L. Specific IgE to penicillin G, amoxicillin and ampicillin were all negative. Single blind controlled oral challenge with amoxicillin and cefuroxime were both negative. This is an exceptional case of an anaphylactic reaction induced by phenoxymethylpenicillin with positive allergologic study in vivo and in vitro tests and with negative allergological study to other beta-lactams.

The Lights and the Shadows of Controlled Sting Challenge With Hymenoptera

Hymenoptera venom immunotherapy (VIT) is effective for protecting individuals with systemic allergic reactions caused by Hymenopterastings. The need for a tool that shows the degree of protection afforded by VIT and the lack of useful biomarkers have made the stingchallenge test (SCT) the gold standard for this disorder, although its use has both lights and shadows. SCT with Hymenoptera involvescausing a real sting in a patient diagnosed with allergy to the venom of the stinging insect and who is undergoing treatment with specificimmunotherapy. In Spain, SCT is included in the list of services offered by some hospitals and forms part of their daily clinical practice. Thisreview aims to analyze the strengths and weaknesses of this test and to describe the standardized procedure and necessary resources,based on the experience of a group of Spanish experts and a review of the literature. (AU)

La inmunoterapia con veneno de himenóptero (ITV) es un tratamiento que se ha mostrado eficaz en la protección de sujetos con reaccionesalérgicas sistémicas por picaduras de himenópteros. La necesidad de una herramienta que demuestre el grado de protección proporcionadapor la ITV, y la ausencia de biomarcadores útiles, convierte a la Prueba de Provocación con Repicadura (PPR) en el gold standard en estapatología, con sus luces y sus sombras. La PPR con himenópteros es una prueba que consiste en provocar una picadura real, a un pacienteque ha sido diagnosticado de alergia al veneno del insecto picador y habitualmente está en tratamiento con inmunoterapia específica.En España, la PPR se incluye en la cartera de servicios de algunos hospitales, formando parte de su práctica clínica habitual. Esta revisióntrata de analizar las fortalezas y debilidades de esta prueba, integrando el procedimiento estandarizado y recursos necesarios, basándoseen la experiencia de un grupo de expertos españoles y en la revisión de la literatura. (AU)

Respuesta inmune disfuncional en pacientes con COVID-19. ¿Qué nos dice la evidencia? / Dysfunctional immune response in COVID-19 patients. What does the evidence tell us?

In December 2019 a novel coronavirus (SARS-CoV-2) was identified in Wuhan, China, and became rapidly the worst pandemic in 100 years. Coronaviruses are respiratory viruses that can cause diseases ranging from mild to fatal lower respiratory tract infections. In a fraction of the affected patients, coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, can lead to acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) admission, both associated with high mortality. To date, the existing evidence suggests a leading role of the immune system in the pathogenesis of severe COVID-19, including mechanisms associated with hyperinflammation, immune evasion, cytokine release syndrome, depletion of functional T cells, and ineffective humoral immunity. Here we discuss the current evidence regarding these findings.

Xenotransplantation of human adipose-derived stem cells in the regeneration of a rabbit peripheral nerve.

Adipose tissue-derived mesenchymal stem cells (AdMSCs) are useful in the regeneration of neural tissues. Furthermore, xenotransplantation of human adipose tissue-derived mesenchymal stem cells (hAdMSCs) into animal models has already been tested and the results encouraged us to study peripheral nerve regeneration in rabbits, in order to test the feasibility of a xenotransplantation of hAdMSCs. ANIMALS AND METHOD: To promote end-to-end nerve fiber contacts of a 4-cm gap in the peroneal nerve of white New Zealand rabbits, an autologous vein conduit was used and three groups of animals were evaluated. In Group I, the gap was repaired with a vein conduit refilled with fibrin. Group II was similar, but the animals were treated with cyclosporine A. In Group III, a fibrin scaffold with hAdMSCs was placed inside the autologous vein conduit, and animals were treated with cyclosporine A. Neurofilament immunohistochemistry results showed 100% nerve regeneration at the vein guidance channel 90 days after the surgery in the hAdMSC-transplanted group but lesser neural regeneration in the neurofilaments of groups I and II. The analysis of variance (ANOVA) test showed statistically significant differences among all groups (p < 0.04). Group III exclusively tested positive for human monoclonal anti-mitochondrial antibody. Electron microscopy images showed tiny bundles, with a predominance of nonmyelinated axons. Myelinated axons caused irregular thickness of the myelin sheath, which was especially observed in group III. CONCLUSIONS: Xenotransplantation of hAdMSCs into a fibrin scaffold promoted nerve regeneration through a vein conduit that connected a 4-cm gap created at the peroneal nerve of rabbits. Animals treated with hAdMSCs presented negative inflammatory response at the regenerated nerve gaps, but it was demonstrated that hAdMSCs were incorporated to the new nerve creating neural tissue and endothelial cells. However, hAdMSCs required immunosuppression with cyclosporine A to achieve axonal regeneration.

A randomized blinded clinical trial of two antivenoms, prepared by caprylic acid or ammonium sulphate fractionation of IgG, in Bothrops and Porthidium snake bites in Colombia: correlation between safety and biochemical characteristics of antivenoms.

A randomized blinded clinical trial was performed in 53 patients bitten by Bothrops sp. and Porthidium sp. in Antioquia and Chocó, Colombia, in order to compare the efficacy and safety of two antivenoms made of whole IgG obtained by either ammonium sulphate (monovalent anti-B. atrox) or caprylic acid (polyvalent) fractionation. Additionally, antivenoms were compared by electrophoretic and chromatographic analyses and anticomplementary activity in vitro. With a protocol of 2, 4 and 6 antivenom vials for the treatment of mild, moderate and severe envenomings, respectively, both antivenoms were equally efficient to neutralize the most relevant signs of envenoming and to clear serum venom levels in patients from the first hour and later on. Three patients with severe envenoming and initially treated with less than six vials on admission had persistent or recurrent venom antigenemia within 12-48 h. Monovalent antivenom fractionated by ammonium sulphate precipitation had higher amounts of protein aggregates and nonimmunoglobulin proteins than polyvalent antivenom fractionated by caprylic acid precipitation. Both antivenoms presented anticomplementary activity in vitro, being higher in the monovalent product. In agreement, monovalent antivenom induced a significantly higher incidence of early antivenom reactions (52%) than polyvalent antivenom (25%).

Selection in a preferred provider organization enrollment.

OBJECTIVE: The study was conducted to determine whether favorable or adverse selection occurred in a preferred provider organization (PPO) enrollment. DATA SOURCES AND STUDY SETTING: Secondary data sources were used to conduct a retrospective study of the utilization of health services and the demographic characteristics of the population involved in the first open enrollment in a new university-based PPO. The PPO under study, sponsored by the University of Michigan (UM) Medical Center, was offered to all 43,005 UM employees, dependents, and retirees. STUDY DESIGN: We analyzed insurance company payments during the one-year period prior to the enrollment to compare the utilization patterns of those who enrolled in the PPO with those who did not. DATA COLLECTION: Prior health care utilization data were obtained from Blue Cross-Blue Shield of Michigan on the entire university population for one year prior to the start of the PPO. Demographic data were obtained from the personnel office of the university. PRINCIPAL FINDINGS: The PPO group had a younger median age than the non-PPO group; the sex distribution was roughly similar for the two groups. In the PPO group 57 percent of all contracts were family contracts compared with only 30 percent in the non-PPO group. The PPO group experienced 20.6 percent lower inpatient payments per member, and 9.4 percent lower outpatient payments per member in the year prior to the enrollment. These differences resulted in an overall 18.7 percent lower payment per member for the PPO group in the year prior to their enrollment. CONCLUSIONS: The results show, based on prior insurance payments, that this PPO received favorable selection during the open enrollment, a finding consistent with favorable selection found in early HMO enrollment.

The constitution of physicians' power: a theoretical framework for comparative analysis.

Drawing on literatures documenting the experience of physicians in both European and American societies, a new theoretical framework for explaining variations in the professional power of physicians is provided. Most studies of professions have used professional organization as the principal explanatory variable, with state policy and the organization of civil society as secondary mediating factors. Our approach instead treats strategies of state power and forms of civil society as central features shaping the ability of the profession to exert power. Such a three-dimensional approach not only allows us to make more powerful classifications explaining contemporary differences, but also allows us to trace historical shifts and anticipate alternative futures in professional power. For example, in those societies where the state's intervention is limited and civil society is pluralistic, professional power is potentially greatest. But increasing state power does not necessarily reduce professional power. Where the state is most powerful and organizes all groups in civil society, professionals and society can be united in common struggle against the state. In response to that, it is likely that such centralized states will opt for corporatist solutions to maximize the internal differentiation of society and pit those once allied against one another, and preclude the organization of powerful autonomous interest groups.

Health care reform and the labor market.

Reform is probably the most frequently used term when discussing health care systems. The literature is broad and general, with topics ranging from reasons for carrying out reform, through discussion and the meaning of the reform, to discussions of methods for reform in developing countries. Interest has been centered more on the definition of content and less on the processes of implementation. Implications in terms of changes in the requirements of health facilities and human resources have been only superficially addressed. This paper presents a conceptual framework to discuss the main issues involved in reform of the health care systems and the shifts in needs of human resources. Assessment of the ways in which reform affects the medical labor market require the application of a conceptual framework that enables us to focus more on process than content. In the organizational change literature, both in theory and practice, human resources have been found critical for the institutionalization of organizational change. They are also critical for assessing health care reform.

The role of doctors as health care managers: an international perspective.

The participation of physicians in health care management has followed different paths in developed and developing countries. However, we can say that in most of the countries the physicians have had cyclical patterns of participation and withdrawal from health care management. It is readily apparent that these patterns are different in each country. We propose to take into account three different levels of analysis in which different factors interact to define the country specific pattern of physician involvement in health care management, as well as to assess the international convergence and divergence paths on physician participation. We present here a conceptual framework that could facilitate the analysis of this theme under a comparative perspective. We start by discussing a conceptual framework of the determinants of physician participation in health care management. Then, we assess the current trends and perspectives in both developed and Latin American countries of physician participation in health care management.

Effect of melatonin on hyperlipidemic nephropathy under constant light exposure.

Studies have shown anti-hyperlipidemic actions of melatonin, with pharmacological doses inducing changes in cholesterol levels. This study was designed to evaluate the effect of melatonin on adriamycin-induced (25mg/kg b.w., i.p.) hyperlipidemia under constant light exposure. Melatonin was injected i.p. (1,000 microg/kg b.w./day). Triglycerides, total cholesterol, high-density lipoprotein cholesterol, light-density lipoprotein cholesterol, non-proteic nitrogen compounds (urea and creatinine levels), total protein in serum, proteins eliminated in the urine and melatonin levels in serum and kidney were determined. Results show a decrease in melatonin levels induced by both adriamycin and constant light. Likewise, adriamycin induced significant increases in triglycerides, total cholesterol and light-density lipoprotein cholesterol, and lowered high-density lipoprotein cholesterol levels. Constant light exposure also prompted an increase in LDL-c levels and a decrease in HDL-c values, and intensified the effects of adriamycin on these two lipoproteins. All changes induced by adriamycin and constant light were reverted toward normality by melatonin administration.

[The incidence and distribution of accidents with biological fluids among health personnel and the general population]. / Incidencia y distribución de accidentes con fluidos biológicos en personal sanitario y población general.

OBJECTIVES: To assess the informative usefulness of the Registry, to calculate the incidence rates of accident with biological fluids among health care workers and in the community, to know about the postaccident rate of seroconversion to HIV and to identify risk groups. METHODS: A descriptive study of the HIV records file of the Registry of Accidental Contacts to Biological Fluids in the Clinic Hospital of Zaragoza was conducted, between January 1987 and September 1993. The registry includes the reports of health care workers and the general population of Health Area III in Aragón (Spain), except for the Calatayud's Hospital. Incidence rates, rate ratios and their 95% confidence intervals were calculated. RESULTS: A total number of 595 accidents were reported, in none of them and HIV infection occurred subsequently. The incidence rate in health care workers was of 1.7 reports per 100 workers per year, while in the community it was of 8.1 per 100,000 people. The housekeeping staff was the group with a higher incidence (rate = 6.7; 95% IC: 3-14.8) and the type of accident more frequently described was needlestick injury. CONCLUSIONS: The incidence of reported accidents has increased in the community and in health care workers, which may be due to the increase in the reporting. In health care workers, the incidence in 1993 was within the range reported from other countries. The perception of risk is universal after accidents with unknown biological fluids. The correct disposal of material with biological contamination should be the more important preventive action.

[Alternative models for the epidemiological analysis of obesity as a public health problem]. / Modelos alternativos para el análisis epidemiológico de la obesidad como problema de salud pública.

Public health problems have been analyzed over time using different approaches involving a variety of methodological and theoretical models. The classical epidemiological model and the social epidemiological model are two examples of models used in public health research. Although each of these models covers a whole range of public research approaches, it is possible to identify the different theoretical and methodological criteria and the different ideological assumptions on which they are based. The objective of this article is to make a comparison of the criteria used by the classical and social epidemiological models in the study of public health problems, with special emphasis on the study of obesity. This comparison shows that the knowledge generated by studies carried out under each of these models is rather different, as an effect of the different theoretical, methodological and ideological criteria used by each model. However, far from being contradictory, the knowledge generated by each model can complement that generated by the other. Finally, the inclusion of social sciences as a tool for the analysis of public health problems, specifically the problem of obesity, is discussed.

[Medical technology and health. A lot of crunching but few nuts?]. / Las tecnologías médicas y la salud. Mucho ruido y pocas nueces?

The present work pretend to describe the development achieved in the field of health technology assessment and to propose a set of criteria to evaluate them, with the intention that it will lead to the development of health programs and policy with a tendency to maximize effectiveness, efficiency and quality, within a frame of increasing needs and scarce technical and economic resources for health care. For this work, a comprehensive review was carried out about the background of health technology adoption in our country, and the context by which to evaluate the accessibility and utilization of the health technology. In the section for technology assessment, it is propose a method to evaluate based upon the natural history of disease, that is, the traditional form of health assessment is restricted to a cross section in time (vertical evaluation), and in this study the authors propose a model with a horizontal approach, that should offer as its main virtues the development of guidelines with regards to prevention, diagnosis and treatment, in addition to cost containment, in support to a more effective and higher quality medical practice.

[Analog gamma camera digitalization computer system]. / Un sistema de digitalización de gamma cámaras analógicas.

OBJECTIVE: Digitalization of analogue gamma cameras systems, using special acquisition boards in microcomputers and appropriate software for acquisition and processing of nuclear medicine images is described in detail. MATERIAL AND METHODS: Microcomputer integrated systems interconnected by means of a Local Area Network (LAN) and connected to several gamma cameras have been implemented using specialized acquisition boards. The PIP software (Portable Image Processing) was installed on each microcomputer to acquire and preprocess the nuclear medicine images. A specialized image processing software has been designed and developed for these purposes. This software allows processing of each nuclear medicine exam, in a semiautomatic procedure, and recording of the results on radiological films. RESULTS: . A stable, flexible and inexpensive system which makes it possible to digitize, visualize, process, and print nuclear medicine images obtained from analogue gamma cameras was implemented in the Nuclear Medicine Division. Such a system yields higher quality images than those obtained with analogue cameras while keeping operating costs considerably lower (filming: 24.6%, fixing 48.2% and developing 26%.) CONCLUSIONS: Analogue gamma camera systems can be digitalized economically. This system makes it possible to obtain optimal clinical quality nuclear medicine images, to increase the acquisition and processing efficiency, and to reduce the steps involved in each exam.

[Determinants of professional status among physicians in Mexico]. / Determinantes del estatus profesional de los médicos en México.

OBJECTIVE: This study explored a number of factors that determine the professional status of physicians in Mexico. METHODS: Using structural equation modelling techniques, causal models were developed to investigate the determinants of professional status within the medical field. RESULTS: The findings suggest that the proposed stratification process in the causal model has empirical support. In the prestige dimension, there is an adscriptive effect of gender, the resultant gender segregated the Mexican medical profession; in addition the achievement effects of medical education and work history within significant occupational and bureaucratic structures. In the economic dimension, the ascriptive effect of gender and the resultant differential in income and job opportunities of female physicians exist. CONCLUSIONS: Although social origin seems to have a weak effect on the dimensions of professional status, it is suggested that both medical education and employment history were both significant positive determinants of professional status in the Mexican medical system. On the other hand, there are still significant gender inequities in the stratification structure of the medical profession.

Detecting lymph nodes metastasis in prostate cancer through extended vs. standard laparoscopic pelvic lymphadenectomy.

INTRODUCTION/OBJECTIVE: Pelvic lymphadenectomy is the best method for staging localized prostate cancer. There is no consensus about how the pelvic lymphadenectomy should be performed for patients with cT2, Gleason score 7 or higher, PSA higher than 10 ng/mL. Scintigraphic studies of prostate lymph drainage show that many lymph nodes are not dissected according to the current recommendation of lymphadenectomy which could explain the high rate of cancer recurrence. The objectives of this work are an analysis of the local lymph node metastasis according to the preoperative data (digital examination, PSA and Gleason score) and a comparison between laparoscopic extended and limited pelvic lymphadenectomy, for staging, their technique and complications. METHODS: Two groups were created for analysis. The indications for laparoscopic pelvic lymph-adenectomy are the following: preoperative PSA 10 ng/mL or higher, Gleason score 7 or higher and/or digital examination cT2. Patients with suspected distant metastasis were excluded. The first group is composed of the patients who under-went a limited laparoscopic pelvic lymphadenectomy (LLPL) between January 1995 and December 2002. The medical data were analyzed retrospectively. The second group was created with patients who received extended laparoscopic pelvic lymphadenectomy (ELPL). These data were consecutively collected between November 2006 and October 2007. LLPL was the extraction of the external iliac and obturator lymph nodes. ELPL included, additionally, dissection of the internal iliac lymph nodes as well as tissue medial to the genitofemoral nerve. Histopathological findings were compared with serum PSA, histopathological stage and preoperative biopsy. Complications, operating time, and number of extracted lymph nodes were also compared. RESULTS: There were no significant differences in age, serum PSA or mean biopsy Gleason between two groups. The first group (LPLL) is composed of 381 patients and the second (ELPL), 163. The mean operating time was 72.5 minutes for LLPL and 84.3 for ELPL. The mean number of lymph nodes extracted was 13.8 (LLPL) and 31.1 (ELPL). Metastases were detected in 18.8% (LLPL) and 24.7% (ELPL). In 37.5% of cases, the metastasis occurred in lymph nodes outside from those dissected by LPLL. The rates of complications and conversion rate were not significantly different for the two groups. CONCLUSIONS: For patients with clinically localized prostate cancer, ELPL is associated with a higher rate of detection of lymph node metastasis outside of the field dissected in the LPLL. Pelvic lymphadenectomy, especially extraction of the lymph nodes of the internal iliac is important in patients with preoperative Gleason score 7 or greater and/or serum PSA greater than 10 ng/mL. Laparoscopic lymphadenectomy does not augment the rate of complications and is an excellent technique in prostate cancer staging.