Yiannias, James A.

Abstract Coccidioides fungi are found primarily in the southwestern United States and are the cause of coccidioidomycosis. Tumor necrosis factor α inhibitors (TNFIs) are therapies for autoimmune and inflammatory conditions; their association with coccidioidomycosis is not well characterized. We aimed to determine the prevalence and characteristics of coccidioidomycosis among TNFI recipients with different inflammatory disorders at a tertiary care center. We retrospectively reviewed the electronic health records of patients at our institution from April 4, 2010 to December 17, 2017, who received TNFIs (infliximab, etanercept, adalimumab, certolizumab pegol, or golimumab) and had positive culture, pathologic, and/or serologic results for coccidioidomycosis. Among 1770 patients identified who received TNFIs, 49 (2.8%) had proven or probable coccidioidomycosis. Of these 49, 28 (57%) were men, 47 (96%) were White, and 42 (86%) had pulmonary coccidioidomycosis. The most common TNFIs used were adalimumab, infliximab, and etanercept. Coccidioidomycosis was identified in 25 of 794 patients with rheumatologic disorders (3.1%), 18 of 783 patients with inflammatory bowel disease (IBD) (2.3%), and six of 193 patients with dermatologic disorders (3.1%) (P = .34). There was no difference in coccidioidal infections among recipients of any particular TNFI agents. A minority of patients (7/49, 14%) had an extrapulmonary infection, and the majority of these (6/7) had IBD. Our study shows a low prevalence of coccidioidomycosis in TNFI recipients, even within the Coccidioides-endemic area. Persons with IBD were disproportionately represented among those with extrapulmonary coccidioidomycosis. Treatment with azoles was effective. Lay Summary Among 1770 patients who received tumor necrosis factor α inhibitors, 49 (2.8%) had newly acquired coccidioidomycosis over a 7-year period. Dissemination occurred in 14.3%, but disproportionately among those with underlying inflammatory bowel disease. All patients recovered with medical management.

AbstractBackgroundGranuloma 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.ObjectivesEvaluate the efficacy of sulphasalazine in treating GA, AEGCG and IGD.MethodsSixteen 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.ResultsSixteen 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.ConclusionsSulphasalazine may be considered as treatment for GA and GA‐related conditions.

Abstract Objective To understand the ways in which providers use a mobile photography application integrated with the electronic health record (EHR) to facilitate clinical care, and the process outcomes that result from the application's use. Methods An e-mail survey was sent on November 13, 2017, to 1,463 health care providers at Mayo Clinic who had used an internally developed, EHR-integrated medical photography application. Results The survey was completed by 712 (49%) providers. Providers reported using the application on approximately 1 in 7 days spent in clinical practice. Median provider satisfaction with the use of the application (0–100 scale; higher numbers indicate favorable response) was 94 (interquartile range [IQR]: 74–100). Although the use for store-and-forward telemedicine was reported (22% often or frequently used the application to send photographs to a specialist for advice), the most common use was for clinical documentation (65% often or frequently used the application to supplement text-based notes with photographs, and 71% often or frequently used the application to take photographs for reference by a colleague who may see the patient in the future). Of the health care providers, 36% indicated that the application's use often or frequently expedited treatment. Discussion Health care providers reported using a mobile point-of-care medical photography application regularly in clinical practice and were generally satisfied with the application. Conclusion Point-of-care medical photography using a secure mobile, EHR-integrated application has potential to become a new standard of care for clinical documentation and may facilitate continuity across the continuum of care with multiple providers who see a patient.

Background A major question in patch testing is when to perform the final reading. Our current standard practice is to place patches on day 1, remove them on day 3, and perform readings on days 3 and 5. For certain allergens, another reading is performed sometime from days 7 to 14≥. Objectives The aim of the study was to identify allergens with positive reactions on day 5 that were negative on day 7 or later and allergens with negative reactions on day 5 that were subsequently positive on day 7 or later. Methods We reviewed records of patients who underwent patch testing from January 2007 to December 2016 at Mayo Clinic with readings on day 5 and day 7 or later. Conclusions In total, 131 allergens had positive reactions on day 5 that were negative on day 7 or later, and 58 allergens had negative reactions on day 5 that were positive on day 7 or later. Twenty-five allergens had significantly higher reaction rates on day 5 than day 7 or later. Our standard practice is to perform readings on days 3 and 5 and on days 3, 5, and 7 or later for series containing metals. Readings on days 3, 5, and 7 or later should also be considered for acrylates.

Background: The standard allergen series used in patch testing contains metals that most commonly cause allergic contact dermatitis, but testing with additional metal allergens is warranted for select patients. Objective: To report our experience with patch testing of metals. Methods: We retrospectively analyzed outcomes of 1,112 patients suspected of having metal allergies. Patients were seen from January 1, 2000, through December 31, 2009. Patch testing was performed with 42 metal preparations (6 in the standard series, 36 in the metal series). Results: Patch testing most commonly was performed for patients with oral disease (almost half the patients), hand dermatitis, generalized dermatitis, and dermatitis affecting the lips, legs, arms, trunk, or face. At least one positive reaction was reported for 633 patients (57%). Metals with the highest allergic patch-test reaction rates were nickel, gold, manganese, palladium, cobalt, Ticonium, mercury, beryllium, chromium, and silver. Metals causing no allergic patch-test reactions were titanium, Vitallium, and aluminum powder. Metals with extremely low rates of allergic patch-test reactions included zinc, ferric chloride, and tin. Reaction rates varied depending on metal salt, concentration, and timing of readings. Conclusion: Many metals not in the standard series were associated with allergic patch-test reactions. The many questions raised by these findings, concerning patch testing with individual metals, will be the subject of future studies.

Parabens now being formally declared as the American Contact Dermatitis Society (non)allergen of the year, the allergologic concerns regarding parabens raised during the past century are no longer a significant issue. The more recent toxicological concerns regarding parabens are more imposing, stemming from the gravity of the noncutaneous adverse health effects for which they have been scrutinized for the past 20 years. These include endocrine activity, carcinogenesis, infertility, spermatogenesis, adipogenesis, perinatal exposure impact, and nonallergologic cutaneous, psychologic, and ecologic effects. To assert that parabens are safe for use as currently used in the cosmetics, food, and pharmaceutical industries, all toxicological end points must be addressed. We seek to achieve perspective through this exercise: perspective for the professional assessing systemic risk of parabens by all routes of exposure. The data reviewed in this article strive to provide a balanced perspective for the consumer hopefully to allay concerns regarding the safety of parabens and facilitate an informed decision-making process. Based on currently available scientific information, claims that parabens are involved in the genesis or propagation of these controversial and important health problems are premature. Haste to remove parabens from consumer products could result in their substitution with alternative, less proven, and potentially unsafe alternatives, especially given the compelling data supporting the lack of significant dermal toxicity of this important group of preservatives.

Background Patch testing to a standard (baseline) series of allergens is the screening tool used to identify culprit allergens in patients with contact dermatitis. The allergens and concentrations used in a standard series are constantly evolving to be most relevant to the patients being patch tested. Objective The aim of this study was to analyze the 2011–2015 patch test results of the Mayo Clinic standard series. Methods We retrospectively reviewed patch test reactions of standard series allergens from 2011 through 2015 and compared these results with the 2011–2012 and 2013–2014 North American Contact Dermatitis Group (NACDG) reports. Conclusions Of 2582 patients included, 1566 (60.7%) had at least 1 positive reaction, and 516 (20.0%) had at least 1 irritant reaction. The 15 allergens with the highest reaction rates (from highest to lowest) were nickel sulfate hexahydrate, methylisothiazolinone, Myroxylon pereirae resin, neomycin sulfate, cobalt (II) chloride hexahydrate, benzalkonium chloride, fragrance mix I, potassium dichromate, bacitracin, methylchloroisothiazolinone/methylisothiazolinone, carba mix, formaldehyde, p -phenylenediamine, quaternium-15, and methyldibromo glutaronitrile. Twelve (80%) of these allergens were also in the top 15 of the most recent NACDG report; the 3 allergens not in the NACDG top 15 allergens were potassium dichromate, benzalkonium chloride, and methyldibromo glutaronitrile (the latter 2 allergens are not included in their series).