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.

Imbalance between plasma double-stranded DNA and deoxyribonuclease activity predicts mortality after out-of-hospital cardiac arrest.

AIM: Despite an increased rate of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients, almost half of patients do not survive up to hospital discharge. Understanding pathophysiological mechanisms of post-cardiac arrest syndrome is essential for developing novel therapeutic strategies. During systemic inflammatory responses and concomitant cell death, double-stranded (ds) DNA is released into circulation, exerting pro-inflammatory effects. Deoxyribonuclease (DNase) degrades dsDNA. The role of DNase activity in OHCA survivors and impact on clinical outcome has not been analyzed yet. METHODS: In a prospective, single-center study, dsDNA and DNase activity were determined at hospital admission (acute phase) and 24 h (subacute phase) after ROSC. The ratio between dsDNA levels and DNase activity was calculated to determine the extent of dsDNA release in relation to the patients' capacity of degradation. Thirty-day mortality was defined as study end point. RESULTS: We enrolled 64 OHCA survivors, of whom 26.6% (n = 17) died within 30 days. A peak of circulating dsDNA was observed at admission which decreased within 24 h. DNase activity did not differ between acute and subacute phase, while dsDNA load per DNase activity significantly decreased. The ratio between dsDNA levels and DNase activity in the subacute phase was the strongest predictor of 30-day mortality with an adjusted HR per 1 SD of 3.59 (95% CI, 1.80-7.18, p < 0.001). CONCLUSION: Disproportionally increased dsDNA levels uncompensated by DNase activity are a strong predictor of mortality in OHCA survivors. This pilot study points to a potentially protective effect of DNase activity in patients undergoing cardiac arrest.

Management strategies to minimize the use of synthetic chemical acaricides in the control of the cattle tick Rhipicephalus (Boophilus) microplus (Canestrini, 1888) in an area highly favourable for its development in Argentina.

The aim of this work was to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Canestrini, 1888) (Ixodida: Ixodidae) in an area highly favourable for its development in Argentina. Control schemes using three or four annual applications of synthetic acaricides were evaluated. Furthermore, the dynamics of the non-parasitic phases of R. microplus were analysed to provide a framework for the application of pasture spelling as a tool for tick control. The treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in abundance of this tick in autumn. A significant overall effect against R. microplus can be achieved when the control strategies tested in this study are applied within the area most ecologically favourable for this tick in Argentina. Analysis of the dynamics of the non-parasitic phase of R. microplus indicates that the spelling period required to achieve a significant reduction of larvae in pastures fluctuates between 12 and 17 weeks if spelling is initiated in spring or early summer, but between 20 and 28 weeks if spelling is started in late summer, autumn or winter.

[Importance of magnetic resonance imaging/ultrasound-guided fusion biopsy for the detection and monitoring of prostate cancer]. / Stellenwert der MRT/Ultraschall-Fusionsbiopsie für die Detektion und Verlaufskontrolle des Prostatakarzinoms.

The use of multiparametric magnetic resonance imaging (mpMRI) is becoming increasingly more important for the primary diagnostics of prostate cancer (PCa) and for monitoring under active surveillance. Current studies confirmed that the use of mpMRI can increase the detection of clinically significant PCa and reduce the detection rate of insignificant PCa as well as the rate of unnecessary biopsies. The information from mpMRI can be cognitively used for in-bore biopsy and using fusion biopsy systems. There are no clear recommendations on the access approach for fusion biopsy (e. g. transrectal or perineal), whereby higher rates of rectal bleeding and infections have been described for transrectal access compared to perineal access. The increasing rate of antibiotic resistance as well as restricted indications for the use of quinolones are a major challenge for transrectal biopsy.

Efficacy of winter-spring strategic control against Rhipicephalus (Boophilus) microplus infestations on cattle in an area with ecological conditions highly favourable for the tick in northeast Argentina.

This work was performed to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Ixodida: Ixodidae) infestations on cattle in the area ecologically most favourable for the development of this tick in Argentina. Two control schemes using three and four annual applications of acaricides, respectively, were evaluated. Animals in Group 1 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, and fipronil on day 85. Animals in Group 2 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, flumethrin on day 85, and fipronil on day 114. Animals in Group 3 represented the control group. Both treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in the frequency of this tick in autumn. The two treatment schemes were similar in terms of efficacy and thus the addition of a fourth treatment does not seem to confer any further advantage. The results of this work indicate that these strategic control methods provide appropriate levels of control against R. microplus.

Educational and practice gaps in the management of volar melanocytic lesions.

BACKGROUND: The benign and malignant patterns of acral melanocytic naevi (AMN) and acral melanomas (AM) have been defined in a series of retrospective studies. A three-step algorithm was developed to determine when to biopsy acral melanocytic lesions. This algorithm has only been applied to a Japanese population. OBJECTIVES: Our study aimed to review the current management strategy of acral melanocytic lesions and to investigate the utility of the three-step algorithm in a predominately Caucasian cohort. METHODS: A retrospective search of the pathology and image databases at Mayo Clinic was performed between the years 2006 and 2016. Only cases located on a volar surface with dermoscopic images were included. Two dermatologists reviewed all dermoscopic images and assigned a global dermoscopic pattern. Clinical and follow-up data were gathered by chart review. All lesions with known diameter and pathological diagnosis were used for the three-step algorithm. RESULTS: Regular fibrillar and ridge patterns were more likely to be biopsied (P = 0.01). The majority of AMN (58.1%) and AM (60%) biopsied were due to physician-deemed concerning dermoscopic patterns. 39.2% of these cases were parallel furrow, lattice-like or regular fibrillar. When patients were asked to follow-up within a 3- to 6-month period, only 16.7% of the patients returned within that interval. The three-step algorithm would have correctly identified four of five AM for biopsy, missing a 6 mm, multicomponent, invasive melanoma. CONCLUSION: We found one major educational gap in the recognition of low-risk lesions with high rates of biopsy of the fibrillary pattern. Recognizing low-risk dermoscopic patterns could reduce the rate of biopsy of AMN by 23.3%. We identified two major practice gaps, poor patient compliance with follow-up and the potential insensitivity of the three-step algorithm to small multicomponent acral melanocytic lesions.

The quantity and quality of α-gal-specific antibodies differ in individuals with and without delayed red meat allergy.

BACKGROUND: IgG to galactose-α-1,3-galactose (α-gal) are highly abundant natural antibodies (Ab) in humans. α-Gal-specific IgE Ab cause a special form of meat allergy characterized by severe systemic reactions 3-7 h after consumption of red meat. We investigated 20 patients who experienced such reactions and characterized their α-gal-specific IgE and IgG responses in more detail. METHODS: α-Gal-specific IgE was determined by ImmunoCAP. IgE reactivity to meat extract and bovine gamma globulin (BGG) was assessed by immunoblotting and ELISA, respectively. In some experiments, sera were pre-incubated with α-gal or protein G to deplete IgG Ab. α-Gal-specific IgG1-4 Ab in individuals with and without meat allergy were assessed by ELISA. RESULTS: In immunoblots, BGG was the most frequently recognized meat protein. Binding of IgE and IgG to BGG was confirmed by ELISA and completely abolished after pre-incubation with α-gal. Neither the depletion of autologous α-gal-specific IgG Ab nor the addition of α-gal-specific IgG Ab from nonallergic individuals changed the IgE recognition of BGG of meat-allergic patients. Meat-allergic patients showed significantly higher α-gal-specific IgG1 and IgG3 Ab than nonallergic individuals, whereas the latter showed significantly higher levels of α-gal-specific IgG4 Ab. CONCLUSION: Patients with delayed meat allergy display IgE and IgG Ab that selectively recognize the α-gal epitope on BGG. Their enhanced α-gal-specific IgE levels are accompanied by high levels of α-gal-specific IgG1 devoid of IgE-blocking activity. This subclass distribution is atypical for food allergies and distinct from natural α-gal IgG responses in nonallergic individuals.

Population dynamics of the cattle tick Rhipicephalus (Boophilus) microplus in a subtropical subhumid region of Argentina for use in the design of control strategies.

The population dynamics of Rhipicephalus microplus (Ixodida: Ixodidae) in northwest Argentina was analysed to support the design of strategic methods for its control. Both parasitic and non-parasitic phases were studied. The seasonal activity of R. microplus in its parasitic phase was characterized by three peaks in abundance: the first in mid-late spring; the second in summer, and the third in autumn. The non-parasitic phase of R. microplus was characterized by a long total non-parasitic period observed after exposures of females from mid-summer to early autumn, a short total non-parasitic period observed after exposures of females from late winter to late spring, a short period of larval longevity in early and mid-summer, and no hatch of the eggs produced by females exposed in mid- and late autumn and winter. Treatments of cattle administered during the period from late winter to late spring will act on small cohorts of R. microplus, preventing the emergence of larger generations in summer and autumn. A 17-week spelling period starting in late spring and early summer will be necessary to achieve optimal control of R. microplus free-living larvae. If spelling begins in mid- or late summer or in autumn, the required period will be 26-27 weeks.

First molecular characterization of Galba neotropica in Uruguay

Until recently, it was believed that only two lymnaeid species (i.e. Galba viatrix and Pseudosuccinea columella) occurred in Uruguay. However, based on a molecular approach, an additional species Galba cubensis, was recently discovered. The aim of this study was to molecularly characterize different lymnaeid populations from the northern region of Uruguay. The lymnaeids collections were carried out in two farms of the departments of Paysandú and Tacuarembó. The collected lymnaeids were divided in two fractions, one fraction was used for conchological analyses and detection of trematode larval stages, while the other fraction was used for molecular studies. Three PCRs targeting the 16S, ITS-2 and COI DNA regions were performed and the amplicons obtained were direct sequenced. The sequences were used for homology search and construction of phylogenetic trees by the maximum-likelihood method. The sequencing results revealed that both isolates corresponded to Galba neotropica. The phylogenetic analyses placed our isolates among the G. neotropica monophyletic group, closely related to other isolates of this species found in several South American countries. To our knowledge, this is the first record of G. neotropica in Uruguay and the confirmation as competent intermediate host of Fasciola hepatica. Further studies are needed to define the distribution and the role of each lymnaeid species in the transmission of F. hepatica in Uruguay.

Tradicionalmente se indicaba que existían dos especies de limneidos en Uruguay: Galba viatrix y Pseudosuccinea columella. Sin embargo, en los últimos años se identificó por medio de técnicas moleculares una tercera especie, Galba cubensis. El objetivo de los autores fue muestrear e identificar por medios moleculares poblaciones de limneidos del norte del país. Las colectas fueron realizadas en establecimientos rurales de los departamentos de Tacuarembó y Paysandú. Los caracoles colectados fueron divididos en dos fracciones, una de ellas fue destinada para el estudio morfológico de las conchillas y búsqueda de larvas de trematodos. La otra fracción se usó para la caracterización molecular. Tres genes fueron amplificados (ITS2, COI y 16S) utilizando protocolos de PCRs previamente descriptos. Las secuencias obtenidas se utilizaron para estudios de homología y construcción de árboles filogenéticos por medio del método de máxima verosimilitud. Por medio de la secuenciación se pudo confirmar que los dos aislamientos corresponden a Galba neotropica. Los estudios filogenéticos colocan ambos aislamientos dentro del grupo monofilético de G. neotropica junto a otros encontrados en distintas regiones de Sudamérica. Hasta lo que sabemos, el presente, es el primer registro de G. neotropica en Uruguay, además de comprobarse su capacidad para actuar como hospedero intermediario de Fasciola hepatica en condiciones de campo. Se sugieren futuros estudios para determinar la distribución y el rol de cada especie de limneido en la transmisión de F. hepatica.

Eprinomectin accumulation in Rhipicephalus (Boophilus) microplus: Pharmacokinetic and efficacy assessment.

Eprinomectin (EPM) is a macrocyclic lactone used against endo-ectoparasites without withdrawal time in milk and meat after its pour-on administration at 0.5mg/kg. Previous experiments evaluated the efficacy of EPM against Rhipicephalus (Boophilus) microplus in cattle. This study assessed EPM efficacy against R. (B.) microplus after topical administration at two dose rates and investigated the relationship between EPM systemic exposure in the host and drug concentrations accumulated in ticks recovered from treated animals. A standardized pharmaco-parasitological study was performed in two phases. In phase 1 eighteen Braford cattle naturally infected with R. (B.) microplus were divided into three experimental groups with a similar level of infestation (Kruskal-Wallis test, P>0.05): control group and treated groups with EPM pour-on (1 and 1.5mg/kg). Samples of heparinized blood and ticks at different life stages were taken between 0 and 21 days (d) post-administration to measure EPM concentrations by HPLC. The efficacy trial (phase 2) included eighteen Braford calves naturally infected with R. (B.) microplus divided into control group and 1mg/kg and 1.5mg/kg EPM treated groups. Female ticks (4.5-8mm) on cattle were counted between 1 and 23 days post-treatment to evaluate the efficacy of EPM. The reproductive efficiency index (REI) and the fertility efficiency index (FEI) were evaluated. Plasma concentrations of EPM showed a linear relationship with the level of dose rate administered. Peak plasma concentrations were within a range between 13.8 and 90ng/ml, which guarantee milk drug concentrations below the maximum residues level. High EPM concentrations were detected in ticks. EPM concentrations in R. (B.) microplus were correlated to plasma concentrations between 1.25 days and 21 days post-administration (r 0.84; P<0.05). EPM efficacy calculated using the Henderson-Tilton formula was 98.9% and 99.1% (7 days post-administration) and 100% (23 days post-administration) after EPM treatment at 1 and 1.5mg/kg, respectively. EPM administered at 1.5mg/kg also showed a significantly higher deleterious effect on tick fertility as measured by FEI (P<0.01). Therefore, treatment with EPM may be useful for controlling ticks in cattle, particularly in dairy production systems.

Chronic interstitial granulomatous dermatitis in coccidioidomycosis.

Coccidioides species are soil-dwelling fungi endemic to the Southwest U.S.A., especially Arizona and California and Northern Mexico. The cutaneous findings of coccidioidomycosis have a wide range of pathology, which includes organism-specific and reactive processes. Interstitial granulomatous dermatitis (IGD), a granuloma annulare-like reaction, has been described, in a limited form, in association with acute pulmonary coccidioidomycosis. We present a case of chronic, widespread IGD spanning over 9 years in association with an active coccidioidomycosis infection. Similar clinical and histopathological features have been described in association with drug reactions, connective tissue diseases, systemic vasculitis, lymphomas, other infectious diseases and inflammatory bowel disease. Our patient's dramatic presentation and chronic course expands upon the clinical spectrum of IGD occurring in association with pulmonary coccidioidomycosis. While IGD in association with coccidioidomycosis is rare, both dermatologists and general practitioners see IGD reactions, and our case highlights the importance of identifying the underlying driver.

Ecology and genetic variation of Amblyomma tonelliae in Argentina.

The ecology of Amblyomma tonelliae (Ixodida: Ixodidae), including its seasonal distribution and the development periods of each stage, was investigated during a study carried out over two consecutive years in northwestern Argentina. In addition, the genetic variation of this tick was studied through analyses of 16S rDNA sequences. Amblyomma tonelliae has a 1-year lifecycle characterized by a long pre-moult period in larvae with no development of morphogenetic diapause. Larvae peak in abundance during late autumn and early winter; nymphs peak in abundance in spring, and adults do so from late spring to early summer. Amblyomma tonelliae shows a marked ecological preference for the driest areas of the Chaco ecoregion. In analyses of 16S rDNA sequences in genes from different populations of A. tonelliae, values for nucleotide diversity and the average number of nucleotide differences showed genetic diversity within this species to be low. No significant differences were found in comparisons among populations.

[Interim results for the Patients' Rights Act and Infection Protection Act]. / Zwischenbilanz Patientenrechtegesetz und Infektionsschutzgesetz.

BACKGROUND: The Patient Rights Act has converted court rulings into legal paragraphs. Two new aspects have been introduced: the duty to hand over a copy of the signed written consent form to the patient (in which detailed recommendations are offered) and the obligation of a thorough documentation of findings and treatments within patient files. In addition the legislators, through the Joint Federal Committee (Gemeinsamer Bundesausschuss, GBA) have made the introduction of clinical risk management mandatory. The Infection Protection Act and its regulations have elevated the prerequisites of hygiene within hospitals and private practices with a parallel increase in liability. RESULTS AND DISCUSSION: Both laws and regulations offer no reference as to who (and to what extent) is financially responsible for the excessive increase in personnel costs, which are as yet not included in the German diagnosis-related groups (G-DRG) system. Despite all additional measures within the area of risk management, mistakes (avoidable or unavoidable) will nevertheless occur. In order to avoid longstanding legal battles the authors recommend an open and rapid communication with the patient and family. The wall of silence should be a thing of the past.

Typification of virulent and low virulence Babesia bigemina clones by 18S rRNA and rap-1c.

The population structure of original Babesia bigemina isolates and reference strains with a defined phenotypic profile was assessed using 18S rRNA and rap-1c genes. Two reference strains, BbiS2P-c (virulent) and BbiS1A-c (low virulence), were biologically cloned in vitro. The virulence profile of the strains and clones was assessed in vivo. One fully virulent and one low-virulence clone were mixed in identical proportions to evaluate their growth efficiency in vitro. Each clone was differentiated by two microsatellites and the gene gp45. The 18S rRNA and rap-1c genes sequences from B. bigemina biological clones and their parental strains, multiplied exclusively in vivo or in vitro, were compared with strain JG-29. The virulence of clones derived from the BbiS2P-c strain was variable. Virulent clone Bbi9P1 grew more efficiently in vitro than did the low-virulence clone Bbi2A1. The haplotypes generated by the nucleotide polymorphism, localized in the V4 region of the 18S rRNA, allowed the identification of three genotypes. The rap-1c haplotypes allowed defining four genotypes. Parental and original strains were defined by multiple haplotypes identified in both genes. The rap-1c gene, analyzed by high-resolution melting (HRM), allowed discrimination between two genotypes according to their phenotype, and both were different from JG-29. B. bigemina biological clones made it possible to define the population structure of isolates and strains. The polymorphic regions of the 18S rRNA and rap-1c genes allowed the identification of different subpopulations within original B. bigemina isolates by the definition of several haplotypes and the differentiation of fully virulent from low virulence clones.

Origin and course of the extracranial vertebral artery: CTA findings and embryologic considerations.

PURPOSE: The aim of this study was to show the different origins and courses of the extracranial VA on CTA with special emphasis on embryological considerations. The duplicated VA is an anomaly that has been assumed to predispose for dissection and to be associated with aneurysms. We report its frequency and clinical significance. METHODS: We retrospectively reviewed CTA of 539 patients by using a contrast-enhanced CTA protocol of the VA on CT. RESULTS: Ninety-four-point-two percent of left VA originated from left subclavian artery and entered the transverse foramen at C6 in nearly all cases. Six-point-three-percent of left VA (m = 4 %, f = 10 %) originated from the aortic arch and entered the transverse foramen either at C4, C5 or C7 but never at C6. One case of an aberrant retroesophageal right VA originated from the aortic arch distal to the left subclavian artery and entered at C7 (0.19 %). All other right VA originated from the right subclavian artery (99.8 %) and entered between C4 and C6. We diagnosed four cases of duplicated VA (0.74 %) with a female predominance (1.9 %) without any signs of dissection on CTA. Two cases with VA duplication had intracranial arterial aneurysms. CONCLUSIONS: The VA is a longitudinal anastomosis of segmental metameric arteries. The level of entrance into the transverse foramen indicates which metameric artery or arteries persist. Duplication corresponds to persistence of two segmental arteries and is a rare phenomenon. VA duplication might be associated with vascular lesions.

Fatal bovine anaplasmosis in a herd with new genotypes of Anaplasma marginale, Anaplasma ovis and concurrent haemoplasmosis.

Haematological and molecular analysis of blood samples was carried out during an outbreak of bovine anaplasmosis in Hungary. Acute disease was observed in five animals, two of which died. Anaplasma-carrier state was diagnosed in 69 (92%) of cattle. Further evaluation of 24 blood samples revealed concurrent infections with Mycoplasma wenyonii and 'CandidatusM. haemobos' in 22 and 21 animals, respectively. In addition, two cows were identified with rickettsaemia. Regarding molecular investigation of potential hard tick vectors, Haemaphysalis inermis and Dermacentor marginatus males collected from the animals were PCR-negative. However, in one pool (out of 18) of Ixodesricinus males, and in six pools (out of 18) of D. reticulatus males the msp4 gene of Anaplasma marginale was detected. In the same I. ricinus pool Anaplasma ovis was also identified. All ticks were negative for haemoplasmas. Anaplasma sequences yielded 97-99% homology to sequences deposited in the Genbank. This is the first report of fatal bovine anaplasmosis associated with divergent A. marginale genotypes and concurrent 'CandidatusM. haemobos' infection, as well as of an A. ovis strain in ticks collected from cattle.