Corrigendum: Approach for delabeling beta-lactam allergy in children

[This corrects the article DOI: 10.3389/falgy.2023.1298335.].

Approach for delabeling beta-lactam allergy in children

A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.

Impact of COVID-19 on Dental Practices in El Salvador and Mexico: A Comprehensive Survey Analysis

BACKGROUND AND OBJECTIVES

This study aimed to identify the relationship between prevention measures and protective barriers in dental practice in El Salvador and Mexico during the COVID-19 pandemic in 2020 and 2021.

MATERIALS AND METHODS

A longitudinal study was conducted from June 2020 to December 2021, involving 1,719 dentists divided into four groups based on location and year. A 20-question survey in Spanish was utilized and validated with a Cronbach's alpha value of 0.84.

RESULTS

The use of phone triage (OR = 1.3), thermometers (OR = 1.4), physical distancing (OR = 1.7), and face shields (OR = 2.6) was significantly associated with dental practice in both countries during the pandemic.

CONCLUSIONS

During 2020 and 2021, dental care in El Salvador and Mexico was significantly linked to COVID-19 preventive measures. Phone triage, thermometers, distancing, and face shields positively correlated with dental services. National health agencies should promote the use of minimum preventive measures in dental care, preparing for potential reinfections or new pandemics from emerging virus variants.

Accuracy of the Diagnosis of Allergic Reactions in the Emergency Department

BACKGROUND AND OBJECTIVE

Suspicion of an acute allergic reaction is a common reason for attending the emergency department (ED). However, there are few comparisons between the initial diagnosis of suspected allergic reaction made in the ED with the definitive diagnosis made subsequently in the allergy department (AD). Objective: To compare details of the initial diagnosis made in the ED relating to allergy with the final diagnosis made in the AD.

METHODS

Patients attending the ED of 2 hospitals with suspected allergic reactions were prospectively enrolled based on key words. A certified allergy specialist reviewed the ED records of these patients and, if these were suggestive of an allergic reaction, the patients were scheduled for further evaluation at the allergy clinic.

RESULTS

In total, 2000 patients were enrolled between April 2013 and October 2015. Of these, 1333 passed the initial assessment and underwent further evaluation. Of the 1333 patients, 528 underwent an allergological study, and 206 were confirmed as being allergic. With respect to drug allergy, nonsteroidal anti-inflammatory drugs were the most common triggers, followed by β-lactams; in food allergy, plant-based foods were the most common. Only 16.4% of patients confirmed as having anaphylaxis in the AD were initially diagnosed with the condition in the ED.

CONCLUSION

Of the 528 patients who finally underwent the full allergological study, fewer than half were confirmed as allergic. Moreover, anaphylaxis appears to be underdiagnosed in the ED. Better communication between the ED and the AD is necessary to improve the diagnosis and management of these patients.

Local allergic rhinitis: Implications for management

A significant proportion of rhinitis patients without systemic IgE-sensitisation tested by skin prick test and serum allergen-specific IgE (sIgE) display nasal reactivity upon nasal allergen provocation test (NAPT). This disease phenotype has been termed local allergic rhinitis (LAR). LAR is an underdiagnosed entity affecting children and adults from different parts of the world, with moderate-to-severe symptoms, impairment of quality of life and rapid progression to symptom worsening. LAR is a stable phenotype and not merely an initial state of AR. Allergic rhinitis and LAR share many clinical features including a positive NAPT response, markers of type 2 nasal inflammation including sIgE in nasal secretions and a significant rate of asthma development. LAR should be considered as a differential diagnosis in those subjects of any age with symptoms suggestive of AR but no evidence of systemic atopy. Although LAR pathophysiology is partially unknown, in some patients sIgE can be demonstrated directly in the nasal secretions and/or indirectly via positive responses in basophil activation test (BAT). LAR can coexist with other rhinitis phenotypes, especially AR. The diagnosis currently relies on the positivity of NAPT to a single or multiple allergens. NAPT has high sensitivity, specificity and reproducibility, and it is considered the gold standard. BAT and the measurement of nasal sIgE can also contribute to LAR diagnosis. LAR patients benefit from the same therapeutic strategies than AR individuals, including the avoidance of allergen exposure and the pharmacotherapy. Moreover, several recent studies support the effectiveness and safety of allergen immunotherapy for LAR, which opens a window of treatment opportunity in these patients.

The clinical and immunological effects of Pru p 3 sublingual immunotherapy on peach and peanut allergy in patients with systemic reactions

BACKGROUND

The peach non-specific lipid transfer protein, Pru p 3, is the primary sensitizer in fruits and responsible for severe reactions in the Mediterranean area. Peach allergy is frequently associated with other allergies such as peanut. Therefore, it is important to assess how specific immunotherapy to Pru p 3 could affect both peach and peanut tolerance.

OBJECTIVES

To evaluate peach and peanut desensitization and immunological changes after 1 year of Pru p 3 sublingual immunotherapy (SLIT) in patients with systemic allergic reactions to peach and/or peanut.

METHODS

Forty-eight peach allergic patients, 36 treated with SLIT and 12 non-treated, were monitored for 12 months. Treated patients were subclassified as peanut allergic (Group A), sensitized (Group B) or tolerant (Group C). SLIT effect was evaluated by skin prick test (SPT) reactivity and food challenge. Immunological changes were evaluated by monitoring sIgE and sIgG4 levels and basophil reactivity.

RESULTS

After 1 year of SLIT, the weal area in SPT significantly decreased and a significant increase in peach threshold in treated patients was observed (P < 0.001). Patients in Group A showed a significant decrease in peanut SPT weal area and an increase in peanut threshold (P < 0.001). Immunological changes were observed in treated patients only, with a significant decrease in sIgE and a parallel increase in sIgG4, sIgG4/sIgE and basophil reactivity for both Pru p 3 and Ara h 9.

CONCLUSIONS AND CLINICAL RELEVANCE

After 1 year, Pru p 3 SLIT induces both desensitization and immunological changes not only for peach but also for other food allergens relevant in the induction of severe reactions such as peanut.

Natural evolution in patients with nonsteroidal anti-inflammatory drug-induced urticaria/angioedema

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequent triggers of drug hypersensitivity with NSAIDs-induced urticaria/angioedema (NIUA) the most common phenotype. Loss of hypersensitivity has been reported for IgE-mediated reactions; however, it has not been assessed in nonimmunological reactions such as NIUA. We evaluated NSAID-hypersensitivity over time in NIUA patients.

METHODS

Patients confirmed as NIUA by positive drug provocation test (DPT) with acetylsalicylic acid (ASA) during 2005-2012 (V1) were included (n=38). Subjects were prospectively re-evaluated by DPT with ASA/other NSAIDs at two time points between 2013 and 2015 (V2 and V3). Atopy was assessed by skin prick test (SPT) using inhalant and food allergens.

RESULTS

Patients were evaluated at V1 and re-evaluated after 60 months (V2; IR:48-81) and a further 18 months (V3; IR:14-24). At V2, the majority (24; 63.15%) tolerated ASA and other NSAIDs (Group A) while 14 (36.84%) still reacted (Group B). At V3, all Group A patients remained tolerant; all Group B patients remained hypersensitive. The number of previous episodes reported at V1 and the percentage of reactions induced by ASA/ibuprofen were significantly lower in Group A (P=.005 and P=.006, respectively). Group A patients developed tolerance 72 months (IR:45-87) after their last evaluated reaction (V1); this interval was shorter in nonatopics (P=.003), patients who experienced reactions over 1 hour after NSAIDs administration (P=.001), and those who experienced isolated urticaria after NSAID intake (P=.024).

CONCLUSIONS

NIUA patients may develop tolerance to NSAIDs over time, a process that seems to be influenced by atopy and type of clinical reaction.

Immunologic responses to the major allergen of Olea europaea in local and systemic allergic rhinitis subjects

OBJECTIVE

To evaluate the in vivo and in vitro responses to nOle e 1 in allergic rhinitis (AR) and local allergic rhinitis (LAR) patients sensitized to olive tree pollen (OL) confirmed by nasal allergen provocation test (NAPT).

METHODS

Twelve subjects with AR, 12 with LAR and 12 subjects as control group (CG) were selected. Skin testing and NAPT with nOle e 1 were performed. Eosinophilic cationic protein (ECP) and tryptase were measured in nasal lavages before and after NAPT. Serum IgE to OL allergens was measured by ELISA. Basophil activation tests (BAT) with OL and nOle e 1 and dendritic cell maturation/proliferation studies were carried out.

RESULTS

All AR (12/12) and 10/12 (83%) of LAR had a +NAPT to nOle e 1. ECP levels in nasal lavages were significantly increased after NAPT in both AR and LAR compared with CG at 15 min (P < 0.05). Serum IgE was positive only in AR. All AR had +BAT responses to OL and 10/12 to nOle e 1 (83%); 8/12 LAR (66.6%) had a +BAT to OL and 4/12 (33%) to nOle e 1, with only one subject of the CG with a +BAT to both OL and nOle e 1 (8%). Dendritic cell proliferation to nOle e 1 was increased in AR compared to LAR and CG (P = 0.019 and P = 0.001, respectively).

CONCLUSION

Both AR and LAR had a similar in vivo response to nOle e 1 with release of inflammatory mediators. Specific basophil activation with OL and nOle e 1 was observed in LAR confirming previous data obtained with dust mites.

Clinical spectrum of males with primary antiphospholipid syndrome and systemic lupus erythematosus: a comparative study of 73 patients

The objective of this study was to compare the clinical findings, laboratory data, functional outcome and chronic damage in male patients with primary antiphospholipid syndrome (PAPS) and systemic lupus erythematosus (SLE). We studied 29 male patients with PAPS and 44 with SLE. Clinical findings, laboratory data, lupus damage index (SLICC/ACR DI), and functional outcome in PAPS, were analysed in each group. The mean age at diagnosiswas 29.8 + 10.4 years in patientswith PAPS and 26 + 10.1 years in SLE patients. The duration of disease was 4.5 + 2.6 versus 5.2 + 3.8 years in patients with PAPS and SLE, respectively(P NS). In patients with PAPS the most frequent clinical manifestations were venous thrombosis, thrombocytopenia, and pulmonary thromboembolism. Patients with SLE had joint, skin and renal involvement more frequently than those with PAPS (P 0.0001). All PAPS patients had anticardiolipin antibodies (aCL), and 14 patients (48%) had lupus anticoagulant (LA). All SLE patients had antinuclear antibodies (ANAs). Anti-dsDNA antibodies were positive in 39% of SLE patients. Five patients died: one with ‘catastrophic’ APS and four with SLE. SLICC/ACR-DI score in SLE patients was 1.9 (SD 1). In PAPS patients poor functional outcome was due to myocardial infarction, pulmonary thromboembolism, stroke and mesenteric thrombosis. Lupus nephritis was the principal organ damage in SLE. In conclusion, in male patients with PAPS and SLE, the clinical manifestations were significantly different. Arterial thrombosis was the major cause of functional impairment and permanent organ damage in PAPS. Renal involvement was the major cause of chronic damage in SLE.

Immediate hypersensitivity reactions to ibuprofen and other arylpropionic acid derivatives

BACKGROUND

Although ibuprofen and other arylpropionic acid derivatives (APs) are the most common medicines involved in hypersensitivity drug reactions (HDRs) to NSAIDs, no patient series studies have been performed regarding immediate selective reactions (SRs) to these drugs.

OBJECTIVE

To characterize patients with immediate selective HDRs to ibuprofen and other APs through clinical history and challenge.

METHODS

Subjects who developed an HDR to APs less than 1 h after drug intake were included. Tolerance to aspirin was assessed and challenge was performed with ibuprofen in all cases, and additionally with the culprit drug (if different) in those patients that tolerated ibuprofen. Serum tryptase levels and tryptase immunohistochemical staining in skin biopsies were also assessed in some patients with a positive DPT to ibuprofen.

RESULTS

From a total of 245 patients with a confirmed history of HDRs to APs, 17% were classified as selective immediate hypersensitivity reactors by both clinical history and challenge. A selective response to naproxen and dexketoprofen with tolerance to ibuprofen was found in 16 of 20 cases. Significant differences in serum tryptase levels were observed between 2 and 24 h in the 11 cases that were studied further.

CONCLUSIONS

Within the group of patients with HDRs to NSAIDs, APs can induce immediate SRs. Within this group, selective responses to a single drug or responders to several APs may exist, suggesting potential immunological cross-reactivity.

Efficacy and safety of D. pteronyssinus immunotherapy in local allergic rhinitis: a double-blind placebo-controlled clinical trial

The effects of allergen immunotherapy (AIT) on local allergic rhinitis (LAR) are largely unknown. We conducted the first randomized, double-blind, placebo-controlled (DBPC), phase II trial of D. pteronyssinus (DP) subcutaneous AIT (DP-AIT) on LAR (clinicaltrials.gov identifier: NCT02123316). Thirty-six LAR patients received Pangramin PLUS DP or placebo for 24 months. The primary endpoints were symptoms, medication scores, and medication-free days. The secondary included skin test, serum specific IgE and IgG4, nasal allergen provocation test (NAPT), and adverse events. AIT-DP produced significant improvements in both primary and secondary endpoints vs placebo. After 12 months of AIT-DP, we detected a significant and marked increase in allergen tolerance with negative NAPT in 50% of patients, and significant increases of serum sIgG4. Immunotherapy was well tolerated; no systemic reactions were reported. This study demonstrated that AIT-DP is a safe and clinically effective treatment for LAR, confirming that LAR is a new indication for AIT.

Initial immunological changes as predictors for house dust mite immunotherapy response

BACKGROUND

Although specific immunotherapy is the only aetiological treatment for allergic disorders, the underlying mechanisms are not fully understood. Specific immunotherapy induces changes in lymphocyte Th subsets from Th2 to Th1/Treg. Whether differences in immunological patterns underlie patient response to immunotherapy has not yet been established.

OBJECTIVES

We studied the immunological changes occurring during a 1-year period of Dermatophagoides pteronyssinus (DP) immunotherapy and their relation with clinical outcome.

METHODS

We included 34 patients with DP allergy who received subcutaneous specific immunotherapy (SCIT) for 1 year. Following treatment, patients were classified as responders or non-responders. Fourteen allergic subjects who did not receive SCIT were included as controls. Peripheral blood was obtained at 0, 1, 3, 6 and 12 months and cultured with nDer p 1. Phenotypic changes, cytokine production and basophil response were analysed by flow cytometry; transcription factors were measured by mRNA quantification. Serum immunoglobulin levels were also measured.

RESULTS

After 1 year of SCIT, 82% of cases showed improved symptoms (responders). Although increases in sIgG4 were observed, BAT reactivity was not modified in these patients. Increases in T-BET/FOXP3 as well as nDer p 1-specific Th1/Treg frequencies were also observed, along with a decrease in Th2, Th9 and Th17. These changes corresponded to changes in cytokine levels.

CONCLUSION

Patients who respond well to DP-SCIT show immunological differences compared to non-responders. In responders, basal differences include a lower frequency of Th1 and higher frequencies of Th2, Th9 and Th17 cells. After 1 year of treatment, an increased production of sIgG4 was observed in responders, along with a change in Th2 response towards Th1/Treg.

Protein-Primed Replication of Bacteriophage Φ29 DNA

The requirement of DNA polymerases for a 3'-hydroxyl (3'-OH) group to prime DNA synthesis raised the question about how the ends of linear chromosomes could be replicated. Among the strategies that have evolved to handle the end replication problem, a group of linear phages and eukaryotic and archaeal viruses, among others, make use of a protein (terminal protein, TP) that primes DNA synthesis from the end of their genomes. The replicative DNA polymerase recognizes the OH group of a specific residue in the TP to initiate replication that is guided by an internal 3' nucleotide of the template strand. By a sliding-back mechanism or variants of it the terminal nucleotide(s) is(are) recovered and the TP becomes covalently attached to the genome ends. Bacillus subtilis phage ϕ29 is the organism in which such a mechanism has been studied more extensively, having allowed to lay the foundations of the so-called protein-primed replication mechanism. Here we focus on the main biochemical and structural features of the two main proteins responsible for the protein-primed initiation step: the DNA polymerase and the TP. Thus, we will discuss the structural determinants of the DNA polymerase responsible for its ability to use sequentially a TP and a DNA as primers, as well as for its inherent capacity to couple high processive synthesis to strand displacement. On the other hand, we will review how TP primes initiation followed by a transition step for further DNA-primed replication by the same polymerase molecule. Finally, we will review how replication is compartmentalized in vivo.

Apical Closure in Apexification: A Review and Case Report of Apexification Treatment of an Immature Permanent Tooth with Biodentine

Materials such as calcium hydroxide paste and mineral trioxide aggregate are used in apexification treatment of immature permanent teeth, but the search for improved materials with higher characteristics of biocompatibility results in different materials. Biodentine is a tricalcium silicate cement that possesses adequate handling characteristics and acceptable mechanical and bioactivity properties. This report describes the case of a 9-year-old boy who was referred to the Department of Dental Clinic of Querétaro Autonomous University of Mexico. One month prior the patient had suffered a dental trauma of his upper left central incisor and had been treated by another dentist. The clinical diagnosis was previously initiated therapy and symptomatic apical periodontitis. The treatment was apexification with Biodentine. At follow-ups performed at 3, 6, and 18 months after treatment the tooth was asymptomatic. The cone-beam computed tomography scan at 18-month postoperative follow-up revealed continuity of periodontal ligament space, absence of periapical rarefactions, and a thin layer of calcified tissue formed apical to the Biodentine barrier. On the basis of sealing ability and biocompatibility, apexification treatment with Biodentine was applied in the present case report. The favorable clinical and radiographic outcome in this case demonstrated that Biodentine may be an efficient alternative to the conventional apexification materials.

Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group

This study aims to systematically review, critically appraise and identify from the published literature, the most effective interventions to improve medication adherence in osteoporosis. A literature search using Medline, EMBASE, Cochrane library, and Cumulative Index to Nursing and Allied Health Literature was undertaken to identify prospective studies published between January 1, 1999 and June 30, 2012. We included studies on adult users of osteoporosis medications that tested a patient adherence intervention (e.g., patient education, intensified patient care, different dosing regimens) and reported quantitative results of adherence. The Delphi list was modified to assess the quality of studies. Of 113 articles identified, 20 studies fulfilled the inclusion criteria. The most frequent intervention was education (n = 11) followed by monitoring/supervision (n = 4), drug regimens (n = 2), drug regimens and patient support (n = 1), pharmacist intervention (n = 1), and electronic prescription (n = 1). Although patient education improved medication adherence in four studies, two large-scale randomized studies reported no benefits. Simplification of dosing regimens (with and without patient support program) was found to have a significant clinical impact on medication adherence and persistence. Monitoring/supervision showed no impact on medication persistence while electronic prescription and pharmacist intervention increased medication adherence or persistence. In conclusion, this review found that simplification of dosing regimens, decision aids, electronic prescription, or patient education may help to improve adherence or persistence to osteoporosis medications. We identified wide variation of quality of studies in the osteoporosis area. The efficacy of patient education was variable across studies, while monitoring/supervision does not seem an effective way to enhance medication adherence or persistence.

Neonatal Food Restriction Induces Hypoplasia in Developing Facial Motor Neurons of Rats

The effects of neonatal food restriction upon the dendritic development of facial nucleus (FN) motor neurons of Wistar rats were analyzed. Rats neonatally underfed by daily (12 h) mother-litter separation in an incubator from 5-30 days after birth exhibited, in brain stem Golgi-Cox sections, significant reductions in the number and extension of stellate, triangular and bipolar FN neuronal dendritic prolongations with negligible effects upon perikarya measurements. Data suggest that in the underfed newborn, the ability of FN neurons to establish synaptic contacts with afferent fibers is reduced, which then interferes with their capacities for the integration and triggering of nerve impulses to modulate facial motor expression in response to sensory cues.

Diagnosis of immediate hypersensitivity reactions to radiocontrast media

BACKGROUND

No consensus exists on the diagnostic approach for immediate hypersensitivity reactions (IHR) to radiocontrast media (RCM). We analyzed the diagnostic value of a skin test (ST), drug provocation test (DPT) and basophil activation test (BAT) in patients with symptoms compatible with IHR to RCM.

METHODS

Ninety patients with symptoms suggestive of IHR to RCM were evaluated. ST with a panel of RCM was performed, and if negative, DPT was carried out with the culprit RCM. If ST or DPT were positive, tolerance was assessed with an alternative RCM and BAT was carried out with the same panel used for ST.

RESULTS

Eight (8.9%) cases were confirmed as having IHR, 5 (62.5%) by ST and 3 (37.5%) by DPT. Five from those confirmed as IHR (62.5%) had a positive BAT.

CONCLUSIONS

Hypersensitivity to RCM was confirmed in 9%, by ST or DPT. BAT proved a valuable method for diagnosis.

Mediator release after nasal aspirin provocation supports different phenotypes in subjects with hypersensitivity reactions to NSAIDs

BACKGROUND

Multiple NSAID-induced urticaria/angioedema (MNSAID-UA) is an entity well differentiated from aspirin-exacerbated respiratory disease (AERD), although no detailed phenotype analysis has yet been performed. The objective was to evaluate the functional characteristics of MNSAID-UA subjects by analyzing the response to nasal lysine-aspirin challenge and measurement of nasal inflammatory mediator release compared with AERD subjects and controls.

METHODS

The study included 85 subjects with confirmed hypersensitivity to NSAIDs (≥3 episodes with >2 different NSAIDs or positive drug provocation) with either cutaneous (MNSAID-UA, n = 25) or respiratory manifestations (AERD, n = 60) and 30 tolerant controls (15 aspirin-tolerant asthmatic patients and 15 healthy controls). Nasal lavages at 0, 15, 60, and 120 min after lysine-aspirin challenge were analyzed for ECP, tryptase, PGE2 , PGD2 , LTD4 , and LTE4 .

RESULTS

Lysine nasal challenge was positive in 80% of the AERD cases but positive only in 12% of the MNSAID-UA group. MNSAID-UA subjects showed no changes in nasal ECP, whereas subjects with AERD had increased levels of ECP, with the highest peak at 15 min after challenge (P < 0.05). Tryptase levels were higher in AERD compared with MNSAID-UA and controls with the highest release of tryptase at 60 min (P < 0.05). Significant increases in PGD2 , LTD4 , and LTE4 were observed in AERD (at 60 min for PGD2 , LTD4 , and LTE4 ) but not in MNSAID-UA or control subjects (P < 0.05).

CONCLUSIONS

Data support the observation that MNSAID-UA, although sharing a common response with AERD to COX inhibitors, seems to have a distinctive phenotype, based on the response to nasal challenge and the release of inflammatory mediators.

Value of the clinical history in the diagnosis of urticaria/angioedema induced by NSAIDs with cross-intolerance

BACKGROUND

Multiple Non-steroidal anti-inflammatory drugs (NSAID)-induced urticaria/angioedema is the most common manifestation of hypersensitivity reactions to NSAIDs. Diagnostic evaluation is based on the clinical history and a drug provocation test.

OBJECTIVE

To evaluate the role of the clinical history in the diagnosis of multiple NSAID-induced urticaria/angioedema.

METHODS

We studied a group of patients with an unequivocal history of urticaria and/or angioedema after NSAID intake. Subjects had to have had at least two episodes of cutaneous symptoms with two different COX-1 inhibitors. The diagnosis was confirmed in all cases by a drug provocation test with acetyl salicylic acid (ASA). Multivariate analysis was done by analysing different variables, including number of drugs involved, episodes and time elapsed between drug intake and symptom onset.

RESULTS

Of the total group of 75 cases with multiple NSAID-induced urticaria/angioedema diagnosed according to the clinical history, 76% developed a positive drug provocation test with ASA. The risk for having hypersensitivity was 17 times higher in patients who developed symptoms within the first 60 min after drug intake, 13 times higher in those who experienced reactions with more than two non-chemically related NSAIDs, and 10 times higher in women.

CONCLUSIONS

Drug provocation testing with ASA confirms the diagnosis of multiple NSAID-induced urticaria/angioedema in up to 92% of cases with an unequivocal clinical history, when reactions occur within 1 h and more than two different NSAIDs are involved.

Drug hypersensitivity reactions: response patterns, drug involved, and temporal variations in a large series of patients

BACKGROUND

Drug hypersensitivity reactions (DHRs) are among the most frequent reasons for consultation in allergy departments, and are becoming more common due to increasing prevalence and case complexity.

OBJECTIVE

To study the clinical characteristics, drugs involved, diagnostic methods, and temporal variation of DHRs in a large series of patients over a 6-year period.

METHODS

We included all patients attending our department between 2005 and 2010. The diagnosis was performed by in vivo and/or in vitro tests (basophil activation test and specific immunoglobulin [Ig] E in serum and drug provocation testing [DPT]) when indicated.

RESULTS

We evaluated 4460 patients who reported 4994 episodes (mean [SD] of 1.13 [0.36] [range, 1-3] episodes per patient). Based on clinical history, 37% of the episodes were attributed to nonsteroidal anti-inflammatory drugs (NSAIDs), 29.4% to beta-lactam antibiotics (BLs), 15% to non-BLs, and 18.4% to other drugs.Analysis of the 1683 patients (37.45%) finally confirmed as allergic showed the most frequent diagnosis to be hypersensitivity to multiple NSAIDs (47.29%), followed by immediate reactions to BLs (18.12%). There was an increase in reactions to non-BLs (from 21.2% to 31.9%; P < .03) over the study period, mainly due to an increase in allergy to quinolones (from 0.5% to 6.8%; P < .02); 44% of patients were diagnosed by clinical history, 14.6% by skin tests, 10.4% by in vitro tests, and 30.8% by DPT.

CONCLUSIONS

NSAIDs were the drugs most frequently involved in DHRs and the most common diagnosis was urticaria/angioedema with cross intolerance. Reactions to emerging drugs such as quinolone derivatives and radiocontrast media are becoming more common.

Tacrolimus causes a blockage of protein secretion which reinforces its immunosuppressive activity and also explains some of its toxic side-effects

BACKGROUND

Tacrolimus (FK506) is a macrolide immunosuppressant drug from the calcineurin inhibitor family, widely used in solid organ and islet cell transplantation, but produces significant side-effects.

OBJECTIVE

This study examined the effect of FK506 on interleukin-2 (IL-2) and insulin secretion, establishing a novel characteristic of this drug that could explain its diverse adverse effects, and developed an experimental model for the simultaneous analysis of mRNA expression and protein secretion affected by this drug.

METHODS

The IL-2 levels when tacrolimus was administered were analysed by Western blot, immunocytochemistry and RT-PCR in a T lymphocyte cellular line (Jurkat) 24 h post-stimulation. The insulin levels when tacrolimus was administered were analysed 4 h after stimulation of glucose-induced insulin secretion in a pancreatic cellular line (MIN6).

RESULTS

The previously published information describes tacrolimus as only capable of partially blocking IL-2 mRNA expression. In our hands, the cellular content of IL-2 is almost undetectable in stimulated Jurkat cells and can be detected in cellular extracts only when the secretory pathway is blocked by brefeldin A (BFA). BFA added 2 h after the beginning of stimulation was able to inhibit IL-2 secretion, without affecting IL-2 mRNA expression. Therefore BFA utilization allowed us to establish a model to analyze the effect on IL-2 secretion, separately from its expression. Tacrolimus added before stimulation inhibits only IL-2 synthesis, but blocks IL-2 protein secretion when added 2 h after stimulation. Similarly, tacrolimus is also capable of blocking the glucose-stimulated secretion of insulin by MIN6 cells. An increase of the intracellular content can be detected concomitantly with a decrease of the hormone measured in the culture medium.

CONCLUSIONS

Results of this study indicate that tacrolimus possesses another important effect in addition to the inhibition of IL-2 gene transcription, namely the ability to act as a general inhibitor of the protein secretory pathway. These results strongly suggest that the diabetogenic effect of the immune suppressant FK506 could be caused by the blockade of insulin secretion. This novel effect also provides an explanation for other side-effects observed in immunosuppressive treatment.

Structural organization of Bacillus subtilis phage phi29. A model

Phage phi29 is a nonisometric virus producing several types of morphological variants in normal infections. The study of these variants by electron microscopy, and their comparison with those from T-even phages, suggest that the capsid of phage phi29 is a prolate icosahedron. Phage phi29 capsid consists of a major protein, p8, and an additional protein, p8.5, making up the fibers. We have determined the number of subunits of each structural protein per viral particle taking into account the phage molecular weight (between 28 and 29.6 x 10(6)), the molecular weight of each structural protein, and the mass percentage of each protein with respect to the total protein mass of the phage. These values, together with the results obtained from chemical crosslinking of the structural proteins on the phage, suggest that the capsid contains protein p8 dimers clustered in trimers.

The orderly, in vitro emergence of DNA from bacteriophage phi29 particles

phi29 DNA-containing 12-13- particles (produced by infecting nonsuppressor hosts of Bacillus subtilis with phage containing suppressible mutations in cistrons 12 and 13) can be complemented with lysates containing proteins p12* and p13 to yield infectious phage. Complementation of these particles with lysates containing p12* but not p13 or complementation with purified p12* in the absence of p13 produces a structure (called complex) which has a markedly different organization. Electron microscopy and sedimentation analysis after digestion with DNase I or proteinase K indicate that complex is composed of an intact phage head with a genome-sized linear DNA molecule attached at the collar-tail region. EcoRI digestion establishes that the DNA molecule has a unique orientation. Gel electrophoresis indicates that p12*, the neck appendage protein, is transferred to the particles when complex is formed. Complex can also be produced by incubation of 12-13- particles at 42 degrees , by incubation at pH 6.0, or by incubation in the presence of 20 mM EDTA. Complex is also formed from DNA-containing 12- particles but to a lesser extent.

Thoracoscopic and laparoscopic repair of complicated Bochdalek hernia in adult

Bochdalek's hernia is a congenital defect of the diaphragm that occurs predominantly in children. Perforation or necrosis of the involved organ is a feared complication and surgical repair constitutes the gold standard of treatment. We present a case of a 42-year-old female patient who presented with a 3-month history of left-upper-quadrant abdominal pain, nausea, tachycardia, and early postprandial vomit. Physical exploration was remarkable for audible peristalsis in the left hemithorax. Total white blood count was elevated and chest X-rays showed images of intestines in the left hemithorax. Tomography with double contrast reported left colon herniated to thorax. Left thoracoscopy was practised, finding a Bochdalek's hernia with presence of herniated descendent colon with a necrotic area, which was perforated and sealed. The herniated content was returned back in place, the diaphragmatic defect was corrected, and colostomy by laparoscopy was simultaneously performed. Her postoperative recovery was uneventful and she was discharged from the hospital. Combined thoracoscopy and laparoscopic surgery is effective in complicated cases of Bochdalek's hernia in adults, lessening surgical trauma and postsurgical morbidity.

Movements restriction and alterations of the number of spines distributed along the apical shafts of layer V pyramids in motor and primary sensory cortices of the peripubertal and adult rat

The number and distribution of spines along apical shafts of rapid-Golgi-stained layer V pyramidal cells from visual, motor and somatosensory cortical areas were analyzed in control and movement-restricted (beginning at 20 days old) Wistar rats killed at 30, 40, 80 and 120 days of age (experiment A). In other group of rats, spine density was analyzed when restriction initiates on day 40 and the animals were killed at 50, 60 and 80 days postpartum, or after restriction starting on day 80 and killed at 120 days of age (experiment B). It has been found that the restriction of movements significantly reduces the total number of spines on apical shafts in the three cortical areas, when this condition starts at 20, 40 or 80 days without changing the overall distribution of spines. Also present findings indicate that the effects of movements restriction are attenuated when they were concurrent with maturational brain processes (20-40 days) than when they occurred later in life. The question remains open of which part of the measured reduction on the number of spines is due to the immobilization and which to the stress associated with this maneuver.

Quality management systems and the admissibility of scientific evidence: the Costa Rican experience

Certainty and truth are, by definition, objectives of science. There is a tendency among people to believe that anything produced by a scientist is science and is therefore certain. On the contrary, scientific findings are not free of error. In fact, science evolves, among other things, by questioning and verifying the ideas and theories that are held to be scientifically valid and by continuously searching for new knowledge. As judicial systems in several countries have evolved over time, they have established minimum criteria for the admissibility of scientific evidence in order to ensure accuracy as far as possible. Forensic laboratories in countries with such requirements have established quality systems as a tool for verifying the standards of the scientific information they provide to courts as evidence. The International Standard ISO/IEC 17025 has been chosen in testing laboratories, including forensic laboratories, to provide uniform technical criteria for developing a quality management system. There is agreement between the ISO standard and admissibility requirements for courts. Therefore, the application of international quality standards to forensic laboratories is of interest to, and must be understood by, not only scientists but also judicial authorities. The present article describes the Costa Rican experience.

Mechanism of transcription activation at the comG promoter by the competence transcription factor ComK of Bacillus subtilis

The development of genetic competence in Bacillus subtilis is regulated by a complex signal transduction cascade, which results in the synthesis of the competence transcription factor, encoded by comK. ComK is required for the transcription of the late competence genes that encode the DNA binding and uptake machinery and of genes required for homologous recombination. In vivo and in vitro experiments have shown that ComK is responsible for transcription activation at the comG promoter. In this study, we investigated the mechanism of this transcription activation. The intrinsic binding characteristics of RNA polymerase with and without ComK at the comG promoter were determined, demonstrating that ComK stabilizes the binding of RNA polymerase to the comG promoter. This stabilization probably occurs through interactions with the upstream DNA, since a deletion of the upstream DNA resulted in an almost complete abolishment of stabilization of RNA polymerase binding. Furthermore, a strong requirement for the presence of an extra AT box in addition to the common ComK-binding site was shown. In vitro transcription with B. subtilis RNA polymerase reconstituted with wild-type alpha-subunits and with C-terminal deletion mutants of the alpha-subunits was performed, demonstrating that these deletions do not abolish transcription activation by ComK. This indicates that ComK is not a type I activator. We also show that ComK is not required for open complex formation. A possible mechanism for transcription activation is proposed, implying that the major stimulatory effect of ComK is on binding of RNA polymerase.

Increased carotid artery intima-media thickness may be associated with stroke in primary antiphospholipid syndrome

OBJECTIVE

To investigate the prevalence and clinical significance of carotid artery intima-media thickness (IMT) in patients with primary antiphospholipid syndrome (APS).

METHODS

28 patients with primary APS with at least a five year follow up, and 28 healthy subjects, matched by age and sex, were included in the study. Colour Doppler with high resolution B mode carotid ultrasonography and spectral analysis were performed in patients and controls. Information on cardiovascular risk factors and the clinical course were collected.

RESULTS

The mean (SD) age of patients and controls (12 male, 16 female in each group) was 40 (8.5) years; the mean (SD) disease duration 7.7 (3) years. Carotid artery IMT was found in 23/28 patients (2.6 (1.14) mm) and 7/28 controls (1.2 (0.44)) (p=0.0001). A decrease in the lumen diameter was also found in 11/28 patients with primary APS without carotid atherosclerotic plaque, and 2/28 controls (p=0.004). Hyperlipidaemia, diabetes, smoking, obesity, and hypertension were not associated with carotid artery IMT. Patients with carotid artery IMT had arterial vascular disease more often than patients without: 9/23 v 0/5 (p<0.009). These patients had stroke (seven patients), myocardial infarction (one), and mesenteric thrombosis (one). Subjects with IMT had a threefold higher risk for stroke than those without IMT (95% CI 0.78 to 14.3).

CONCLUSIONS

Patients with primary APS have a high prevalence of carotid artery IMT and a decreased lumen diameter. IMT in primary APS may be associated with stroke. Patients with primary APS with IMT must be considered as carriers of atherosclerosis.