Ten years of contact allergy from acrylic compounds in an occupational dermatology clinic.

BACKGROUND: Contact allergy from acrylic compounds is a "hot topic". Knowledge on the exact chemical composition of acrylic products is superficial. AIMS: To retrospectively describe patients with allergic reactions to acrylic compounds. METHODS: We included patients who had been tested with acrylate patch test series and displayed allergic reactions to at least one acrylic compound. Chemical analyses were often performed when safety data sheets of implicated products failed to reveal acrylic compounds to which the patient tested positive. RESULTS: In 2010-2019 a total of 55 patients met the inclusion criteria. Eight cases of allergic contact dermatitis were due to anaerobic sealants, seven to dental products, three to windscreen glues, seven to eyelash glues and/or nail products in the beauty sector, three to UV-cured printing inks, two to paints/lacquers, and one to polyester resin system. The origin of these contact allergies was occupational with the exception of four beauty sector workers who had developed eyelid symptoms from eyelash extensions glued onto their own eyelashes. We invariably detected methacrylate monomers in 15 chemical analyses of 12 different anaerobic sealants. CONCLUSIONS: Safety data sheets of anaerobic sealants often lack warnings for skin sensitization, although these products regularly contain sensitizing methacrylates.

Risk Assessment of residual monomer migrating from acrylic polymers and causing Allergic Contact Dermatitis during normal handling and use.

Acrylic, Poly Methyl Methacrylate (PMMA) based polymers are found in many industrial, professional and consumer products and are of low toxicity, but do contain very low levels of residual monomers and process chemicals that can leach out during handling and use. Methyl Methacrylate, the principle monomer is of low toxicity, but is a recognized weak skin sensitizer. The risk of induction of contact allergy in consumers was determined using a method based upon the Exposure-based Quantitative Risk Assessment approach developed for fragrance ingredients. The No Expected Sensitization Induction Level (NESIL) was based on the threshold to induction of sensitization (EC3) in the Local Lymph Node Assay (LLNA) since no Human Repeat Insult Patch Test (HRIPT) data were available. Categorical estimation of Consumer Exposure Level was substituted with a worst case assumption based upon the quantitative determination of MMA monomer migration into simulants. Application of default and Chemical-Specific Adjustment Factors results in a Risk Characterization Ratio (RCR) of 10,000 and a high Margin of Safety for induction of Allergic Contact Dermatitis (ACD) in consumers handling polymers under conservative exposure conditions. Although there are no data available to derive a RCR for elicitation of ACD it is likely to be lower than that for induction.

Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options.

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit.

'To bead or not to bead?' Treatment of osteomyelitis and prosthetic joint-associated infections with gentamicin bead chains.

Gentamicin-containing polymethylmethacrylate (PMMA) beads are frequently used to prevent and treat orthopaedic infections. The beads are typically inserted to fill anatomical defects secondary to surgical debridement. Local gentamicin use results in low serum levels whilst achieving high concentrations at the site of infection. However, a systematic review of the available literature showed that, despite these theoretical advantages, no prospective study has thus far proven gentamicin-containing PMMA beads to be effective in treating orthopaedic infections. Available studies are based on small patient numbers and do not show significantly better results when local and parenteral antibiotics are combined compared with systemic therapy alone. These poor results may be explained partially by reduced aminoglycoside efficacy when biofilms or gentamicin-resistant bacteria are present. Moreover, little is known regarding the potential side effects of gentamicin-containing beads. In this paper, the pros and cons regarding the use of gentamicin-containing PMMA beads are discussed. It is concluded that more well-executed, prospective studies are needed to settle the discussion on the use of gentamicin-containing beads in the treatment of orthopaedic infections.

Adverse reactions caused by consecutive injections of different fillers in the same facial region: risk assessment based on the results from the Injectable Filler Safety study.

BACKGROUND: The combination of different injectable fillers in one area is considered to increase the risk of adverse reactions. OBJECTIVES: To characterize adverse reactions in patients who received more than one filler in the same facial region. METHODS: Data (up to July 2009) of the Injectable Filler Safety Study, a German-based registry for adverse filler reactions, was analysed descriptively. All cases were discussed individually. RESULTS: In 22 of the 161 patients (13.7%), two or more different fillers were injected consecutively into the same facial region. All patients were female with an average age of 50.6 (SD 13.6) years. In 12 of the 22 patients (54.5%), a specific filler could be attributed to the adverse reactions whereas in the other 10 patients (45.5%), the filler was not clearly attributable to one filler substance causing the adverse reactions. CONCLUSIONS: With the continuous changes in the filler market, the combination of different fillers in one area becomes more likely. Based on our data, there is not a lot of evidence that the combination of different injectable fillers, specifically biodegradable fillers, in the same region increases the risk of adverse reactions.

Pre-packed vacuum bone cement mixing systems. A further step in reducing methylmethacrylate exposure in surgery.

OBJECTIVES: Polymethylmethacrylate bone cements are widely used in orthopaedic and trauma surgery as well as in dentistry. The toxic side effects of inhaled methylmethacrylate (MMA) fumes generated during mixing have been well studied. Vacuum cement mixing systems have been shown to reduce the risk of airborne MMA significantly compared to handmixing. In an effort to further reduce MMA exposure, the latest generation of mixing devices are pre-packed with the ingredients and thus allow preparation in nearly closed circuits. Until now, there has been no study proofing the efficacy of those systems in protecting theatre staff from MMA vapours. METHODS: A pre-packed vacuum mixing system (Optipac®) was compared with two standard systems (Palamix® and Easymix®) regarding MMA emission. The latter systems require loading with the bone cement compounds prior to mixing. Following a standardized procedure, 10 mixes were performed with each system and the emission of MMA vapours in the breathing zone was recorded using photoionization detection over a period of 3 min. RESULTS: The mean MMA exposure was reduced when using the pre-packed system compared to the devices that require filling with the components. The highest emission peaks were recorded during the mixing and preparation steps in all systems. CONCLUSIONS: Modern pre-packed vacuum mixing systems further help to reduce the occupational hazards created by bone cement preparation. However, MMA fumes can still be detected using this technique. Although this is an important step in reducing MMA exposure in the operating theatre, further technical effort has to be taken to eliminate the continuous leakage of monomer from the devices while mixing and to minimize necessary manipulation for final delivery.

The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study.

BACKGROUND: For the glabellar region, severe partly vascular adverse events have been reported after treatment with injectable fillers. METHODS AND MATERIALS: For this study, data from the Injectable Filler Safety Study, a German-based registry for those reactions, was analyzed to characterize adverse events seen in the glabellar region. Patients were analyzed descriptively. RESULTS: Forty of 139 registered patients reported adverse events in the glabellar region. All patients were female, with an average age of 52.3. Nineteen patients with adverse reactions to hydroxyethylmethacrylate (HEMA) and ethylmethacrylate (EMA) in a fixed combination with hyaluronic acid (HA) and 10 patients with adverse reactions to different hyaluronic acid products were reported; five patients reacted to poly-L-lactic acid (PLA). The most common adverse reactions to HEMA/EMA in HA and PLA were nodules and hardening. In HA-treated patients, erythema and inflammation, swelling, and pain were most frequent. The adverse reactions to HEMA/EMA in HA were severe in 50% of the patients. Severe adverse reactions were found to a lesser extent in patients treated with HA and PLA. Potential vascular complications were documented in only two patients. CONCLUSION: Adverse reactions seen in the glabella are overwhelmingly product associated and to a lesser extent location associated. Vascular complications with necrosis and ulceration were rare.

Electron microscopic documentation of late changes in permanent fillers and clinical management of granulomas in affected patients.

BACKGROUND: The manufacturers of permanent injectable fillers claim that their products are widely inert, biocompatible, atoxic, and nonimmunogenic. There are polymer gels without microparticles on the market and combination products that use collagen suspension or a hyaluronic acid gel as a vector to which polymer microspheres or polygonal particles are added. The filling effect of the polymer gels is based on the volume injected and, for the combination gels, partly on the volume injected and partly on the intended host foreign-body reaction to the microparticles. Foreign body reactions that are seen as inflammatory, sometimes disfiguring, nodules may develop years later at the injection sites. OBJECTIVES: Permanent fillers differ with respect to composition and chemical and biological characteristics. There have been reports that intend to explain how host tissue reacts with different permanent fillers and how adverse reactions differ depending on the filler used. The changes that some of the permanent fillers undergo during years of residence in human tissue have not been included in this discussion. These structural changes may be one of the reasons why adverse reactions to permanent fillers occur clinically with a delay of several years. METHODS: In a series of 10 patients who had been injected with a permanent filler of hydroxymethylmethacrylate and ethylmethacrylate (40%) in hyaluronic acid gel (60%) and had developed adverse reactions with inflammatory nodules after variable time elapsed, biopsies could be obtained for histologic and electron microscopic examinations. RESULTS: After 2 years in all specimens, changes of degradation of the filler material could be detected. Bacteria were not found in any of the specimen. In 40% of the particles, the size of the particles did not correspond to the size declared by the manufacturer (45-65 microm) and was smaller, thus being more susceptible to phagocytosis. CONCLUSIONS: Inflammatory nodules due to adverse reactions to permanent fillers containing microparticles with a hydrophobic surface were treated with good results with a regimen of allopurinol and intralesional injections with a mixture of fluorouracil and low-dose triamcinolon.

Pulmonary cement embolism after percutaneous vertebroplasty: a rare and nonthrombotic cause of pulmonary embolism.

Percutaneous vertebroplasty consists of injection of acrylic cement - polymethylmethacrylate - into a vertebral body to obtain pain relief and increase its mechanical stability. The procedure is indicated for painful hemangiomas and for painful vertebral compression fractures due to osteoporosis or malignancy. Although vertebroplasty is an efficient treatment, it is not free of complications. We present the case of a patient with pulmonary cement embolism after percutaneous vertebroplasty. Because such patients may be completely asymptomatic, but may also present with acute and severe, cardiovascular instability, clinicians and nuclear physicians should be aware that pulmonary embolism of polymethylmethacrylate may occur after percutaneous vertebroplasty.

Cardiovascular changes after pulmonary cement embolism: an experimental study in sheep.

BACKGROUND AND PURPOSE: Most cement leaks during vertebroplasty are asymptomatic, but pulmonary cement embolism has been reported to cause cardiovascular disturbances and even death. Adding hydroxyapatite (HA) to polymethylmethacrylate (PMMA) cement to reduce the quantity of barium may aggravate cardiovascular deterioration in the event of cement embolism by activating coagulation. Thus, we investigated the cardiovascular changes after pulmonary cement embolism of PMMA with and without HA. MATERIALS AND METHODS: In 13 sheep, cement (2.0 mL) was injected into the pulmonary trunk. Two different cements were used: 1) standard PMMA and 2) PMMA with 10% HA (PMMA & HA). Arterial, central venous and pulmonary arterial pressures, heart rate, and cardiac output were monitored continuously until 60 minutes after the injection. Blood gases and coagulation parameters (antithrombin, D-dimer) were measured before and after injection. RESULTS: Mean pulmonary arterial pressure had increased by approximately 9% (PMMA) and 14% (PMMA & HA) 1 minute after injection and stayed elevated. There were no significant differences between the groups. No evidence of thromboembolism was detected. CONCLUSION: Cement embolism did not result in clinically significant pulmonary arterial hypertension. Adding HA to PMMA cement did not cause more severe cardiovascular changes.

Patients with osteoporosis on steroid medication tend to sustain subsequent fractures.

BACKGROUND AND PURPOSE: Repeat fractures after percutaneous vertebroplasty can be seen in patients with osteoporotic compression fractures. The purpose of this study was to identify characteristics of patients with new fractures after vertebroplasty. MATERIALS AND METHODS: Fifty-five consecutive patients were treated with vertebroplasty for painful osteoporotic compression fractures at our institution. The charts and radiographic studies of all patients were retrospectively reviewed. Special attention was paid to patient age and sex, imaging studies, long-term use of steroid medication, and treatment for osteoporosis. We used logistic regression analysis and the Fisher exact test for statistical evaluation. RESULTS: Thirty-five patients were treated with vertebroplasty at one time and did not develop new fractures, whereas 20 patients returned with new fractures. Sixteen of 55 patients had been on steroid medication. The incidence of subsequent vertebral compression fractures after vertebroplasty in patients on long-term steroid therapy was 69% (11/16), compared with 23% (9/39) in those with primary osteoporosis (ie, those who were not on steroid therapy). There was a statistically significant association between use of steroids and new fractures (P<.01). No statistically significant difference was noted in patient age, sex, and medication for osteoporosis. CONCLUSION: Patients who are on long-term steroid medication have an elevated risk of developing new fractures after vertebroplasty.

The biomechanical effect of vertebroplasty on the adjacent vertebral body: a finite element study.

The increased use of vertebroplasty for the treatment of osteoporotic vertebral compression fractures has led to concerns that the technique may increase the risk of fracture in the adjacent vertebrae. The aim of this study was to simulate the biomechanical effects of vertebroplasty using an osteoporotic two-vertebrae finite element model. Following a simulated compression fracture, the model was augmented with one of three volumes of PMMA-based cement or left untreated. Upon reloading, an increase in segment stiffness was found with increasing volumes of cement. However, in all the treated models there was an increase in endplate deflection into the adjacent vertebra causing plastic failure of the surrounding trabecular bone. More damage was caused in the adjacent vertebra of the treated models than in the untreated model. The model results suggest that clinicians should be wary of using standard vertebroplasty cements to treat compression fractures in patients with highly osteoporotic bone.

Safeness of Simplex-tobramycin bone cement in patients with renal dysfunction undergoing total hip replacement.

PURPOSE: To compare the pharmacokinetic profile of tobramycin in blood, urine, and at the operative site following the use of Simplex-tobramycin bone cement in primary total hip replacement between patients with and without renal dysfunction. METHODS: Six patients with renal dysfunction underwent cemented primary total hip replacement for osteoarthritis. The elution characteristics of Simplex-tobramycin bone cement in the 6 patients with renal dysfunction were compared with 9 patients who had normal renal function. Blood, urine, and drainage fluid specimens were collected for 72 hours postoperatively. RESULTS: Very high concentrations of tobramycin were seen in the drainage fluid of the 2 groups. Mean serum tobramycin levels peaked at postoperative 3 hours, and declined rapidly to negligible levels at 72 hours in both groups. Mean urinary tobramycin concentrations peaked at postoperative 12 hours and declined rapidly until 48 hours in both groups. Urinary tobramycin was excreted significantly more slowly in renal dysfunction group in the first 12 hours, but not thereafter. Although serum creatinine levels of the renal dysfunction group were higher throughout the study period, the difference was not significant. Both groups achieved excellent local delivery of the antibiotic with minimal systemic concentrations. CONCLUSION: Simplex-tobramycin bone cement appears to be an effective and safe means to deliver antibiotic for patients with renal dysfunction who undergo total hip replacement.

Medium-term results of percutaneous vertebroplasty in multiple myeloma.

Vertebral compression fractures (VCFs) are common in multiple myeloma (MM). Percutaneous vertebroplasty (PVP) is used to stabilize vertebral collapse and treat the pain. Few studies have been carried out on PVP in MM and follow-up has tended to be short. We have prospectively evaluated the safety and efficacy of PVP in the VCFs resulting from MM or plasmacytomas. Nineteen PVP were performed in 12 consecutive patients. We monitored their pain and functional status using visual analog (VAS) and Eastern Cooperative Oncology Group (ECOG) scale, respectively. For a subjective assessment, every patient was asked about his/her degree of satisfaction. The mean age of the participants was 66 yr. Significant improvement occurred 1 d after PVP according to the VAS score (7.5 pre-PVP to 3.7, P < 0.0001) and ECOG assessment (3.1 to 2.5, P = 0.002). This significant improvement was maintained after 3.2 yr of follow-up. Sixty-three percent of patients were highly satisfied with the result of the PVP and 37% were satisfied. The peri-operative mortality was 0%. Leakage of the cement outside of the vertebral body was noted in 16 of 19 injected vertebrae (84%) but none of the patients developed any clinical or neurological symptoms. At the last follow-up, no further collapse in the treated or neighboring vertebrae was noted. VCFs caused by MM or plasmacytomas can be effectively treated by vertebroplasty. PVP is associated with early clinical improvement of pain and function and can be maintained after a long follow-up without major procedure-related complications.

Postoperative pain after root-end resection and filling.

OBJECTIVE: To evaluate the pain experience following root-end resection and filling with Mineral Trioxide Aggregate or Intermediate Restorative Material. STUDY DESIGN: Referred adult patients recruited using strict entry criteria were randomly allocated to receive either material. A standardized surgical technique was employed. Postoperative instructions and a pain questionnaire were given to each patient to record the severity of their pain at 3 time intervals-3-5 hours, 24 hours, and 48 hours after surgery-on a standard visual analog scale (VAS). Patients were also asked to record consumption of any self-prescribed analgesics, the type, and dosage. RESULTS: At 3-5 hours after surgery, regardless of the material used, 90% of all patients experienced some level of postoperative pain. Twenty-four hours after surgery 82% of patients experienced pain, as did 72% after 48 hours. Thirty-seven percent of patients did not take any analgesics at all. In order of popularity, the analgesics taken were ibuprofen, acetaminophen, and acetaminophen plus codeine phosphate. The VAS measurements were reduced over time in both treatment groups (P < .001). There was no statistically significant difference in the proportion of subjects taking analgesics in each treatment group. Patients who used analgesics showed higher median VAS measurements at all time periods (P < .05). CONCLUSIONS: There was no significant difference in the pain experienced by both treatment groups. The postoperative pain was of a relatively short duration, at its maximum intensity early in the postoperative period but progressively decreased with time. Even if pain relief medication was needed, nonprescription analgesics were adequate and effective.

In vitro comparison of three materials as apical sealants of equine premolar and molar teeth.

REASONS FOR PERFORMING STUDY: Surgical endodontic therapy is a conservative dental technique used in horses with some degree of clinical success. Failure of this procedure can partially be explained by inadequate sealing of the root apices with resultant microleakage in the periapical area. OBJECTIVES: To assess and compare in vitro sealing ability of 3 different dental restorative materials used as apical sealants during equine surgical endodontics. METHODS: Thirty extracted equine cheek teeth were divided randomly into 3 groups and subjected to apicoectomy and apical sealing using 3 materials: reinforced zinc oxide-eugenol cement; intermediate restorative material (IRM); a resin-modified glass ionomer; and amalgam. After apical sealing, the teeth were submerged in a solution of Procion Brilliant Cresyl Blue stain for a period of 7 days. The teeth were then washed, embedded in resin, sectioned and assessed microscopically for dye leakage around the apical restorations. RESULTS: Although the materials proved effective as apical sealants, some dye leakage was encountered in all 3 groups with no statistical difference (P = 0.114). CONCLUSIONS AND POTENTIAL RELEVANCE: IRM, a resin-modified glass ionomer and amalgam all showed comparative features as apical sealants when used in vitro in equine teeth. IRM is currently regarded as the superior material in clinical situations due to its ease of handling and lesser sensitivity to environmental moisture during placement compared to the other 2 materials.

[Sensitivity to constituents of bone cement in a patient with joint prosthesis]. / Prothesenunverträglichkeit bei Typ-IV-Sensibilisierung gegen Knochenzement.

Failure to tolerate prosthetic material can lead to a variety of clinical findings. A 55-year-old woman had a total replacement of the right knee. Two weeks later she developed pruritic skin lesions over the joint, as well as pain and impaired function. Allergic testing showed clinically relevant Type IV sensitization to methylmethacrylate, as well as to various formulations of the bone cement, including one with an added antibiotic. The symptom complex of pruritic skin lesions in the area of the prosthesis, pain and disability, as well as relevant Type IV sensitization justified replacing the prosthesis.