Treatment of granuloma annulare and related granulomatous diseases with sulphasalazine: a series of 16 cases.

BACKGROUND: Granuloma annulare (GA) and the related annular elastolytic giant cell granuloma (AEGCG) and interstitial granulomatous dermatitis (IGD) are idiopathic histiocytic inflammatory disorders, which are frequently recalcitrant to treatment. OBJECTIVES: Evaluate the efficacy of sulphasalazine in treating GA, AEGCG and IGD. METHODS: Sixteen patients were identified with granulomatous disease who were treated with sulphasalazine between September 2015 and September 2019. Outcomes were based on patients' and providers' subjective evaluations. RESULTS: Sixteen patients were included in the study (ages 56-89, four male and twelve female). Previous treatments were attempted in fifteen patients. Clinical improvement was seen in fourteen patients (87.5%). Initial improvement was noted within a mean (SD) of 66.4 (35.1) days after starting therapy, with increasing benefits over time. Ten patients (62.5%) reported complete or near-complete clearance, three patients (18.8%) reported significant improvement, and one (6.3%) reported partial improvement. Twelve patients elected to stop or reduce therapy, resulting in relapse or worsening in five patients. CONCLUSIONS: Sulphasalazine may be considered as treatment for GA and GA-related conditions.

Comparison of interactive voice response, patient mailing, and mailed registry to encourage screening for osteoporosis: a randomized controlled trial.

UNLABELLED: Guidelines recommend screening for osteoporosis with bone mineral density (BMD) testing in menopausal women, particularly those with additional risk factors for fracture. Many eligible women remain unscreened. This randomized study demonstrates that a single outreach interactive voice response phone call improves rates of BMD screening among high-risk women age 50-64. INTRODUCTION: Osteoporotic fractures are a major cause of disability and mortality. Guidelines recommend screening with BMD for menopausal women, particularly those with additional risk factors for fracture. However, many women remain unscreened. We examined whether telephonic interactive voice response (IVR) or patient mailing could increase rates of BMD testing in high risk, menopausal women. METHODS: We studied 4,685 women age 50-64 years within a not-for-profit health plan in the United States. All women had risk factors for developing osteoporosis and no prior BMD testing or treatment for osteoporosis. Patients were randomly allocated to usual care, usual care plus IVR, or usual care plus mailed educational materials. To avoid contamination, patients within a single primary care physician practice were randomized to receive the same intervention. The primary endpoint was BMD testing at 12 months. Secondary outcomes included BMD testing at 6 months and medication use at 12 months. RESULTS: Mean age was 57 years. Baseline demographic and clinical characteristics were similar across the three study groups. In adjusted analyses, the incidence of BMD screening was 24.6% in the IVR group compared with 18.6% in the usual care group (P < 0.001). There was no difference between the patient mailing group and the usual care group (P = 0.3). CONCLUSIONS: In this large community-based randomized trial of high risk, menopausal women age 50-64, IVR, but not patient mailing, improved rates of BMD screening. IVR remains a viable strategy to incorporate in population screening interventions.

Nonpenetrating deep sclerectomy: a 6-year retrospective study.

PURPOSE: Nonpenetrating trabeculectomy, also called nonpenetrating deep sclerectomy (NPDS), is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. This, technique was developed to minimize the complications of trabeculectomy. The authors investigated its safety and efficacy in a retrospective noncomparative study. METHODS: A total of 258 eyes (179 patients, mean age 61.4 +/- 11.56 years) with uncontrolled open angle glaucoma with prior medical therapy were treated. NPDS with a biocompatible collagen device (157 eyes) sutured to deep scleral bed or with the use of a 5-fluorouracil sponge (90 eyes) were analyzed. The main outcome measure was postoperative intraocular pressure (IOP) with an average follow-up of 54.4 +/- 17.07 months (range 1-85). Efficacy was determined 1 month, 3 months, and every 6 months after the procedure for 6 years. RESULTS: Mean preoperative IOP was 24.47 +/- 5.92 mmHg. Mean postoperative IOP was 14.44 +/- 5.31 mmHg (average lowering of the IOP was 38.94 +/- 23.81%) at 1 month, 15.16 +/- 4.57 mmHg (35.73 +/- 21.35%) at 3 months, 15.87 +/- 4.24 mmHg (32.45 +/- 20.52%) at 6 months, 16.32 +/- 4.53 mmHg (29.96 +/- 23.69%) at 12 months, 17.12 +/- 4.45 mmHg (26.51 +/- 23.93%) at 18 months, 16.77 +/- 4.44 mmHg (28.18 +/- 21.73%) at 24 months, 16.43 +/- 4.15 mmHg (28.89 +/- 23.69%) at 30 months, 16.34 +/- 4.12 mmHg (30.05 +/- 21.61%) at 36 months, 16.16 +/- 4.01 mmHg (30.06 +/- 22.55%) at 42 months, 15.71 +/- 3.74 mmHg (32.49 +/- 19.08%) at 48 months, 15.61 +/- 3.48 mmHg (31.26 +/- 21.01%) after 5 years, and 15.81 +/- 3.79 mmHg (33.73 +/- 20.9%) after 6 years. YAG goniopuncture was performed in 47.3% of cases with a mean follow-up of 12 +/- 13 months. These goniopunctures were effective in lowering IOP after a long-term follow-up (24 months). Additional 5-fluorouracil injections were used in 7% of cases. Visual field (Octopus or Humphrey mean defect and corrected loss variance or loss variance) was not modified (p < 0.01). Number of preoperative glaucoma medications was 2.01 +/- 0.58 and number of postoperative glaucoma medications was 0.85 +/- 0.92. Complications were peroperative microperforations in 27 eyes (10.5%), shallow anterior chamber in 2 eyes, hyphema in 2 eyes (0.8%), cataract in 5 eyes (2%), and dellen in 1 eye (0.4%). No cases of endophthalmitis or choroidal detachment were found. After surgery, 23 eyes (8.9%) required a new filtering surgical procedure, and diode laser cyclophotocoagulation was necessary in 2 eyes (0.8%). The probability success rate, defined as an IOP lower than 21 mmHg, was 66.46% (Kaplan Meier) at 60 months off all glaucoma medications and 80.32% with medical or new surgical treatment. CONCLUSIONS: NPDS appears to be an effective and safe filtering procedure for lowering IOP and could be an alternative to trabeculectomy in open angle glaucoma with the advantage of having fewer complications.

[Scoring system for chronic open glaucoma]. / Evaluation du glaucome chronique à angle ouvert par un score de gradation: analyse préliminaire.

PURPOSE: The aim of this study was to evaluate a scoring system for chronic open-angle glaucoma. We devised an empirical scoring system grading severity of the disease and correlated this with treatment. MATERIAL: and methods: Ninety patients were evaluated on 11 parameters: 1) Family history of glaucoma: blindness (2), yes (1) no (1); 2) Age: infantile (4), juvenile (4); 3) Race: Caucasian (0), Asian (1), Afro-Caribbean (2); 4) Myopia: 0-6 diopters (1), 6-12 diopters (2),>12 diopters (3); 5) Pigment dispersion or pseudoexfoliation (1); 6) Intraocular pressure without treatment:>30 mmHg (4); 25-30 mmHg (3), 20-25 mmHg (2); 7) Corneal central thickness:<500 micro m (3),>500 micro m (0); 8) Optic disc appearance: suspect (1), pathological (4); 9) Visual field defect: early (1), moderate (3), advanced (5); 10) Vascular risk factors: yes (1), no (0); 11) Loss of eyesight in one eye due to glaucoma (4). Scoring values were 2-34. We correlated this score with patient treatment: medical or surgical, number of glaucoma medications. RESULTS: Patients were divided into three groups: group 1 (36 patients), score 0-8; group 2 (24 patients), score 9-13; group 3 (30 patients), score above 13. Distribution between patients treated with medicine (mean number of medications) and patients with filtering surgery was: group 1, medical treatment with 1.63+/-0.73 medications, surgery 4/36; group 2, medical treatment with 2.00+/-0.7 medications, surgery 17/24 and group 3, medical treatment with 2.12+/-0.67 medications, surgery 27/30. In group 1, 88% of the patients did not have filtering surgery, but 90% of the patients in group 3 had filtering surgery. CONCLUSION: This scoring system seems to be an easy and practical tool to evaluate chronic open-angle glaucoma, which could also be used to evaluate target pressure. Other studies are necessary to validate this scoring system.

Successful reversal of severe refractory cardiac allograft rejection by photopheresis.

We treated 4 patients with refractory International Society of Heart and Lung Transplantation Grades IIIA to IV cardiac allograft rejection with extracorporeal photopheresis. Following treatment on 2 consecutive days, 3 patients demonstrated complete histologic reversal of rejection. The remaining patient improved more gradually, but manifested complete cessation of rejection following three 2-day treatments. We conclude that photopheresis is a safe and effective modality for the treatment of severe refractory cardiac allograft rejection and that these results support the use of photopheresis in this clinical setting.

Therapeutic advances in biological response modifiers in the treatment of cutaneous T-cell lymphoma.

Cutaneous T-cell lymphoma (CTCL) is most often a skin-infiltrating malignancy of clonal CD4+ T-cells. Therapy is based on staging and the likelihood of progression. Biological response modifiers and chemotherapeutic agents are used to preserve the integrity of the host antitumour response while selectively targeting the malignant cells. The biological response-modifying treatment options currently used to treat CTCL are bexarotene, denileukin diftitox, interferon-alpha, interferon-gamma and interleukin-12, as well as extracorporeal photopheresis and phototherapy. A combination therapy approach maximises response in patients with advanced CTCL. Biological response modifiers in combination with photopheresis are used for patients with the leukaemic phase of the disease. Among the majority of patients with advanced stage disease so treated, immune response augmentation appears to prolong survival. Future areas of research should assess not only survival and optimal treatment combinations, but also quality of life during the treatment period.

Fluorescence polarization immunoassay: can it result in an overestimation of vancomycin in patients not suffering from renal failure?

It has been reported in scientific data that fluorescence polarization immunoassay (FPIA) results in overestimation of vancomycin in patients with renal failure. This overestimation is caused by interference of the degradation product, CDP-1, in this assay. Increases in vancomycin levels have also been reported in patients not suffering from renal failure (nonrenal failure patients) who are receiving vancomycin therapy for approximately 10 days or more. The authors tested whether this increase in vancomycin in nonrenal failure patients is a result of CDP-1 interfering with FPIA or a change in the pharmacokinetics of the drug. Serum vancomycin peak and trough samples were obtained from 10 adult (mean age +/- SD: 55.9 years +/- 17.5) nonrenal failure patients (mean ClCr +/- SD: 76.2 mL/min +/- 29.20) receiving vancomycin therapy for at least 10 days. These peaks and troughs were obtained at steady state and again at approximately 10 days of therapy. All serum samples were analyzed initially by fluorescence polarization immunoassay (FPIA, TDx) (Abbot Diagnostics; Irving, TX) and again by enzyme multiplied immunoassay (EMIT Vancomycin Assay) (Dade Behring; San Jose, CA). Statistical analysis (Wilcoxon signed-rank test) determined that there was no difference between the values obtained from the two assays. This demonstrates that the increase in vancomycin levels is not caused by the accumulation of CDP-1 and may be the result of a change in the pharmacokinetics of the drug.

Vancomycin and ceftazidime bioactivities persist for at least 2 weeks in the lumen in ports: simplifying treatment of port-associated bloodstream infections by using the antibiotic lock technique.

The residual antibiotic concentration of vancomycin (2 mg/ml)- or ceftazidime (2 mg/ml)-heparin solutions instilled in ports in pediatric hematology-oncology patients 1 to 34 days earlier was measured. Antibiotic concentrations of > or = 100 microg of either antibiotic per ml persisted for at least 21 days. For treatment of lumenal port infections, antibiotic-heparin dwell times of > or = 2 weeks may be appropriate.

The turn-back-and-look behaviour: bee versus robot.

Honeybees and social wasps departing from a novel food source perform stereotype flight manoeuvres, termed the turn-back-and-look behaviour (TBL). Based on results of behavioural studies, it is proposed that the image motion generated by the TBL provides the insect with information about the three-dimensional structure of the goal's surroundings, thus enabling it to select reliable landmarks that will guide it to the goal upon return. The colour, shape, and size of landmarks, on the other hand, are learned mainly during arrival at the food source. However, when bees are prevented from learning these cues on arrival, they learn them during the TBL, despite the fact that this performance does not require the use of image motion. A recently developed model shows that landmark learning can indeed be accomplished during the TBL by exploiting cues others than image motion. A mobile robot equipped with the appropriate software selects, during the TBL, reliable marks and returns to the site of departure from different locations by accomplishing image matching along a two-dimensional vector field.

Successful reversal of recalcitrant hepatic allograft rejection by photopheresis.

Extracorporeal photopheresis (ECP) is an immunologic modality that has shown efficacy in the treatment of clonal T-cell diseases, including Sézary syndrome and allograft rejection. In this case report, we expand on this observation to include recalcitrant hepatic allograft rejection. A 14-year-old boy with hepatic allograft rejection refractory to high-dose corticosteroid and lymphocytolytic therapy was treated with 4 sessions of ECP over a 6-week period. After 2 sessions, a liver biopsy showed complete reversal of acute cell-mediated rejection. No opportunistic infections or other adverse events were noted. Photopheresis appears to be a safe and effective modality for the treatment of refractory hepatic allograft rejection.

Involvement of follicular stem cells in forming not only the follicle but also the epidermis.

The location of follicular and epidermal stem cells in mammalian skin is a crucial issue in cutaneous biology. We demonstrate that hair follicular stem cells, located in the bulge region, can give rise to several cell types of the hair follicle as well as upper follicular cells. Moreover, we devised a double-label technique to show that upper follicular keratinocytes emigrate into the epidermis in normal newborn mouse skin, and in adult mouse skin in response to a penetrating wound. These findings indicate that the hair follicle represents a major repository of keratinocyte stem cells in mouse skin, and that follicular bulge stem cells are potentially bipotent as they can give rise to not only the hair follicle, but also the epidermis.

Shape Perception in the Honeybee: Symmetry as a Global Framework.

This study is concerned with the honeybee's spatial vision in light of the spatial signals that natural flowers display. A large amount of behavioral data shows that bees are perfectly adept at learning and exploiting a variety of spatial cues in the task of recognizing and discriminating between visual stimuli. These cues include spatial frequency, distribution of contrasting areas, orientation of contours, size and distance, different types of edges, and symmetry (or, in a broader sense, geometry). Symmetry constitutes a global feature that is only one of the cues that the target offers. Symmetrical stimuli always contain several further spatial cues that become relevant as the bee comes nearer to the stimuli. The results reviewed here show that the spatial signals used by the bee depend on whether the stimuli are presented on a horizontal or a vertical plane, on whether bees make their choices at a lesser or a greater distance, and on whether the target's image is stationary at the level of the eye, as opposed to moving. Further, it is shown that pattern recognition in the bee does not always require a learning process (i.e., several types of response to visual stimuli are based on hard-wired, innate behavioral programs). Finally, the results show that although it is not a prerequisite for spatial vision, color vision participates in spatial vision, whereas spatial cues extracted from image motion are processed by a color-blind system.

Honeybee memory: navigation by associative grouping and recall of visual stimuli.

Studies of navigation in bees and ants are beginning to reveal that foraging insects traveling repeatedly to a food source navigate by using a series of visual images of the environment acquired en route (Collett, 1996; Collett et al., 1993; Judd & Collett, 1998; Wehner et al., 1990, 1996). By comparing the currently viewed scene with the appropriate stored image, the insect is able to ascertain whether or not it is on the correct path and make any necessary corrections. If a bee happens to forage at more than one site, then she needs not only to memorize a separate set of images for each route that she has learned but also to retrieve the set of images that is appropriate to each route. Here we examine the bee's capacity to learn and later retrieve from memory two different sets of visual stimuli. Bees were trained to fly through a compound Y-maze where they were presented alternately with two different sequences of visual stimuli on their route to a food reward. We find that bees can indeed store two different sequences of images simultaneously. Furthermore, the trained bees are able to classify the memorized images into two groups, one pertaining to each three-stimulus set. Exposure to any of the images pertaining to one set triggers recall of all of the other images associated with that set. Associative grouping and recall of visual stimuli, demonstrated here for the first time in honeybees, provide an effective means of retrieving the appropriate navigational information from memory.

Honeybee navigation: odometry with monocular input.

Recent studies have revealed that navigating honeybees, Apis mellifera, estimate the distance to a food source by integrating over time the image motion that they experience en route. Here we examine the ability of honeybees to gauge distance travelled when visual input is available primarily to one eye. Bees were trained to fly into a tunnel, lined with textured patterns, to collect a reward at a feeder placed at a certain distance. Their ability to estimate distance flown was then assessed by testing them in a fresh tunnel without the feeder. The results show that (1) bees can estimate distance flown under monocular conditions, performing nearly as accurately as when information is available to both eyes; (2) bees can learn to fly two different distances, where each distance is measured in terms of the image motion experienced by a different eye; and (3) bees that have acquired information on the distance to a food source using one eye can measure out the same distance when they are required to use the other (naive) eye. The need to measure distance using signals from a single eye becomes important when a bee flies to a food source along the face of a cliff or the edge of a forest. Furthermore, under such conditions, it is important to be able to deal with odometric signals that are transposed interocularly when the bee returns home from the food source. This is because, although distances are learnt primarily on the way to a food source, foraging bees monitor distance flown on the homebound as well as the outbound routes. Copyright 1998 The Association for the Study of Animal Behaviour.

Looking all around: honeybees use different cues in different eye regions

Based on results of early as well as recent behavioural studies, the present review compares the performance of different eye regions in exploiting information on shape, colour and motion, relevant to the honeybee's foraging task. The comparisons reveal similarities, as well as differences, among the performances of various eye regions, depending on the visual parameter involved in the task under consideration. The outcome of the comparisons is discussed in the light of anatomical and optical regional specializations found in the bee's peripheral visual pathway, as well as in the light of the foraging bee's natural habits. It is concluded that the functional differences found among different eye regions are based on neural mechanisms subserving the bee's natural needs, rather than on peripheral specializations.

Strategies of epithelial repair: modulation of stem cell and transit amplifying cell proliferation.

Using double labeling techniques, we studied the replication of corneal epithelial stem cells that reside exclusively in the limbal zone, and their progeny transit amplifying cells. We show that corneal epithelial stem cells can be induced to enter DNA synthesis by wounding and by TPA. We demonstrate the existence of a hierarchy of TA cells; those of peripheral cornea undergo at least two rounds of DNA synthesis before they become post-mitotic, whereas those of central cornea are capable of only one round of division. However, the cell cycle time of these TA cells can be shortened and the number of times these TA cells can replicate is increased in response to wounding. These results thus demonstrate three strategies of epithelial repair: (i) stem cell replication, (ii) the unleashing of additional rounds of cell proliferation that remain as an untapped reserve under normal circumstances, and (iii) enhancement of TA cell proliferation via a shortening of the cycling time.

Perinatal toxicology screening: comparison of various maternal and neonatal samples.

OBJECTIVES: Because cocaine metabolites are concentrated in amniotic fluid, we designed this study to assess the usefulness of amniotic fluid and that of neonatal gastric aspirate for perinatal drug screening and to compare the concentration of cocaine metabolites in various maternal and neonatal specimens. STUDY DESIGN: We compared the reliability of various maternal and neonatal specimens for detecting drug exposure and the concentration of cocaine metabolites in these specimens. RESULTS: Our data showed that screening for perinatal drug abuse with any single specimen leads to false-negative results. Drug screening with neonatal amniotic fluid, gastric aspirate, or cord blood did not improve the reliability of perinatal drug screening. CONCLUSION: Testing more than one type of body fluid may increase the reliability of perinatal drug screening.

The role of gas chromatography/mass spectrometry. Instrumental techniques in forensic urine drug testing.

Appropriate GC/MS analytic techniques can provide conclusive confirmatory evidence for the presence of drugs and metabolites in forensic urine drug testing. Although forensic laboratories are required to utilize GC/MS, they have flexibility and freedom in selecting instrumentation, modes of operation, and actual analytic methods. It is incumbent on the laboratory to optimize analytic procedures so that reliability and accuracy are maximized. The laboratory needs to be aware of potential pitfalls in both the handling and the analyses of specimens. Specificity can be enhanced by utilizing mass spectrometric operating modes such as CI and full scan, which serve to complement SIM analyses. They are useful in solving difficult identification problems and in enhancing sensitivity as well as specificity. Newer types of GC/MS systems utilizing ion trapping or tandem mass spectrometry offer the promise of enhanced analytic performance and productivity gains. Knowledge of the advantages and potential pitfalls of different GC/MS systems as well as ionization and detection modes is helpful in optimizing the accuracy of compound identification.

Support services for parents and their children who are deaf or hard of hearing. A national survey.

In the spring and summer of 1996, 404 parents of children who are deaf or hard of hearing and were born in 1989 or 1990 completed questionnaires about early services received and the current status of their children's development. The children were enrolled in 137 different programs in 39 states; about one quarter of the programs participating in Gallaudet's Annual Survey of Deaf and Hard-of-Hearing Children and Youth. Children who are deaf comprised 46% of the group for whom responses were provided; those who are hard of hearing comprised 54%. Hearing loss was confirmed at the mean age of 14.5 months for the deaf group, and at the mean age of 28.6 months for the hard of hearing group. Additional conditions place 32% at risk for educational or developmental difficulties. One or both parents are deaf in 13% of responding families. Almost 40% of mothers have some training beyond high school; one third of the children came from non-White or mixed-race backgrounds. (These characteristics of children and families are used in analyzing other data collected from responding parents). Communication approaches used in children's initial programs included: speech alone (24%), sign + speech (66%), sign alone (5%), cues (3%), and sign + cues (3%). Parents gave highly favorable evaluations to intervention programs, and placed teachers at the top of a "sources of help" list. Parents from minority groups and those with no college training reported that their children showed more behavior problems and less language progress, and gave more negative responses to questions regarding the impact of deafness on their families. This suggests that program personnel may need to increase their intervention efforts for these subgroups of special education consumers.