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Topic:Parasites

Parasites are organisms that live on or within a host, deriving nutrients at the host's expense. In horses, parasitic infections can affect various systems, including the gastrointestinal tract, skin, and respiratory system. Common equine parasites include strongyles, ascarids, tapeworms, and bots. These parasites can lead to a range of health issues, from mild discomfort to severe disease, depending on the type and burden of the infestation. This page compiles peer-reviewed research studies and scholarly articles that explore the biology, life cycle, and impact of parasites on equine health, as well as strategies for diagnosis, treatment, and prevention of parasitic infections in horses.
Parascaris and cyathostome nematodes in foals: parasite in transit or real infection?
Polish journal of veterinary sciences    January 1, 2010   Volume 13, Issue 4 713-717 doi: 10.2478/v10181-010-0010-7
Kornaś S, Cabaret J, Nowosad B.Faecal egg counts were performed in 187 foals of a large Polish stud farm between February and September 2007. Eggs of Parascaris equorum were present in faeces of 7% and those of cyathostomins in 13% of the foals aged less than 194 days. Information dealing with age of foals and/or efficiency of ivermectin treatment as well as the nematode parasite prepatent periods, it can be conducted that most of the infections recorded on the basis of faecal egg counts were false-infections in animals up to the age of six months, probably due to the ingestion of infected faeces of their dam or some other ...
Prevalence of equine Piroplasmosis and its association with tick infestation in the State of São Paulo, Brazil. Kerber CE, Labruna MB, Ferreira F, De Waal DT, Knowles DP, Gennari SM.Serum samples were collected from 582 horses from 40 stud farms in the State of São Paulo and tick (Acari: Ixodidae) infestations were evaluated on them. Serum samples were subjected to the complement fixation test (CFT) and a competitive inhibition ELISA (cELISA) for Babesia caballi and Theileria equi. Logistic regression analyses were performed to construct multivariate models that could explain the dependent variable (horses positive for B. caballi or T. equi) as a function of the independent variables (presence or abundance of each one of the tick species found on the farms). A higher ove...
Echinococcus granulosus infection in humans and livestock in the Coquimbo region, north-central Chile.
Veterinary parasitology    December 21, 2009   Volume 169, Issue 1-2 102-110 doi: 10.1016/j.vetpar.2009.12.009
Acosta-Jamett G, Cleaveland S, Cunningham AA, Bronsvoort BM, Craig PS.Cyst echinococcosis (CE) is one of the most important zoonosis in Chile, where studies have focussed mainly in moist southern regions. The present study was conducted to determine the prevalence of cystic echinococcosis (CE) in livestock and humans in the semiarid Coquimbo region in north-central Chile. A review of all surgical cases of CE in humans reported in the Elqui, Limarí and Choapa provinces in Coquimbo region for the period comprising 1995-2006 was obtained. In addition, a retrospective study of CE covering condemnation records from slaughterhouses of these provinces from the same pe...
Comparison of three alternative methods for analysis of equine Faecal Egg Count Reduction Test data.
Preventive veterinary medicine    December 3, 2009   Volume 93, Issue 4 316-323 doi: 10.1016/j.prevetmed.2009.11.009
Denwood MJ, Reid SW, Love S, Nielsen MK, Matthews L, McKendrick IJ, Innocent GT.The Faecal Egg Count Reduction Test (FECRT) is the most widely used method of assessing the efficacy of anthelmintics, and is the only in vivo technique currently approved for use with horses. Equine Faecal Egg Count (FEC) data are frequently characterised by a low mean, high variability, small sample size and frequent zero count observations. Accurate analysis of the data therefore depends on the use of an appropriate statistical technique. Analyses of simulated FECRT data by methods based on calculation of the empirical mean and variance, non-parametric bootstrapping, and Markov chain Monte ...
Analysis of somatic and salivary gland antigens of third stage larvae of Rhinoestrus spp. (Diptera, Oestridae).
Experimental parasitology    December 3, 2009   Volume 124, Issue 4 361-364 doi: 10.1016/j.exppara.2009.11.014
Milillo P, Traversa D, Elia G, Otranto D.Larvae of Rhinoestrus spp. (Diptera, Oestridae) infect nasal and sinus cavities of horses, causing a nasal myiasis characterized by severe respiratory distress. Presently, the diagnosis of horse nasal botfly relies on the observation of clinical signs, on the post mortem retrieval of larvae or on molecular assays performed using pharyngeal swabs. The present study was carried out to characterize larval somatic proteins and salivary glands of Rhinoestrus spp. in a preliminary assessment towards the immunodiagnosis of equine rhinoestrosis. Out of the 212 necropsied horses 13 were positive for th...
Viability of the nematophagous fungus Pochonia chlamydosporia after passage through the gastrointestinal tract of horses.
Veterinary parasitology    December 2, 2009   Volume 168, Issue 3-4 264-268 doi: 10.1016/j.vetpar.2009.11.020
Braga FR, Araújo JV, Silva AR, Carvalho RO, Araujo JM, Ferreira SR, Carvalho GR.The predatory capacity of the nematophagous fungus Pochonia chlamydosporia (isolate VC4) embedded in sodium alginate pellets after passage through the gastrointestinal tract of horses was assessed in vitro against Oxyuris equi eggs. Twelve previously dewormed crossbred mares, average weight of 362.5kg (+/-21) were used in the experiment. Each animal of the treated group received an oral dose (100g) of sodium alginate pellets containing P. chlamydosporia mycelial mass. The control group received pellets without fungus. Faecal samples from fungus-treated and control groups were collected at inte...
Use of a reverse line blot assay to survey small strongyle (Strongylida: Cyathostominae) populations in horses before and after treatment with ivermectin.
Veterinary parasitology    December 1, 2009   Volume 168, Issue 3-4 332-337 doi: 10.1016/j.vetpar.2009.11.021
Ionita M, Howe DK, Lyons ET, Tolliver SC, Kaplan RM, Mitrea IL, Yeargan M.A sensitive and specific PCR hybridization assay was applied for species-specific monitoring of the small strongyle (Strongylida: Cyathostominae) populations in horses in a herd before and after treatment with the anthelmintic drug ivermectin. Fecal samples were collected pre- and post-treatment weekly from eight individual horses (four foals and four yearlings) for 6 weeks to determine counts of strongyle eggs per gram of feces (EPGs). Additionally, one foal and one yearling were nontreated controls. Also, one horse, from another herd known to be infected with Strongylus spp., was a positive ...
Clinical trial of efficacy of ivermectin pour-on against gastrointestinal parasitic nematodes in silvopasturing horses.
Equine veterinary journal    November 26, 2009   Volume 41, Issue 7 713-715 doi: 10.2746/042516409x447275
Francisco I, Sánchez JA, Cortiñas FJ, Francisco R, Mochales E, Arias M, Mula P, Suárez JL, Morrondo P, Díez-Baños P, Sánchez-Andrade R....The aim of this study was to assess, by a clinical trial, the efficacy of an ivermectin-based pour-on treatment against gastrointestinal parasitic nematodes in naturally infected horses using 2 groups of mature indigenous Pura Raza Galega grazing mares. Faecal and blood samples were collected individually over a 21 week period. Faeces were analysed by the coprological flotation, sedimentation and migration techniques. Changes in circulating blood cells were monitored over the study period. The administration of the ivermectin suppressed the egg-elimination of ascarids and pinworms throughout t...
Anthelmintic efficacy on Parascaris equorum in foals on Swedish studs.
Acta veterinaria Scandinavica    November 22, 2009   Volume 51, Issue 1 45 doi: 10.1186/1751-0147-51-45
Lind EO, Christensson D.In the last few years stud farms have experienced increasing problems with Parascaris equorum infections in foals despite intensive deworming programs. This has led to the question as to whether the anthelmintic drugs used against this parasite are failing. This study aimed to investigate the efficacy of ivermectin, fenbendazole and pyrantel on the faecal output of ascarid eggs of foals. Methods: A Faecal Egg Count Reduction Test (FECRT) was performed on nine large studs in Sweden. Anthelmintic drugs were given orally and faecal samples were examined for ascarid eggs on the day of deworming an...
Development and evaluation of real-time PCR assays for the quantitative detection of Babesia caballi and Theileria equi infections in horses from South Africa.
Veterinary parasitology    November 20, 2009   Volume 168, Issue 3-4 201-211 doi: 10.1016/j.vetpar.2009.11.011
Bhoora R, Quan M, Franssen L, Butler CM, van der Kolk JH, Guthrie AJ, Zweygarth E, Jongejan F, Collins NE.A quantitative real-time polymerase chain reaction (qPCR) assay using a TaqMan minor groove binder (MGB) probe was developed for the detection of Babesia caballi infection in equids from South Africa. Nine previously published sequences of the V4 hypervariable region of the B. caballi 18S rRNA gene were used to design primers and probes to target unique, conserved regions. The B. caballi TaqMan MGB qPCR assay was shown to be efficient and specific. The detection limit, defined as the concentration at which 95% of positive samples can be detected, was determined to be 0.000114% parasitized eryt...
Serological and parasitological survey of dourine in the Arsi-Bale highlands of Ethiopia.
Tropical animal health and production    November 20, 2009   Volume 42, Issue 4 769-776 doi: 10.1007/s11250-009-9485-6
Hagos A, Abebe G, Büscher P, Goddeeris BM, Claes F.This study was conducted from August 2005 to January 2007 to determine prevalence and distribution of dourine in horses and to investigate the occurrence of clinical and carrier cases in donkeys and mules in the Arsi-Bale highlands. Study methodology was based on questionnaire, serological, clinical and parasitological survey. The questionnaire indicated that dourine is a major health problem of equines in the Arsi-Bale highlands. Though dourine is commonly observed throughout the year, it has a seasonal character and occurs mostly during the breeding season from June to late September. Serolo...
Distribution and species-specific occurrence of cyathostomins (Nematoda, Strongylida) in naturally infected horses from Italy, United Kingdom and Germany.
Veterinary parasitology    November 10, 2009   Volume 168, Issue 1-2 84-92 doi: 10.1016/j.vetpar.2009.10.006
Traversa D, Milillo P, Barnes H, von Samson-Himmelstjerna G, Schurmann S, Demeler J, Otranto D, Lia RP, Perrucci S, Frangipane di Regalbono A....A broad scale study was carried out in 2008 to evaluate the distribution and species-specific occurrence of cyathostomin populations in horse yards from Europe. In total 102 properties and 3123 horses were included in Italy (60 yards and 1646 animals), United Kingdom (22 yards and 737 animals) and Germany (20 yards and 740 animals). Individual faecal samples were examined with a McMaster technique while pooled samples were subjected to the microscopic examination of in vitro cultured larvae and to a Reverse Line Blot (RLB) assay able to molecularly identify the most diffused 13 species of cyat...
Equine protozoal myeloencephalitis caused by Neospora hughesi in an adult horse in Saskatchewan.
The Canadian veterinary journal = La revue veterinaire canadienne    November 3, 2009   Volume 50, Issue 8 851-853 
Wobeser BK, Godson DL, Rejmanek D, Dowling P.A protozoal parasite identified as Neospora hughesi was found in inflammatory lesions in the central nervous system of a Canadian-born adult horse presented with neurological signs. This is believed to be the first case of equine protozoal myeloencephalitis (EPM) caused by Neospora hughesi in a horse outside of the United States. Un parasite protozoaire identifié comme a été trouvé dans les lésions inflammatoires du système nerveux central d’un cheval adulte né au Canada présentant des signes neurologiques. On croit qu’il s’agit du premier cas d’encéphalomyélite protozoai...
Trypanosoma evansi infection in mainland Spain.
Veterinary parasitology    October 7, 2009   Volume 167, Issue 1 74-76 doi: 10.1016/j.vetpar.2009.09.050
Tamarit A, Gutierrez C, Arroyo R, Jimenez V, Zagalá G, Bosch I, Sirvent J, Alberola J, Alonso I, Caballero C.An outbreak of Trypanosoma evansi infection that occurred in mainland Spain is described. The outbreak occurred on an equine and camel farm to which dromedary camels from an infected area of the Canary Islands had recently been introduced. One of these camels developed clinical signs and T. evansi was discovered in a blood smear examination. The herd was evaluated in order to determine the extent of the disease. The results showed that 76% of the camels, 35% of the donkeys and 2% of the horses were affected. The animals were isolated and treated using Cymelarsan((R)) (0.5mg/kg). After treatmen...
A study of neonatal cryptosporidiosis of foals in New Zealand.
New Zealand veterinary journal    October 6, 2009   Volume 57, Issue 5 284-289 doi: 10.1080/00480169.2009.58622
Grinberg A, Pomroy WE, Carslake HB, Shi Y, Gibson IR, Drayton BM.To assess the occurrence of Cryptosporidium oocysts in faecal specimens from foals, and investigate an outbreak of neonatal cryptosporidiosis in foals revealed in the course of the study. Methods: Faecal specimens from foals received by a diagnostic veterinary laboratory in New Zealand between 2006 and 2007 were submitted to Massey University and tested microscopically for the presence of Cryptosporidium oocysts. The Cryptosporidium isolates in the oocyst-positive specimens were genetically identified to species level. In addition, specimen submission data from the participating laboratory for...
A zoonotic genotype of Enterocytozoon bieneusi in horses.
The Journal of parasitology    October 6, 2009   Volume 96, Issue 1 157-161 doi: 10.1645/GE-2184.1
Santín M, Vecino JA, Fayer R.This is the first report of Enterocytozoon bieneusi in an equid species. Feces from 195 horses from 4 locations in Colombia were examined for E. bieneusi by polymerase chain reaction. Of these, 21 horses (10.8%) were found positive for E. bieneusi . The prevalence of E. bieneusi in horses 1 yr of age (2.5%). No significant differences in prevalence were observed between male (13.7%) and female horses (9%). Sequencing of the internal transcribed spacer region of the SSUrRNA locus identified 3 genotypes. Two genotypes appear to be unique to horses and were named Horse 1 and Horse 2. A third geno...
Effects of fecal collection and storage factors on strongylid egg counts in horses.
Veterinary parasitology    September 30, 2009   Volume 167, Issue 1 55-61 doi: 10.1016/j.vetpar.2009.09.043
Nielsen MK, Vidyashankar AN, Andersen UV, Delisi K, Pilegaard K, Kaplan RM.Fecal analyses are becoming increasingly important for equine establishments as a means of parasite surveillance and detection of anthelmintic resistance. Although several studies have evaluated various egg counting techniques, little is known about the quantitative effects of pre-analytic factors such as collection and storage of fecal samples. This study evaluated the effects of storage temperature, storage time and airtight versus open-air storage on fecal egg counts. The experimental protocols were replicated in two study locations: Copenhagen, Denmark and Athens, Georgia, USA. In both loc...
Equine parasites: diagnosis and control – a current perspective.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 I1 doi: 10.1186/1756-3305-2-S2-I1
Traversa D.No abstract available
Faecal Cyathostomin Egg Count distribution and efficacy of anthelmintics against cyathostomins in Italy: a matter of geography?
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S4 doi: 10.1186/1756-3305-2-S2-S4
Milillo P, Boeckh A, Cobb R, Otranto D, Lia RP, Perrucci S, di Regalbono AF, Beraldo P, von Samson-Himmelstjerna G, Demeler J, Bartolini R, Traversa D.In the framework of a trial carried out in 2008 in Europe to evaluate the efficacy of major parasiticides against horse cyathostomins, pre- and/or post-treatment Faecal Egg Counts (FEC) were evaluated in a total of 84 yards and 2105 horses from nine different regions from the South, the Center, the North-Center and North-East of Italy. Specifically, on the basis of FECs of the horses present in each property, 60 out of the 84 yards were enrolled for a Faecal Egg Count Reduction Test (FECRT) using fenbendazole, pyrantel, ivermectin and moxidectin. Results: Of the 1646 horses bred in the 60 recr...
Equine cyathostomins: a review of biology, clinical significance and therapy.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S1 doi: 10.1186/1756-3305-2-S2-S1
Corning S.The small strongyles of horses, also known as cyathostomins, are considered the most prevalent and pathogenic parasites of horses today. The clinical syndrome of larval cyathostominosis which occurs as a result of mass emergence of inhibited stages has a high fatality rate despite the best standard of care given to affected horses. Management of the challenge level of cyathostomins to prevent the syndrome is preferable. Many different management programmes have been tried over the past two decades, with mixed success. Programmes have relied heavily on repeated use of anthelmintic treatments th...
Effects of worm control practices examined by a combined faecal egg count and questionnaire survey on horse farms in Germany, Italy and the UK.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S3 doi: 10.1186/1756-3305-2-S2-S3
von Samson-Himmelstjerna G, Traversa D, Demeler J, Rohn K, Milillo P, Schurmann S, Lia R, Perrucci S, di Regalbono AF, Beraldo P, Barnes H, Cobb R....For the control of worm infections, the strategic use of anthelmintics, often accompanied by additional farm and/or pasture management procedures, is currently applied on most horse farms in industrialized countries. However, the particular effects of the specific worm control procedures are often unclear and have only been investigated to a limited extent. We examined faecal egg count (FEC), faecal egg count reduction (FECR) and questionnaire data on farm and pasture management procedures. The aim of this study was to determine whether specific worm control practices reported to be applied in...
Determination of genomic DNA sequences for beta-tubulin isotype 1 from multiple species of cyathostomin and detection of resistance alleles in third-stage larvae from horses with naturally acquired infections.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S6 doi: 10.1186/1756-3305-2-S2-S6
Lake SL, Matthews JB, Kaplan RM, Hodgkinson JE.Genetic resistance against benzimidazole (BZ) anthelmintics is widespread in cyathostomins, the commonest group of intestinal parasitic nematodes of horses. Studies of BZ-resistant nematodes of sheep, particularly Haemonchus contortus, have indicated that an anthelmintic resistance-conferring T/A polymorphism, encoding an F (phenylalanine) to Y (tyrosine) substitution, in beta-tubulin isotype 1 is present at two loci, codons 167 and 200 (F167Y, F200Y). Recent studies using complementary (c) DNA derived from BZ-susceptible and -resistant cyathostomins identified statistical differences in the f...
Restrictions of anthelmintic usage: perspectives and potential consequences.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S7 doi: 10.1186/1756-3305-2-S2-S7
Nielsen MK.Given the increasing levels of anthelmintic resistance in equine parasites, parasitologists now recommend traditional treatment approaches to be abandoned and replaced by more sustainable strategies. It is of crucial importance to facilitate veterinary involvement to ensure that treatment decisions are based on parasitic knowledge. Despite recommendations given for the past two decades, strategies based on the selective therapy principle have not yet been implemented on a larger scale in equine establishments. In contrast, treatment regimens appear to be derived from recommendations originally...
Moxidectin: a review of chemistry, pharmacokinetics and use in horses.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S5 doi: 10.1186/1756-3305-2-S2-S5
Cobb R, Boeckh A.This article reviews the current knowledge of the use of moxidectin (MOX) in horses, including its mode of action, pharmacokinetic and pharmacodynamic properties, efficacy, safety and resistance profile.Moxidectin is a second generation macrocyclic lactone (ML) with potent endectocide activity. It is used for parasite control in horses in an oral gel formulation. The principal mode of action of MOX and of other MLs is binding to gamma-aminobutyric (GABA) and glutamate-gated chloride channels. Moxidectin is different from other MLs in that it is a poor substrate for P-glycoproteins (P-gps) and ...
Anthelmintic resistance in cyathostomin populations from horse yards in Italy, United Kingdom and Germany.
Parasites & vectors    September 25, 2009   Volume 2 Suppl 2, Issue Suppl 2 S2 doi: 10.1186/1756-3305-2-S2-S2
Traversa D, von Samson-Himmelstjerna G, Demeler J, Milillo P, Schürmann S, Barnes H, Otranto D, Perrucci S, di Regalbono AF, Beraldo P, Boeckh A....A large survey was carried out in 2008 in Europe to evaluate the efficacy of fenbendazole (FBZ), pyrantel (PYR), ivermectin (IVM) and moxidectin (MOX), i.e. the major anthelmintic molecules used in current practice against cyathostomins affecting horses. A total of 102 yards and 1704 horses was studied in three countries: 60 yards and 988 horses from Italy, 22 and 396 from the UK, 20 and 320 from Germany. The survey consisted of Faecal Egg Count Reduction Tests (FECRTs) with a faecal egg count reduction (FECR) categorization of (I) resistance present if FECR <90% and the lower 95% confidenc...
Ticks on domestic animals in Pernambuco, Northeastern Brazil. Dantas-Torres F.The objective of this article was to discuss some aspects of ticks associated with domestic animals in the State of Pernambuco, northeastern Brazil, based on a literature review and present new data obtained from recent tick collections carried out in this northeastern Brazilian state. From August 2007 to June 2008, 1,405 ticks were collected and five species were identified: Amblyomma cajennense (Fabricius, 1787), Amblyomma ovale Koch, 1844, Dermacentor nitens Neumann, 1897, Rhipicephalus (Boophilus) microplus (Canestrini, 1887), and Rhipicephalus sanguineus (Latreille, 1806). Dogs from urban...
Occurrence of Leishmania sp. in cutaneous lesions of horses in Central Europe.
Veterinary parasitology    September 15, 2009   Volume 166, Issue 3-4 346-351 doi: 10.1016/j.vetpar.2009.09.001
Müller N, Welle M, Lobsiger L, Stoffel MH, Boghenbor KK, Hilbe M, Gottstein B, Frey CF, Geyer C, von Bomhard W.The present report describes a novel etiological agent of cutaneous leishmaniasis in horses that, at least for some cases, sporadically appeared as autochthonous infections in geographically distant regions of Germany and Switzerland. The infection was initially diagnosed upon clinical and immunohistological findings. Subsequent comparative sequence analysis of diagnostic PCR products from the internal transcribed spacer 1 (ITS1) of ssrRNA classified the respective isolates as neither Old World nor New World Leishmania species. However, four isolates subjected to molecular analyses all exhibit...
Infectious agents detected in the feces of diarrheic foals: a retrospective study of 233 cases (2003-2008).
Journal of veterinary internal medicine    September 11, 2009   Volume 23, Issue 6 1254-1260 doi: 10.1111/j.1939-1676.2009.0383.x
Frederick J, Giguère S, Sanchez LC.Diarrhea is common in foals but there are no studies investigating the relative prevalence of common infectious agents in a population of hospitalized diarrheic foals. Objective: To determine the frequency of detection of infectious agents in a population of hospitalized foals with diarrhea and to determine if detection of specific pathogens is associated with age, outcome, or clinicopathologic data. Methods: Two hundred and thirty-three foals < or = 10 months of age with diarrhea examined at a referral institution. Methods: Retrospective case series. Each foal was examined for Salmonella s...
Viability of Rhodococcus equi and Parascaris equorum eggs exposed to high temperatures.
Current microbiology    September 1, 2009   Volume 60, Issue 1 38-41 doi: 10.1007/s00284-009-9497-5
Hébert L, Cauchard J, Doligez P, Quitard L, Laugier C, Petry S.There is great concern about the potential pathogen contamination of horse manure compost spread in the same fields horses graze in. To ensure that pathogen destruction occurs, temperatures need to be sufficiently high during composting. Here, we investigated the survival rate of two marker organisms, Rhodococcus equi and Parascaris equorum eggs, exposed to temperatures potentially encountered during horse manure composting. Our results show that the time required to achieve a 1 log10 reduction in R. equi population (D-value) are 17.1 h (+/-1.47) at 45 degrees C, 8.6 h (+/-0.28) at 50 degrees ...
Identification and characterisation of an immunodiagnostic marker for cyathostomin developing stage larvae.
International journal for parasitology    August 22, 2009   Volume 40, Issue 3 265-275 doi: 10.1016/j.ijpara.2009.08.004
McWilliam HE, Nisbet AJ, Dowdall SM, Hodgkinson JE, Matthews JB.Parasitic nematodes of the group Cyathostominae are an important cause of disease in horses. This group consists of approximately 50 species, all of which have similar life cycles that involve encystment of larval stages in the large intestinal wall. Encysted larvae can persist for months to years and, occasionally, large numbers can accumulate and emerge synchronously to cause severe pathology, resulting in diarrhoea, weight loss, colic and/or oedema. This syndrome, known as larval cyathostominosis, can be fatal in up to 50% of cases, despite treatment. There is no diagnostic method that enab...
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