What is in? What is out? Updating the British Society for Cutaneous Allergy facial series.

BACKGROUND: Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012. OBJECTIVES: To review and update the BSCA facial series. METHODS: We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified. RESULTS: Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%. CONCLUSIONS: This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

Desmoplastic melanoma: a review of its pathology and clinical behaviour, and of management recommendations in published guidelines.

Desmoplastic melanomas are uncommon. Their behaviour differs from that of other melanoma subtypes; therefore, management guidelines for non-desmoplastic melanomas may not be applicable. This review sought to examine all available evidence relating to the behaviour and management of desmoplastic melanomas, based on review of all relevant English-language publications, and to critically assess the recommendations for their management in current published melanoma management guidelines. Compared with other melanoma subtypes, patients with 'pure' desmoplastic melanomas (where ≥90% of the invasive melanoma is of desmoplastic melanoma subtype) have much lower rates of sentinel node positivity and distant metastasis. Local recurrence rates are higher for desmoplastic melanomas, but resection margins wider than those recommended for non-desmoplastic melanomas have not been shown to be of benefit. Adjuvant radiotherapy reduces the risk of local recurrence when a satisfactory histological clearance (≥8 mm) cannot be achieved. Of 29 published melanoma management guidelines identified, only 11 specified management for desmoplastic melanomas, while seven simply stated that the feature should be reported. Desmoplastic melanoma is a unique melanoma subtype with biology that differs from that of other melanoma subtypes. It requires specific management strategies but few current guidelines address these.

The impact and indications for Oncotype DX on adjuvant treatment recommendations when third-party funding is unavailable.

OBJECTIVES: Industry-supported decision impact studies demonstrate that Oncotype Dx (ODX) changes treatment recommendations (TR) in 24-40% of hormone receptor+/HER2- patients. ODX is not reimbursed by third-party payers in Australia, potentially resulting in more selective use. We sought to evaluate the impact of self-funded ODX on TRs. METHODS: Data collected included demographics, tumor characteristics, indication for ODX and pre- and post-recurrence score (RS) TR. Primary endpoint was frequency of TR change and associations with TR change were sought. RESULTS: Eighteen physicians contributed 382 patients (median age 54). A total of 232 (61%) of tumors were T1 and were grade 1, 2 and 3 in 49 (13%), 252 (66%) and 79 (21%). A total of 257 (67%) were node negative. Assay indications were: confirm need for chemotherapy (CT) (36%), confirm omission of CT (40%) and genuine equipoise (24%). RS was low (≤17) in 55%, intermediate (18-31) in 36% and high (≥32) in 9%. Thirty-eight percent of patients had TR change post-ODX. Sixty-five percent of patients recommended CT pre-ODX changed to hormone therapy alone (HT)-more likely if lower grade and if ER and/or PR > 10%. Fourteen percent of patients with pre-ODX TR for HT added CT-more likely if ER and/or PR ≤10% and if Ki67 > 15% Overall, TR for CT decreased from 47% to 24%. CONCLUSION: Patient-funded ODX changed TRs in 38% of patients, de-escalating 65% from CT to HT and adding CT to 14% of those recommended HT. These changes were greater than an industry-funded study suggesting that physicians can identify situations where the assay may influence decisions.

Long-term impaired neutrophil migration in mice overexpressing human interleukin-8.

The proinflammatory chemokine interleukin-8 (IL-8/NAP-1) has been implicated in recruiting neutrophils to sites of acute and chronic tissue inflammation. In transgenic mice, elevated serum IL-8 levels ranging from 1 to 118 ng/ml were correlated with proportional increases in circulating neutrophils and proportional decreases in L-selectin expression on the surface of blood neutrophils. No change in the expression of the beta 2-integrins Mac-1 and LFA-1 was apparent on peripheral blood neutrophils of the IL-8 transgenic mice. Additionally, L-selectin expression on bone marrow neutrophils and neutrophil precursors was normal in all transgenic lines. IL-8 transgenic mice demonstrated an accumulation of neutrophils in the microcirculation of the lung, liver and spleen. Moreover, there was no evidence of neutrophil extravasation, plasma exudation or tissue damage in any IL-8 transgenic mice. Neutrophil migration into the inflamed peritoneal cavity was severely inhibited in IL-8 transgenic mice, but not in nontransgenic littermates. The IL-8 transgenic mice should serve as useful models for studying the putative role of neutrophils in mediating tissue damage in models of inflammation, such as hepatic ischemia and reperfusion injury, cecal puncture and ligation, and glomerulonephritis.

Transplantation rate of the blood group B waiting list is increased by using A2 and A2B kidneys.

BACKGROUND: We have increased the transplantation rate for blood group B cadaveric waiting list candidates by transplanting them with A2 and A2B kidneys. METHODS: Since 1991, five of the seven renal transplant programs in our organ procurement organization service area have preferentially transplanted blood group A2 and A2B cadaveric kidneys to B blood group waiting list candidates with histories of low anti-A isoagglutinin titers. RESULTS: Between 1991 and 1997, these five centers performed transplantations on 71 patients from the B cadaveric waiting list. Of those 71 patients, 29% (21 of 71) underwent transplantation with either A2 (n=18) or A2B (n=3) cadaveric kidneys. In 1997 alone, 48% (11 of 23) of the B patient transplant recipients received A2 or A2B kidneys. CONCLUSIONS: Transplantation of A2 and A2B kidneys into B waiting list patients has successfully increased access of B patients to kidneys. Such an allocation algorithm implemented nationally may similarly increase the transplantation rate of B waiting list candidates.

Ten-year experience in transplantation of A2 kidneys into B and O recipients.

BACKGROUND: This article summarizes our 10-year multicenter experience with transplantation of 50 blood group A2 and A2B kidneys into B and O patients. METHODS: Since 1986, we have transplanted kidneys from 46 cadaver donors and 4 living donors who were blood group A2 (47 donors) or A2B (3 donors) into 19 B and 31 O patients. In 1991, we began allocating these kidneys preferentially to B and O recipients who were selected based on a history of low (< or =4) anti-A IgG isoagglutinin titers. Immunosuppression was no different from that used in ABO-compatible grafts. RESULTS: The 1-month function rate before thus selecting the patients was 68% (19/28), but is now 94% (17/18). Two-year cadaver-donor graft survival with this selection method is 94%, compared with 88% for 640 concurrent and consecutive ABO-compatible transplants (log-rank, 0.15). All four living-related transplants are still functioning, with a mean follow-up of 71 months. Since we began allocating A2 kidneys preferentially to B and O recipients, the percentage of the B patients who received A2 or A2B kidneys has increased from 29% (8/28) to 55% (10/18). CONCLUSIONS: Transplantation of A2 or A2B kidneys into B and O patients is clinically equivalent to that of ABO-compatible transplantation when recipients are selected by low pretransplant anti-A titer histories. This approach increases access of blood group B recipients to kidneys.

Surgical resection for metastatic melanoma to the liver: the John Wayne Cancer Institute and Sydney Melanoma Unit experience.

HYPOTHESIS: Metastatic melanoma to the liver is not incurable; complete surgical resection can achieve long-term survival in selected patients. BACKGROUND: Metastases to the liver are diagnosed in 10% to 20% of patients with American Joint Committee on Cancer stage IV melanoma. Surgical resection has not been generally accepted as a therapeutic option, as most patients will have other sites of disease that limit their survival to a median of only 4 to 6 months. However, there is little information on outcomes following resection in those patients with disease limited to the liver. PATIENTS AND METHODS: Review of the prospective melanoma databases at the John Wayne Cancer Institute, Santa Monica, Calif, and the Sydney Melanoma Unit, Sydney, Australia, identified 1750 patients with hepatic metastases, of whom 34 (2%) underwent exploration with intent to resect the metastases. Prognostic factors within the group of patients who underwent resection were examined by univariate and multivariate analysis, and median disease-free survival (DFS) and overall survival (OS) were calculated. RESULTS: Of 34 patients undergoing exploratory celiotomy, 24 (71%) underwent hepatic resection and 10 (29%) underwent exploration but not resection. Eighteen patients (75%) underwent complete surgical resection, while the remaining 6 underwent palliative or debulking procedures with incomplete resection. The operative resections included lobectomy (n=14), segmentectomy (4), nonanatomic resection (5), and extended lobectomy (1). The median number of resected lesions was 1, and median lesion size was 5 cm (range, 0.7-22 cm). The median disease-free interval between initial diagnosis of melanoma and development of hepatic metastases was 58 months (range, 0-264 months). Median DFS and OS estimates in the 24 patients who underwent surgical resection were 12 months (range, 0-147 months) and 28 months (range, 2-147 months), respectively. Five-year DFS and OS in this group were 12% and 29%. Macroscopically, complete resection of disease (P =.001) and histologically negative resection margins (P =.03) significantly improved DFS by univariate analysis. Patients rendered surgically free of disease also tended to have improved OS (P =.06). Median OS was 28 months for patients who underwent surgical resection compared with 4 months for patients who underwent exploration only (P<.001). CONCLUSIONS: Resection of metastatic melanoma to the liver may improve DFS and OS in selected patients, similar to resection of other metastatic sites. Therefore, patients with limited metastatic sites, including the liver, who can be rendered free of disease should be considered for complete surgical resection, as their prognosis is otherwise dismal.

Sarcoma metastases due to iatrogenic implantation.

AIM: To demonstrate the ability of extremity soft tissue sarcomas (STSs) to implant into tissues exposed during surgery. METHODS: We use two cases to illustrate that wounds created during surgery for STSs, including donor sites for skin grafts, pedicled and free flaps and blood vessels used in reconstruction, should be regarded as potential sites of quasi-local recurrence. CONCLUSIONS: This report reinforces the need for meticulous surgical technique and planning of procedures to avoid contamination of clean areas that might not be included in adjuvant radiotherapy fields. The cases also highlight the pivotal importance of the correct initial management of these uncommon tumours.

Atypical pattern of (meth)acrylate allergic contact dermatitis in dental professionals.

(Meth)acrylates in dental bonding agents are a common source of allergic contact dermatitis in dental professionals. The distribution of the contact dermatitis is commonly on finger tips, but is determined by individual habits as demonstrated by the two case reports in this article. Despite the site of contact dermatitis, the bonding agents are often not suspected as a source of contact allergy due to misconception regarding the protective effect of natural rubber latex gloves. With these case reports, we endeavour to emphasize the inadequacy of the latex gloves in protecting against the (meth)acrylate induced contact allergy and also list the measures a dental professional needs to incorporate in order to minimise the risks of sensitisation to (meth)acrylates.

Flexural allergic contact dermatitis to benzalkonium chloride in antiseptic bath oil.

Benzalkonium chloride (BAK) is an acknowledged irritant but has also been identified as a cause of allergic contact dermatitis. The antiseptic bath emollient Oilatum Plus (Stiefel, High Wycombe, U.K.) contains a relatively high concentration of 6% BAK. We describe six patients who presented with flexural eczema, particularly involving the anogenital area, who had a history of using Oilatum Plus. Patch testing showed all six to have a type 4 allergy to BAK as well as other allergens. Avoidance of Oilatum Plus led to a resolution of the flexural eczema in each case.

'Black henna' tattoos: an occult source of natural rubber latex allergy?

Temporary 'black henna' tattoos are an increasingly popular body decoration with a growing incidence of associated adverse events. We report the case of a 14 year old girl presenting with an acute allergic contact dermatitis to hair dyes. Some years previously she had a 'black henna' tattoo with prior application of a tacky transfer to the skin to outline the design followed some days later by an acute localised blistering reaction. Patch testing to an extended British Contact Dermatitis Society standard series showed relevant positive reactions to paraphenlyenediamine (PPD) and thiuram mix, as well as to several of the azo disperse dyes. We went on to perform prick testing to natural rubber latex (NRL), showing a positive reaction to the commercial HEP 100 concentration. We propose that through the initial acute reaction caused by PPD in the 'black henna' our patient was not only sensitized to PPD, but also to thiuram and natural rubber latex which may have been present in the tacky transfer applied prior to 'tattooing.' We would add that temporary 'black henna' tattoos may have more important consequences than previously thought on patients' future health by sensitization to NRL.

Peristomal allergic contact dermatitis--case report and review of the literature.

Allergic contact dermatitis (ACD) is a rare cause of peristomal skin problems. Only 23 cases have previously been reported in the literature. We report the case of a colostomy patient with a severe disabling blistering peristomal dermatitis. Patch testing to a British Contact Dermatitis Society standard series, medicaments and a plastics and glues series was negative. Patch testing to the patient's own products gave a positive reaction (+) at D2 and D4 to Dansac soft paste and Stomahesive paste. Further patch testing to the components of Dansac soft paste showed a positive (+) reaction at D2 and D4 to ester of polymethyl vinyl/maleic acid copolymer (Gantrez-ES) only. This is the first reported case of ACD due to Dansac soft paste. ACD to Gantrez has previously been reported but in different products. We also review the other previously reported cases of ACD causing peristomal dermatitis and stress the importance of patch testing in these cases, in particular to the patient's own products, as avoidance of identified allergens can have a large impact on the quality of life.

The diagnosis of gastrointestinal tract injuries resulting from blunt trauma.

BACKGROUND: This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS: MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS: The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.

A case of rectal infarction after sigmoid colectomy for traumatic perforation in a patient with a major pelvic fracture.

Rectal ischemia and infarction are very uncommon. We report a case of rectal infarction complicating sigmoid colectomy for blunt trauma in a patient with a severe pelvic fracture. We advise that the superior rectal arteries must be preserved in severe pelvic fracture to prevent rectal ischemia.

Combined inguinal and pelvic lymph node dissection for stage III melanoma.

BACKGROUND: The incidence of melanoma is increasing in the UK and a significant number of patients are still presenting with primary lesions of poor prognosis. As a consequence there is likely to be an increasing number of patients with lymph node metastases for whom the appropriate extent of groin dissection remains controversial. This review summarizes the evidence to enable surgeons to make an informed decision about the management of patients with melanoma metastases to the groin lymph nodes. METHODS: A Medline search was performed to identify all English language articles about melanoma containing the words lymphadenectomy, lymph nodes, inguinal or lymphoedema. Eighty-seven relevant articles were selected from 3904 abstracts retrieved; 34 were related directly to the aim of this review. RESULTS: There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection (CLND) and superficial inguinal lymph node dissection (SLND). Excision of pelvic lymph node metastases is reported to yield a 5-year survival rate of 0-35 per cent. Recurrence within the pelvis occurs in 9-18 per cent of patients after SLND and in less than 5 per cent after CLND. Morbidity following either CLND or SLND is poorly reported. Major long-term lymphoedema limiting patient activity affects 6-20 per cent of patients after groin dissection. Cloquet's node was demonstrated in one study to be a useful predictor of pelvic lymph node involvement. Patients may be selected for pelvic node dissection on the basis of clinical findings, the results of pelvic computed tomography and the status of Cloquet's node. CONCLUSION: The controversy surrounding the appropriate management of cytologically positive inguinal nodes in melanoma can be resolved only by a prospective randomized trial comparing CLND with SLND. Morbidity and local disease control must be measured as outcomes in addition to disease-free and overall survival.

Young's syndrome: an often unrecognized correctable cause of obstructive azoospermia.

Young's syndrome consists of azoospermia owing to bilateral epididymal obstruction in patients with chronic sinus and pulmonary infections. Azoospermia may be corrected by vasoepididymostomy in these patients but postoperative fertility rates are yet to be determined. Because the infertility of Young's syndrome potentially is remediable with vasoepididymostomy and because the syndrome is observed commonly by surgeons outside of this country, we report 2 cases to illustrate what may be a frequently unrecognized and potentially correctable cause of azoospermia.

Angiographic embolisation in pelvic fracture.

Pelvic angiography is accepted in the control of haemorrhage due to pelvic fracture. The technique is reported to be effective in patients bleeding from small arterial branches of the internal iliac artery. Despite its widespread use, complications of the technique are scarcely reported. We reviewed all patients having undergone this intervention at our institution over a 10 year period. The technique was applicable in a minority of pelvic fracture cases. Sepsis was common in patients subsequently undergoing internal fixation of the pelvic fracture. Angiographic embolisation may be useful in controlling haemorrhage due to pelvic fracture. However, standardized parameters of a successful intervention are yet to be defined. Caution must be exercised when using this technique, particularly when proceeding to internal fixation of the pelvic ring.