Severe and near-fatal anaphylactic reactions triggered by chlorhexidine-coated catheters in patients undergoing renal allograft surgery: a case series.

PURPOSE: Although intraoperative anaphylaxis during surgery is a rare event, we describe five patients who experienced perioperative anaphylactic reactions during renal transplantation and were referred for investigation. CLINICAL FEATURES: Skin-prick and intradermal skin tests were done to investigate potential allergies to drugs given perioperatively prior to the development of anaphylaxis, including basiliximab, propofol, cefazolin, cis-atracurium, fentanyl, latex, remifentanil, and chlorhexidine. In addition, in vitro serologic testing for specific IgE was done in patients suspected to have had chlorhexidine anaphylaxis. All five patients were male, with a mean age of 48 yr (range 30-69). Skin testing for all drugs was non-reactive except for chlorhexidine, which was positive in four of five patients (one patient refused intradermal testing). In vitro test results for chlorhexidine-specific IgE were positive in all of the patients. Anesthetic records showed that intraoperative anaphylaxis had occurred immediately after insertion of a chlorhexidine-coated central venous catheter. CONCLUSIONS: Intraoperative insertion of chlorhexidine-coated central venous catheters can trigger life-threatening anaphylaxis in susceptible patients undergoing renal transplantation.

Canadian physician survey on the medical management of hereditary angioedema.

BACKGROUND: Hereditary angioedema (HAE) is a rare disease that has significant morbidity and may be potentially fatal because of airway obstruction. OBJECTIVE: To determine practice patterns in physicians treating HAE. METHODS: A survey was designed to determine HAE practice patterns among Canadian physicians. These physicians were identified by sending the survey to members of 3 physician organizations (Canadian Hereditary Angioedema Network, Canadian Society of Clinical Immunology and Allergy, and Canadian Hematology Society). RESULTS: Thirty-six physicians responded to the survey. Thirty-four physicians were included in the analysis. Most referrals to HAE-treating physicians were from family and emergency department physicians. The most common sites of swelling reported by patients to physicians were facial, peripheral, and abdominal. A mean of 53.9% of patients with type 1 and 2 HAE and 53.4% of patients with HAE with normal C1 esterase inhibitor were undergoing long-term prophylaxis. A mean of 41.9%, 19.4%, and 93.5% of respondents had some patients taking danazol, tranexamic acid, and C1-esterase inhibitor, respectively. Most physicians believed that severity and frequency of attacks were the most important determinants in deciding when to use prophylaxis. A mean of 88.2% of physicians used C1-esterase inhibitor to treat acute attacks and 79.4% used icatibant. All respondents were aware of HAE guidelines. CONCLUSION: Physicians are using guidelines to support their practice and using agents suggested by guidelines with confidence. C1 inhibitor is being used widely for prophylaxis and treatment of acute attacks along with icatibant. However, certain special patient populations may require additional focus in future guidelines.

Home-based subcutaneous immunoglobulin therapy vs hospital-based intravenous immunoglobulin therapy: A prospective economic analysis.

BACKGROUND: Home-based subcutaneous immunoglobulin (SCIg) administration used for immunoglobulin replacement therapy for patients with primary immunodeficiency has been demonstrated to have benefits compared with hospital-based intravenous immunoglobulin (IVIg) therapy. OBJECTIVE: To estimate the cost savings associated with treating eligible patients with primary immunodeficiency with home-based SCIg compared with hospital-based IVIg in a prospective study. METHODS: This study was a 12-month prospective observational study that collected information from patient charts, directly from the nurse for time spent with patients and materials used, and directly from the physicians for billing. Data were collected on case report forms at each follow-up. Data were entered in a web-based REDCap database and statistical comparisons were performed. RESULTS: The average hospital (including hospital personnel such as nurses) and physician costs were significantly lower in the SCIg group ($1,836 and $84, respectively) than in the IVIg group ($4,187 and $744, respectively), which supported the findings in the number of hospital and physician visits in each group. The total cost was reported from the hospital's (only hospital-related costs) and the health system's (hospital- and physician-related costs) perspectives. For the 2 perspectives, the SCIg group reported significantly lower average total costs than the IVIg group. CONCLUSION: This is the first prospective analysis of the cost savings associated with home-based SCIG therapy compared with hospital-based IVIG therapy. These findings could help justify provision of home-based therapy training to suitable patients to lower health care costs or improve the capacity of care.

Evaluating an owner-to-worker training intervention in California nail salons using personal air monitoring.

BACKGROUND: Chemicals in nail products have been linked to numerous health concerns. METHODS: We recruited Vietnamese-American nail salon owners and workers in California and randomized salons into an intervention or control group. Owners in the intervention group received training and then provided education to workers in their salons on best practices to reduce workplace chemical exposures. Methyl methacrylate (MMA), toluene, and total volatile organic compounds (TVOCs) were measured using personal air monitors worn by workers during the work-shift. RESULTS: We enrolled 77 salons (37 intervention and 40 control) and 200 workers. There was no significant intervention effect between the two groups. However, MMA and TVOCs were higher for workers who used gel polish and acrylic nails as well as in busy salons. CONCLUSIONS: Although the intervention did not show reductions in chemical levels, identifying worker tasks and salon characteristics that predict chemical levels can inform future interventions to reduce exposures.

Pediatric Wells syndrome (eosinophilic cellulitis) after vaccination: A case report and review of the literature.

A 4-year-old boy presented with erythematous vesicular plaques, ulceration, edema, and pruritus on the left foot and ankle 10 days after receiving the tetanus, diphtheria, pertussis, and polio; measles, mumps, rubella, and varicella; and hepatitis A/B vaccines. Biopsy showed eosinophilic infiltrates and flame figures, suggesting Wells syndrome. Patch testing showed a 1+ reaction to neomycin and aluminum hydroxide, with a recall reaction of Wells syndrome of the feet bilaterally. We report a rare case of pediatric Wells syndrome triggered by nonthimerosal vaccine components confirmed by patch testing.

Differences in personal care product use by race/ethnicity among women in California: implications for chemical exposures.

BACKGROUND: Personal care products may contain many chemicals, some of which are suspected endocrine disrupters. This is an important source of chemical exposure for women, but little is known about how chemical exposure differs among different races/ethnicities. OBJECTIVE: This study examines differences in personal care product use among Black, Latina, Vietnamese, Mixed Race, and White women in California. METHODS: We used a community-based participatory process to create and administer a personal care product usage survey to 321 Black, Latina, Vietnamese, Mixed Race, and White women. We used multivariate regression models with pairwise comparisons to examine the frequency of product use by race/ethnicity. RESULTS: We found distinct trends of personal care product use by race/ethnicity: Latina women typically used makeup most frequently; Black women used certain hair products or styles most frequently; and Vietnamese women were most likely to use facial cleansing products compared to other races/ethnicities. Latina and Vietnamese women were less likely to try to avoid certain ingredients in their products. SIGNIFICANCE: These findings can help estimate disparities in chemical exposure from personal care product use and complement future research on health inequities due to chemical exposures in the larger environmental and social context.

Chemicals of concern in personal care products used by women of color in three communities of California.

BACKGROUND: Personal care products (PCPs) may contain chemicals associated with adverse health effects. Prior studies found differences in product use by race/ethnicity and suggest some women are disproportionately exposed to chemicals of concern (CoCs). OBJECTIVE: We quantified chemicals linked to cancer, reproductive or developmental harm, or endocrine disruption in PCPs used by women of color. METHODS: We documented PCPs in stores frequented by Black, Latina, and Vietnamese women in their communities in California and CoCs on ingredient labels of 546 unique hair, skin, makeup, nail, deodorant/perfume, and intimate care products. Community partners chose 31 products for a combined targeted and suspect screen (National Institute of Standards and Technology mass spectral library search) two-dimensional gas chromatography time-of-flight mass spectrometry (GCxGC-TOFMS) analysis to detect chemicals not on ingredient labels. RESULTS: We found that 65% of labels included CoCs, and 74% of labels had undisclosed ingredients listed as "fragrance." The most prevalent chemicals were parabens, cyclosiloxanes, and formaldehyde releasers. GCxGC-TOFMS found additional CoCs, including fragrances, solvents, preservatives, ultraviolet filters, and contaminants. SIGNIFICANCE: These findings contribute to awareness of potentially hazardous chemicals in PCPs, can help estimate disparities in chemical exposure, and complement research on health inequities due to chemical exposures from various contributors. IMPACT STATEMENT: This study is one of the first detailed assessments of chemicals of concern found in various types of PCPs used by several racial/ethnic groups. We found that over half of the 546 products selected by community partners as marketed to and/or used by them contained ingredients linked to cancer, reproductive or developmental harm, or endocrine disruption. Laboratory analysis identified additional chemicals in a subset of products, including unlabeled fragrance chemicals and contaminants. Elucidating exposures to chemicals in PCPs is important for risk assessment and health inequity research.

Newer approaches in topical combination therapy for acne.

Acne vulgaris is a common chronic inflammatory cutaneous disease involving the pilosebaceous unit. Its pathophysiology is multifactorial and complex, including obstruction of the pilosebaceous unit due to increased sebum production, abnormal keratinization, proliferation of Propionibacterium acnes (P. acnes), and inflammation. Topical agents are the most commonly used therapy for acne. First generation topicals mainly consist of single agent retinoids, benzoyl peroxide (BPO) and antibacterials that target comedones, P. acnes, and inflammation. Novel topical therapies include combination products with advanced vehicle formulations that target multiple acne pathophysiologies and offer simplified treatment regimes. For example, the combination of clindamycin and tretinoin in a unique vehicle formulation allows for progressive follicle penetration and decreased irritation, resulting in increased efficacy. Furthermore, adapalene or clindamycin with BPO combinations target comedones, inflammation, and P. acnes synergistically. These newer combination products have the potential to increase both efficacy and patient adherence when compared with single agent treatment.

Using Photovoice to assess and promote environmental approaches to tobacco control in AAPI communities.

Asian American and Pacific Islander (AAPI) communities face enormous health disparities, with tobacco use contributing to high rates of cancer and heart disease. There is growing interest nationwide on the influence of environmental factors on tobacco use. AAPI communities have been found to have higher exposures to tobacco company marketing compared to the general population. The authors describe the use of Photovoice (a qualitative needs assessment technique) to empower AAPI youth to identify and understand environmental characteristics associated with tobacco use in four AAPI communities in California and Washington. Of the six major environmental themes identified from the photos, three themes were found across all four communities. Debrief sessions with youth and community leaders underscore the relevance of Photovoice for identifying community needs and motivating community organization for change. Despite some logistical challenges, Photovoice exemplifies the power and potential of this community-based methodology to capture how the environment influences youth on tobacco use.

Correction to: The International/Canadian Hereditary Angioedema Guideline.

[This corrects the article DOI: 10.1186/s13223-019-0376-8.].

Temporal evolution of cortical ensembles promoting remote memory retrieval.

Memories of fearful events can last a lifetime. The prelimbic (PL) cortex, a subregion of prefrontal cortex, plays a critical role in fear memory retrieval over time. Most studies have focused on acquisition, consolidation, and retrieval of recent memories, but much less is known about the neural mechanisms of remote memory. Using a new knock-in mouse for activity-dependent genetic labeling (TRAP2), we demonstrate that neuronal ensembles in the PL cortex are dynamic. PL neurons TRAPed during later memory retrievals are more likely to be reactivated and make larger behavioral contributions to remote memory retrieval compared to those TRAPed during learning or early memory retrieval. PL activity during learning is required to initiate this time-dependent reorganization in PL ensembles underlying memory retrieval. Finally, while neurons TRAPed during earlier and later retrievals have similar broad projections throughout the brain, PL neurons TRAPed later have a stronger functional recruitment of cortical targets.

The International/Canadian Hereditary Angioedema Guideline.

This is an update to the 2014 Canadian Hereditary Angioedema Guideline with an expanded scope to include the management of hereditary angioedema (HAE) patients worldwide. It is a collaboration of Canadian and international HAE experts and patient groups led by the Canadian Hereditary Angioedema Network. The objective of this guideline is to provide evidence-based recommendations, using the GRADE system, for the management of patients with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. New to the 2019 version of this guideline are sections covering the diagnosis and recommended therapies for acute treatment in HAE patients with normal C1-INH, as well as sections on pregnant and paediatric patients, patient associations and an HAE registry. Hereditary angioedema results in random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased health-related quality of life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada, as in many countries, continues to be neither optimal nor uniform. It lags behind some other countries where there are more organized models for HAE management, and greater availability of additional licensed therapeutic options. It is anticipated that providing this guideline to caregivers, policy makers, patients, and advocates will not only optimize the management of HAE, but also promote the importance of individualized care. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency and intensive care physicians, primary care physicians, gastroenterologists, dentists, otolaryngologists, paediatricians, and gynaecologists who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.

Environmental Street Audits and Black Carbon Measurements in Vietnamese Immigrant Communities.

BACKGROUND: The Vietnamese population has grown significantly in California and has clustered in geographic areas with potential disproportionate exposures to environmental stressors. No studies to date have focused on environmental exposures in this immigrant population. OBJECTIVE: To characterize neighborhood-level environmental hazards in Vietnamese communities in California to inform environmental health research. METHODS: We engaged Vietnamese community members in the Alameda, Marin, Orange, and Santa Clara regions to conduct community audits in neighborhoods where they lived and worked. Audits included surveys of observational neighborhood characteristics, Photovoice documentary and real-time personal black carbon (BC) aerosol monitors. RESULTS: Traffic-related air pollution, litter, smoking, and neighborhood safety were identified as major environmental concerns. Audits in Alameda County reported a higher percentage of metal bars on windows and litter relative to other counties. Orange County had the highest percentage of audit segments with idling trucks (20.8%) and tobacco ads (8.3%), as well as average 5-minute truck count (9.8). The mean BC concentration across all four regions was 1.8 µg/m3, and ranged from 1.7 µg/m3 in Santa Clara County to 2.0 µg/m3 in Orange County. When analyzed at smaller geographic units (neighborhoods), there was more variation across the regions, with Alameda County having the highest neighborhood concentration (7.7 µg/m3). CONCLUSIONS: Our results showed higher mean BC concentrations at the regional and neighborhood levels compared with the statewide concentration (0.737 µg/m3). Community members collected quantitative and qualitative data including real-time BC data. The audit process helped to initiate dialogue about environmental health issues in the Vietnamese communities.

Identifying and understanding the role of key stakeholders in promoting worker health and safety in nail salons.

The nail salon sector is booming, predominantly with Vietnamese immigrant workers who regularly handle nail care products containing harmful chemicals. Based on lessons learned from an ongoing randomized controlled trial, occupational interventions need to incorporate inputs from different stakeholders, including salon owners, workers, and customers as well as governmental regulatory agencies.

Developing a proactive research agenda to advance nail salon worker health, safety, and rights.

THE PROBLEM: Nail salons represent a burgeoning industry with Vietnamese immigrant workers making up the majority. Workers routinely handle cosmetic products containing hazardous compounds, with implications for their health. PURPOSE OF ARTICLE: This paper describes how a collaborative of multiple organizations and community members collectively developed a proactive research agenda for salon worker health, safety, and rights during a pivotal multistakeholder convening, and advanced on such recommendations, including creating groundbreaking policy changes. KEY POINTS: Key recommendations included (1) creating a multidisciplinary research advisory committee, (2) conducting research on workplace exposures and long-term health impacts, (3) advocating for better governmental oversight of product manufacturers, and (4) identifying safer product alternatives via green chemistry, albeit with cost considerations to salon businesses. CONCLUSION: The participation of diverse stakeholders in the discussions allowed for cross-dialogue on a complex issue, helped to align different stakeholders as allies, and identified critical resources to addressing research gaps.

Systemic role for vitamin d in the treatment of psoriasis and metabolic syndrome.

The novel discovery of the systemic role of vitamin D in the modulation of the immune system especially the Type 1 helper T cell (Th1) pathway reveals its potential for treating Th1 inflammatory diseases. Psoriasis has been recently established to be a systemic disease centered on inflammation and involvement of cytokines of the Th1 pathway. There is an increased prevalence of metabolic syndrome in patients with psoriasis. Metabolic syndrome also involves a proinflammatory state. This paper proposes the idea of the potential use of oral vitamin D to treat psoriasis and metabolic syndrome concurrently. We propose there is merit in more clinical trials investigating the use of vitamin D to treat both psoriasis and metabolic syndrome through its anti-inflammatory effects. On application to psoriasis management and prognosis, the goal is to decrease the risk for cardiovascular disease and decrease disease morbidity and mortality.