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PubMed2006

Clinical and entomological factors influence the outcome of sting challenge studies.

BACKGROUND: The reported frequency of systemic reactions to challenge sting varies greatly. OBJECTIVE: To evaluate the interaction of clinical and entomological factors that determine the outcome of a challenge sting. METHODS: Patients allergic to yellow jacket were stung and monitored for systemic reaction. The frequency and severity of sting reactions were analyzed in relation to the species of insect used and patient characteristics. RESULTS: Objective systemic reactions occurred in 21 of 69 patients (30%) stung with Vespula maculifrons and in 8 of 71 patients (11%) with Vespula germanica (P=.005). Systemic reactions were more frequent in patients with a severe history (9/30; 30%) than in those with a mild or moderate history (21/145; 14%; P=.04). In only 1 of 111 patients (0.9%) was the reaction to sting challenge more severe than previous reactions. The reaction rate was higher when venom skin tests were positive at <1.0 microg/mL (17/75=23%) than when sensitivity was milder (9/100=9%; P=.012). We compared sting outcome and venom-induced histamine release in relation to insects collected in July or in October, and found no difference. CONCLUSION: Allergic reactions to sting challenge are determined by the species of yellow jacket used, the severity of previous sting reactions, and the degree of skin test sensitivity, but not by the time of year. These factors are important to clinicians when they evaluate the chance of reaction to a future sting and to researchers when they design and report sting challenge studies.

Adult↗

PubMed1997

Discontinuation of yellow jacket venom immunotherapy: follow-up of 75 patients by means of deliberate sting challenge.

BACKGROUND: Venom immunotherapy is effective in preventing systemic reactions in patients with a history of an anaphylactic reaction to Hymenoptera stings. It is uncertain how long venom immunotherapy should be continued. OBJECTIVE: We evaluated whether the duration of venom immunotherapy given to yellow jacket-sensitive patients related to the risk of an anaphylactic reaction to a later sting. METHODS: Seventy-five yellow jacket-sensitive patients (29 male and 46 female) received a median number of three in-hospital sting challenges from a live insect in 3 subsequent years after discontinuation of venom immunotherapy. An anaphylactic reaction to one or more of the sting challenges was considered a relapse. We analyzed whether patients with and patients without a relapse differed in terms of gender, age, preimmunotherapy skin test data, preimmunotherapy level of venom-specific IgE, severity of the field-sting reaction that preceded immunotherapy, severity of the reaction to the sting challenge that preceded immunotherapy, adverse reactions to immunotherapy, changes in IgE and IgG4 levels during immunotherapy, duration of immunotherapy, and presence of venom-specific IgE after cessation of therapy. RESULTS: Venom immunotherapy was given for a median duration of 40 months (range, 7 to 120 months). Relapses were observed in six patients. In two of them, a rather severe anaphylactic reaction was observed after the second sting challenge. No relation was found between duration of venom immunotherapy and relapse risk. The relapse rate was higher among patients with high levels of specific IgE before and after immunotherapy. During therapy, the mean level of specific IgE decreased. This decline persisted in the 3 following years. No relapses of sting reactions were observed among patients without detectable specific IgE. CONCLUSION: Discontinuation of venom immunotherapy appears safe for patients with pretreatment IgE antibodies if these antibodies can no longer be detected during immunotherapy. For the remaining patients, a treatment period of 3 years may suffice. After discontinuation of immunotherapy, a clinical sting challenge can be considered to estimate the patient's current grade of hypersensitivity.

Adolescent↗

PubMed1996

Removing bee stings.

BACKGROUND: Conventional advice on immediate treatment of honey-bee stings has emphasised that the sting should be scraped off, never pinched. The morphology of the sting suggested little basis for this advice, which is likely to slow down removal of the sting. METHODS: The response to honey-bee stings was assayed with a measurement of the size of the resulting weal. Injection of known quantities of venom showed that this measurement is a good indicator of envenomisation. FINDINGS: Weal size, and thus envenomisation, increased as the time from stinging to removal of the sting increased, even within a few seconds. There was no difference in response between stings scraped or pinched off after 2 s. INTERPRETATION: These data suggest that advice to patients on the immediate treatment of bee stings should emphasise quick removal, without concern for the method of removal.

Animals↗

PubMed1993

Venom-specific IgG antibodies in bee and wasp allergy: lack of correlation with protection from stings.

This paper investigates the relationship between venom IgG levels and protection from stings. Venom-specific IgG antibody levels have been measured by radioimmunoassay in untreated wasp-(n = 38) and bee-allergic (n = 16) patients presenting with systemic reactions to stings and in a sub-group of these (wasp = 15; bee = 9), before and after the initial course of venom immunotherapy (VIT). A history was taken of all reactions, the last systemic reaction being graded on a scale of 1-8 and of the number and timing of stings. In untreated patients venom IgG levels were much higher in bee-allergic patients (mean +/- s.e. = 68.2 +/- 7.1% positive pool) than in the wasp group (27.1 +/- 4.2%) (P < 0.05 Mann-Whitney U-test). There was a marked rise in venom IgG after the initial course of VIT in the wasp group (geometric mean and 95% confidence intervals = 40.5%, 28.8-54.3) but a much smaller rise in the bee group (15.3%, 6.6-24.1), with no overlap in the 95% confidence intervals. Bee patients, who were mainly beekeepers or their relatives, had been more heavily immunized with venom than wasp patients. They had received: (i) more stings (mean number of stings: bee, 26; wasp, 4; P < 0.001) and (ii) more stings per year. Wasp patients received their smaller number of stings over a much longer period, up to 40 yr. There was no correlation between the severity of the last systemic reaction and the venom IgG levels alone or venom IgG and IgE levels in combined analysis in either bee or wasp patients. This study shows that the pattern of IgG response differs in bee and wasp-allergic subjects, and that most bee-allergic subjects with systemic reactions have high levels of venom IgG. The degree of immunization with venom seems to be an important determinant of the venom IgG level. Our findings suggest that venom-specific IgG levels do not predict systemic reactions to stings and are not useful for monitoring VIT. If protection from stings is IgG-mediated, our observations suggest that the relevant immune response is more complex, possibly involving IgG sub-classes, IgG antibodies to individual venom antigens or antibody affinity, and not adequately reflected by measurement of the concentration of venom-specific IgG.

Adolescent↗

PubMed1983

Death caused by wasp and bee stings in Denmark 1960-1980.

During a 21-year period in Denmark a total of 26 deaths were caused by wasp or bee stings (according to the National Health Service). The deaths might be classified, with some overlapping, as caused by either anaphylactic/anaphylactoid shocks (between 65% and 80%), suffocation after stings in the airways (about 15%) or preexisting diseases, especially arteriosclerotic heart disease (approx. 20%). Characteristically, in most persons with shock reactions unconsciousness and death occurred very shortly after the sting (within 45 min), while the interval between sting and death was longer (30 min to a couple of hours) when death was caused by suffocation. In more than 21 of the 26 cases it seemed reasonable to assume that insect allergy might have contributed to the fatal outcome. Six of these cases had a previous history of abnormal reactions to insect venom, thus only a small group would have benefited from the prophylactic effect of hyposensitisation. There was no known previous history of reactions to insect stings in the other cases, but it is likely that more than six persons had had severe reactions to insect stings on other occasions. Presumably many deaths where insect stings have been involved--through not verified as causal--are classified as inexplicable or accidental, thus the real number of deaths caused by wasp or bee stings could be substantially greater. Consequently hyposensitisation after severe insect sting reactions of verified allergic genesis can still be advised.

Adolescent↗

PubMedDate not supplied

[Hymenoptera stings in forestry department agents: evaluation of risk].

BACKGROUND: In sensitized subjects Hymenoptera stings may provoke the awakening of mediated systemic reactions of I type IgE, which can sometimes be serious. Considering the type of work performed activity and the high frequency of reported hymenoptera sting episodes, a sample of 206 Forestry Department agents was surveyed who worked outside urban areas in the Marche Region. OBJECTIVES: The aim of the study was to analyse the prevalence of stings and their possible systemic reactions, as well as to evaluate the type of occupational risks involved. METHODS: A total of 206 agents were examined and questioned about the number of stings suffered during work and about the kind of subsequent skin and systemic reactions; they were then classified according to the method proposed by H.L. Mueller. RESULTS: 179 agents reported having suffered from hymenoptera stings and, of these, 53 subjects (29,6%) remembered that one episode at least occurred during work. Among 175 operators (98%), 4 had a regular reaction, with appearance of a generalized urticaria and uneasiness. In the remaining 4 agents (2%) there was a local extensive reaction, which was not associated with systemic reactions and they were all referred to allergological examination. 19 agents (10,6%) suffered more than 5 stings altogether, but none developed a systemic reaction. 87% of the subjects practised self-medication, 7% reported to the casualty department of the local hospital or to their own doctor, and 6% undertook no cure at all. CONCLUSIONS: Epidemiological studies agree in recognizing that, in the general population, the percentage of systemic reactions after one or more hymenoptera stings varies from 0,15% to 3,3%. In categories of workers occupationally at risk, the prevalence of systemic reactions varies from 4,5% to 26%. The prevalence of systemic reactions in Forestry Department agents was 2%, which is similar to the prevalence in the general population. Therefore, rather than occupational risk, there appeared to be a generic risk made more serious by working conditions for Forestry Department agents due to their possible exposure to hymenoptera stings. The occupational health physician needs to monitor these events, due to the fact that frequent exposure to stings, above all occurring within a short period of time (less than two months) favours an increase in the tendency to develop systemic reactions, with a more serious prognosis, especially when working in isolated conditions.

Adult↗

PubMed2026

Cell-type specific activation of the cGAS-STING pathway in tumor immunotherapy: mechanisms and therapeutic implications.

BACKGROUND: The cyclic GMP–AMP synthase–stimulator of interferon genes (cGAS–STING) pathway acts as a pivotal innate immune sensor that detects cytosolic DNA and links genomic instability to antitumor immune activation. Therapeutic activation of this pathway has garnered substantial interest as a strategy to enhance cancer immunotherapy by promoting dendritic cell maturation, augmenting antigen presentation, and facilitating cytotoxic lymphocyte infiltration. However, the functional outcomes of cGAS–STING signaling are highly context dependent and influenced by both cell type and tumor microenvironmental (TME) conditions. MAIN BODY: Recent advances in single-cell and spatial transcriptomic profiling have revealed profound heterogeneity in cGAS–STING activation across distinct cellular and regional compartments within tumors. Acute and spatially restricted activation of the pathway can elicit potent antitumor immune responses, whereas chronic or dysregulated signaling may promote immune tolerance and tumor progression. Moreover, metabolic stress, epigenetic silencing, and microenvironmental immunosuppressive factors such as TGF-β and IL-10 can further modulate STING activity, leading to resistance to immunotherapy. Current translational efforts focus on next-generation STING agonists, nanoparticle-based delivery systems, and rational combination strategies with immune checkpoint blockade and metabolic modulators to overcome tumor-intrinsic resistance and minimize systemic toxicity. CONCLUSIONS: Understanding the cell-type-specific and spatial dynamics of cGAS–STING signaling is crucial for the rational design of precision immunotherapies. Future research should emphasize context-dependent modulation of STING activity to maximize therapeutic benefit while limiting adverse effects. Integrating multi-omics technologies and spatially guided drug delivery may ultimately enable personalized modulation of the cGAS–STING axis, transforming it into a clinically effective and safe strategy for cancer immunotherapy.

Humans↗

PubMed2006

Identification of oxalic acid and tartaric acid as major persistent pain-inducing toxins in the stinging hairs of the nettle, Urtica thunbergiana.

BACKGROUND AND AIMS: Once human skin contacts stinging hairs of Urtica spp. (stinging nettles), the irritant is released and produces pain, wheals or a stinging sensation which may last for >12 h. However, the existence of pain-inducing toxins in the stinging hairs of Urtica thunbergiana has never been systematically demonstrated. Experiments were therefore conducted to identify the persistent pain-inducing agents in the stinging hairs of U. thunbergiana. METHODS: The stinging hairs of U. thunbergiana were removed and immersed in deionized water. After centrifugation, the clear supernatants were then subjected to high-performance liquid chromatography (HPLC), enzymatic analysis and/or behavioural bioassays. KEY RESULTS: The HPLC results showed that the major constituents in the stinging hairs of U. thunbergiana were histamine, oxalic acid and tartaric acid. However, the well-recognized pain-inducing agents, serotonin and formic acid, existed at a low concentration as estimated by HPLC and/or enzymatic analyses. The behavioural tests showed that 2% oxalic acid and 10% tartaric acid dramatically elicited persistent pain sensations in rats. In contrast, 10% formic acid and 2% serotonin only elicited moderate pain sensation in the first 10 min. Moreover, no significant pain-related behavioural response was observed after injecting 10% acetylcholine and histamine in rats. CONCLUSIONS: Oxalic acid and tartaric acid were identified, for the first time, as major long-lasting pain-inducing toxins in the stinging hairs of U. thunbergiana. The general view that formic acid, histamine and serotonin are the pain-inducing agents in the stinging hairs of U. dioica may require updating, since their concentrations in U. thunbergiana were too low to induce significant pain sensation in behavioural bioassays.

Animals↗

PubMed1987

Studies of the natural history of stinging-insect allergy: long-term follow-up of patients without immunotherapy.

This study reports the clinical and immunologic responses of 29 patients who were observed during a prolonged period after insect-sting anaphylaxis without venom immunotherapy. At the time of their initial evaluation, all patients had venom-specific IgE, detected by skin test or RAST. Their mean age was 21 years; 16 patients were 16 years of age or less. There were 18 male and 11 female patients. Eleven patients had urticaria and angioedema as their only symptoms of anaphylaxis, and 18 patients had respiratory and/or cardiovascular symptoms. Reassessment was done 5 or more years after the initial evaluation. The average time at reevaluation was 10.1 years after the initial sting reaction. There had been 25 re-stings in 17 patients, with three systemic reactions occurring in two patients, an overall reaction rate of 12%. The time interval between the initial sting reaction and the follow-up sting was 2 to 14 years, mean 7.3 years. In patients with initial urticaria/angioedema symptoms only, there were 11 re-stings with no reactions. In patients with initial cardiovascular/respiratory symptoms, there were 14 re-stings with three reactions. At the time of follow-up evaluation, venom-specific IgE had generally decreased. In six of 25 patients, venom skin tests became negative, and in eight of 24 patients, the RAST became negative. These observations suggest that in many patients, stinging insect allergy is a self-limited process, with loss of clinical sensitivity and immunologic reactivity.

Adolescent↗

PubMed1993

Duration of venom immunotherapy: relationship to the severity of symptoms of initial insect sting anaphylaxis.

BACKGROUND: This study assessed the postulate that the adequate duration of venom immunotherapy (VIT) is related to the severity of the initial sting anaphylactic symptoms. METHODS: Data were collected from patients with venom allergy who had sting anaphylaxis and subsequent positive venom skin test results, received maintenance VIT, and had field re-stings after cessation of VIT. There were 217 re-stings in 113 patients with 15 systemic reactions in 10 patients (a re-sting reaction rate of 9% per sting and 7% per patient). RESULTS: Re-sting reactions occurred in 1 of 25 patients with initial mild anaphylaxis (4%), 2 of 41 patients with moderate reactions (5%), and 7 of 47 patients with initial severe symptoms (15%). The results were not influenced by the duration of VIT or the interval between cessation of VIT and the re-sting. Eighteen patients who converted to negative skin test reactions had no reactions when re-stung. CONCLUSIONS: These results suggest a relationship between the severity of anaphylaxis and subsequent duration of VIT. Two to three years is sufficient for patients who had mild to moderate anaphylaxis. Longer duration of therapy is advisable for patients who had severe symptoms and continue to have positive venom skin test results.

Adolescent↗

PubMed1994

Rate and quantity of delivery of venom from honeybee stings.

To determine the rate and completeness of delivery of venom from honeybee stings, European bees were collected at the entrance of a hive and studied with the use of two laboratory models. In one model bees were induced to sting the shaved skin of anesthetized rabbits. The stings were removed from the skin at various time intervals after autotomization, and residual venom was assayed with a hemolytic method. In the other model the bees were induced to sting preweighed filter paper disks, which were weighed again after removal of the sting at various intervals. Results of both experiments were in agreement, showing that at least 90% of the venom sac contents were delivered within 20 seconds and that venom delivery was complete within 1 minute. The data suggest that a bee sting must be removed within a few seconds after autotomization to prevent anaphylaxis in an allergic person. The extensive variation found in the amount of venom delivered at each time point may explain inconsistencies in relationships among reactions to field stings, sting challenge testing, venom skin tests and RAST.

Anaphylaxis↗

PubMed1995

Subsequent insect stings in children with hypersensitivity to Hymenoptera.

To investigate the risk of life-threatening reactions to future stings, we sequentially challenged 113 children (aged 2 to 17 years) allergic to insect stings with a sting by the relevant insect. The time interval between the challenges varied from 2 to 6 weeks. The history of the index stings was a large local reaction (LR) in 16% and a systemic reaction (SR) in 84% of the test subjects. On the first challenge, 76% had a normal LR, 11% a large LR, and 13% an SR. On the second challenge, 78% of the children had a normal LR, 5% a large LR, and 17% an SR. Thirty-nine of the untreated children were exposed to a field sting during the subsequent 3-year follow-up period. In comparison with other diagnostic evaluations such as skin-prick tests, determinations of specific IgE and IgG antibodies, and single-sting exposure, the dual sting challenge scheme appears to be the best predictor of reactions to subsequent stings. It also appears to be helpful in selecting patients with an uncertain sensitization status for venom immunotherapy.

Adolescent↗

PubMed1997

Risk assessment in determining systemic reactivity to honeybee stings in beekeepers.

BACKGROUND: The use of laboratory tests as a reliable method for risk assessment in determining the systemic reactivity of beekeepers to honeybee stings has proven unsatisfactory. OBJECTIVE: This study was conducted to evaluate the usefulness of a structured questionnaire as a supplement to bee venom-specific IgE data in the prediction of systemic sting reactions of 78 beekeepers to honeybee stings. METHODS: Participants in previous studies completed a questionnaire concerning potential risk factors of systemic sting reactions. Serum bee venom IgE was measured by CAP-RAST. Skin prick tests were performed with standardized bee venom extracts prior to the beekeeping season. Venom challenges were performed using unintentional field stings. A new questionnaire concerning sting reactions during the recent beekeeping season was sent to the beekeepers after it had ended. A multiple logistic regression analysis was done to evaluate the influence of potential risk factors upon systemic bee sting reactions. RESULTS: Four variables were significant. The pre-season presence of serum bee venom-specific IgE at concentrations exceeding 1.0 kU/L increased the risk of systemic reactions 12-fold. The risk was 10-fold if nasal or respiratory symptoms had occurred while working at hives. When the years spent in beekeeping were fewer than eight the risk of systemic sting reaction was 9-fold, any previous systemic reaction increased the risk 8-fold. CONCLUSION: The use of more detailed patient histories in combination with laboratory tests may markedly improve the reliability of risk assessment.

Adult↗

PubMed2004

Outcomes of allergy to insect stings in children, with and without venom immunotherapy.

BACKGROUND: Children are thought to "outgrow" the allergy to insect stings, but there are no reports documenting the natural history of this reaction. We studied the outcome of allergic reactions to insect stings in childhood 10 to 20 years afterward in patients who had not received venom immunotherapy and in those who had been treated. METHODS: Between 1978 and 1985, we diagnosed allergic reaction to insect stings in 1033 children, of whom 356 received venom immunotherapy. We conducted a survey of these patients by telephone and mail between January 1997 and January 2000, to determine the outcome of stings that occurred in the period from 1987 through 1999. RESULTS: Of the 1033 patients, 512 patients (50 percent) responded, with a mean follow-up period of 18 years, a mean duration of venom immunotherapy of 3.5 years in treated patients, and an incidence of stings of 43 percent. Systemic reactions occurred less frequently in patients who had received venom immunotherapy (2 of 64 patients, or 3 percent) than in untreated patients (19 of 111 patients, or 17 percent; P=0.007). Patients with a history of moderate-to-severe reactions had a higher rate of reaction if they had not been treated (7 of 22 patients, or 32 percent) than if they had received venom immunotherapy (2 of 43 patients, or 5 percent; P=0.007). In patients who had been treated and who had a history of mild (cutaneous) systemic reaction (i.e., one with only cutaneous manifestations), none of the 21 subjects who received stings had a systemic reaction. CONCLUSIONS: A clinically important number of children do not outgrow allergic reactions to insect stings. Venom immunotherapy in children leads to a significantly lower risk of systemic reaction to stings even 10 to 20 years after treatment is stopped, and this prolonged benefit is greater than the benefit seen in adults.

Animals↗

PubMed2002

An autopsy approach to bee sting-related deaths.

Although severe reactions to the sting of the common honey bee (Apis mellifera) are a common problem in Australia, reported deaths are uncommon, with the estimated mortality varying from one to four persons each year. The following study presents the postmortem findings in three cases of bee sting fatality, including one in which no observable sting was found. An autopsy approach to such cases is detailed. Overreporting of bee sting-related deaths may occur due to the inclusion of deaths unrelated to a reaction to bee venom, while under-reporting may be due to unexplained deaths where a history of a bee sting is not available or apparent at autopsy. A classification of bee sting-related deaths is proposed, which would allow more accurate reporting of bee sting-related fatalies. A serum tryptase and specific IgE to bee venom on serum obtained at autopsy can assist in confirming anaphylactic reaction to bee venom as the cause of death, particularly in the absence of observable stings. Although there are limitations to the usefulness of serum tryptase tests in the postmortem situation, it may still be useful to confirm suspected anaphylaxis in autopsy cases with an undetermined cause of death.

Adult↗

PubMed1994

Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy.

The aim of the study was to determine whether a short interval (< 2 months) between two consecutive stings influences the development of Hymenoptera venom allergy. The study compared the sting-interval distribution in 120 allergic patients who experienced a first-time systemic reaction to a Hymenoptera sting, and in 100 healthy controls. A significant difference in sting-interval distribution between the two groups was found (P = 0.0001). In 71 of 120 allergic patients, the sting that provoked the systemic reaction had been preceded by another, completely tolerated sting not more than 2 months before. However, in the control group only four subjects out of 100 had received two consecutive stings within less than 2 months. In conclusion, a short interval between two consecutive stings seems to be a risk factor for the onset of Hymenoptera venom allergy.

Adolescent↗

PubMed2026

Context-Dependent cGAS-STING Activation Shapes Metastatic Progression and Dormancy.

Cancer cells survive, proliferate, and metastasize in part because the immune system fails to detect and eliminate them. Moreover, the tumor microenvironment (TME) that surrounds the tumor supports cancer cell survival and resistance to chemo- and immunotherapies by inhibiting antitumor immune responses and thereby reducing the efficacy of immunotherapeutic interventions. cGAS-STING signaling senses cytoplasmic DNA and coordinates innate immune responses that shape tumor-intrinsic outcomes and the TME. Emerging evidence reveals a context-dependent, dualistic role for cGAS-STING in metastatic progression and cancer dormancy. Acute, robust activation in antigen-presenting cells promotes type I interferon responses, leading to suppression of tumor growth. By contrast, chronic, low-level cancer-intrinsic STING signaling can engage inflammatory programs that foster immune suppression and therapy resistance. Dormant disseminated tumor cells exploit niche cues to downregulate STING signaling and evade immune detection, whereas reactivation of dormant cells often involves restoration of STING activity that can promote immune elimination. In this article, we review mechanisms linking genome instability and cytoplasmic DNA to STING activation, summarize evidence for tumor-suppressive versus tumor-promoting functions across metastatic niches, and discuss how STING agonists and combination strategies may be optimized to maximize antitumor immunity while avoiding protumorigenic effects.

Humans↗

PubMed2004

The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter.

PURPOSE: With the advent of tissue bulking agents, in particular dextranomer/hyaluronic acid copolymer (Dx/HA), for endoscopic implantation for vesicoureteral reflux (VUR), there has been a major shift in the surgical paradigm throughout Europe, and more recently, in the United States. We describe a modification of the technique used for implantation that has significantly improved our results. MATERIALS AND METHODS: Between October 2001 and October 2003, 285 children 7 months to 15 years old (mean age 4.6 years) underwent endoscopic implantation of Dx/HA for VUR at our institutions. A modified STING (subureteral transurethral injection) procedure (implantation submucosally within the intramural ureter) was introduced during the last year of the study. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months flouroscopic voiding cystourethrograms were used to evaluate for the presence of VUR. A subset of 122 patients treated with STING (52) were compared to those treated with modified STING (70). RESULTS: A total of 459 ureters in 231 girls and 54 boys were treated (174 bilateral cases). Mean maximum grade per patient was 2.5/5. Mean injected volume was 0.9 cc ureter. There were 181 patients with at least 3 months of followup. After 1 treatment 76% (137 of 181) of cases were cured (grade 0 reflux), while 54% (24 of 44) of the failures were improved. The overall cure rate was 94% for grade I, 85% for grade II, 78% for grade III and 71% for grade IV reflux. The patients treated with STING had a mean age of 4.8 years, mean maximum reflux grade was 2.5 and success rate was 71% (37 of 52; 86% grade I, 89% grade II, 70% grade III and 63% grade IV reflux). The patients treated with a modified STING had a mean age of 5.5 years, mean maximum grade was 2.8 and a success rate was 89% (62 of 70; 100% grade I, 92% grade II, 91% grade III and 90% grade IV reflux). Ureteral success rates were significantly (p <0.01) greater for the modified STING (92%) vs the standard STING (79%). There were no cases of hydronephrosis at 3 months postoperatively. CONCLUSIONS: The majority of patients undergoing minimally invasive therapy for VUR with Dx/HA are cured after 1 treatment. The modified STING is our preferred method of implant injection for the correction of VUR and in our hands produces a resolution rate of 89% (92% of ureters). The technique optimizes ureteral coaptation, is easy to perform and is not associated with any significant short-term complications. Persistence of VUR in a minority of patients continues to be the only significant adverse effect of endoscopic implantation.

Adolescent↗