Quick cuts: A comparative study of two tools for ring tourniquet removal.

BACKGROUND: Ring tourniquet occurs when a ring becomes entrapped due to swelling or trauma. As the finger expands the blood flow restriction causes additional swelling, which can lead to nerve damage and other complications. Ring tourniquet can be an emergency that requires rapid ring removal. Standard devices for ring removal have been described but rarely tested. We conducted a randomized study to compare removal time, user and participant satisfaction and complications between a motorized diamond disc ring cutter (MDDRC) and a ring cutter attached to trauma shears (TS). METHODS: In pairs, emergency medicine providers removed rings using both devices and wore randomized rings to be removed (silver or steel). Each effort was timed from initiation to removal. After each effort both user and subject rated their satisfaction with the device, using a visual analog scale and reported any complications. Median and interquartile ranges were generated for the primary and secondary outcomes with 95% confidence intervals where applicable. Wilcoxon Rank Sum tests were calculated with a = 0.05 to compare removal time and secondary outcomes between the two tools. RESULTS: Thirty subjects completed the study. Median time to ring removal was significantly lower with the TS compared to the MDDRC (7.7 vs 67.0 s, p < .0001). Device user satisfaction (9.7/10 vs 3.8/10, p < .0001) and participant satisfaction (9.7/10 vs 6.8/10, p < .0001) were significantly higher with the TS, while participant discomfort was significantly lower with the TS (0.0/10 vs 2.2/10, p < .0001). CONCLUSION: This study is the first to compare efficacy, satisfaction and complications of two standard tools for removal of ring tourniquets. The TS took significantly less time than the GEM MDDRC and demonstrated significantly better satisfaction for both the ring wearer and ring remover.

Chromium and cobalt release from metallic earrings from the Danish market.

BACKGROUND: Chromium and cobalt are important skin sensitizers. It has, however, been difficult to identify causative exposures. Studies on nickel allergy have demonstrated piercing as critical for both sensitization and elicitation. It may be speculated that the same applies for chromium and cobalt. OBJECTIVE: To examine the content and release of chromium and cobalt from earrings randomly purchased in Denmark. METHODS: Three hundred four earrings were examined with x-ray fluorescence (XRF) spectrometry. Earrings with measured content of chromium or cobalt were spot tested with diphenylcarbazide spot test (n = 166) or Nitroso-R spot-test (n = 99), respectively. Chromium and cobalt release were quantified in a selected subsample (n = 100) with the artificial sweat test (EN 1811). RESULTS: Chromium was present in 54.6% (166/304) of earrings and cobalt was present in 72.0% (219/304),- measured by XRF. All chromium spot tests for chromium VI were negative. The cobalt spot test was positive for one component. Chromium release was found from 59/100 (median concentration = -0.06 µg/cm2 /week) and cobalt release from 29/100 (median concentration = -0.06 µg/cm2 /week) of earrings in tested subsample. CONCLUSION: Earrings for piercing release chromium and cobalt and may on a case basis be a source of chromium and cobalt allergy.

DNA damage analysis concerning GSTM1 and GSTT1 gene polymorphism in gold jewellery workers from Peshawar Pakistan.

PURPOSE: To evaluate the genotoxic effects of gold jewellery fumes and its association with GSTM1 and GSTT1 genetic polymorphisms. MATERIALS AND METHODS: We examined 94 subjects including 54 gold jewellery workers and 40 controls. The DNA damage was evaluated by alkaline comet assay and genotyping by PCR. RESULTS: The mean total comet score (TCS) in gold jewellery workers was significantly higher as compared to the control subjects (128.0 ± 60.6 versus 47.7 ± 21.4; p = 0.0001). Duration of occupational exposure had positive correlation (r = 0.453, p < 0.01) with DNA damage. Age and tobacco use had significant effects on the TCS of the exposed group as compared to the control group (p < 0.05). The frequency of the GSTM1-null genotype in the exposed group was significant (p = 0.004) as compared to the control group. No significant association (p > 0.05) between the GSTM1 and GSTT1 genotypes and DNA damage was found. CONCLUSIONS: Our results suggest that there is increased DNA damage in gold jewellery workers due to their occupational surroundings. Hence there is a strong need to educate the workers about the adverse health effects of potentially hazardous chemicals and highlight the importance of using protective measures.

Prevalence of contact allergy to metals: nickel, palladium, and cobalt in Southern Sweden from 1995-2016.

BACKGROUND: In 2001, the EU nickel directive was introduced to prevent contact allergy to nickel. Contact allergy to palladium and/or cobalt is often seen together with contact allergy to nickel. OBJECTIVES: To compare the contact allergy prevalence of nickel, palladium, and cobalt allergy before and after the introduction of the EU nickel directive in consecutive patients with dermatitis. METHODS: A retrospective analysis of patch test results from 1995-2016 was performed (n = 18 264). Chi-square tests were used to examine trends for nickel, palladium, and cobalt across test years. Logistic regression was used for associations. RESULTS: The prevalence of nickel allergy decreased significantly in the youngest age group (6-30 years) for both female and male patients from 1995-1999 to 2012-2016: females: 33.4% to 19.1% (P < .001); males: 5.9% to 2.1% (P < .05). The concomitant reactions between nickel and palladium and nickel and cobalt among young females, respectively, also decreased significantly. Isolated palladium and cobalt allergy remained stable (1.4% and 2.3%, respectively) during the same time period for both men and women. CONCLUSIONS: The prevalence of nickel has decreased among young females and males suspected of contact allergy in Southern Sweden after the introduction of the EU nickel directive. There has been no change in isolated palladium or cobalt allergy.

Epidemiology of nickel sensitivity: Retrospective cross-sectional analysis of North American Contact Dermatitis Group data 1994-2014.

BACKGROUND: Nickel is a common allergen. OBJECTIVE: To examine the epidemiology of nickel sensitivity in North America. METHODS: Retrospective, cross-sectional analysis of 44,097 patients patch tested by the North American Contact Dermatitis Group from 1994 to 2014. Nickel sensitivity was defined as a positive patch test for nickel. We evaluated the frequency of nickel sensitivity and patient demographics. For each positive reaction to nickel, we tabulated clinical relevance, occupational relatedness, and exposure sources. RESULTS: The average frequency of nickel sensitivity was 17.5% (1994-2014). Nickel sensitivity significantly increased over time (from 14.3% in 1994-1996 to 20.1% in 2013-2014 [P < .0001]). Nickel-sensitive patients were significantly more likely to be female, young, nonwhite, and atopic (have eczema and asthma) and/or have dermatitis affecting the face, scalp, ears, neck, arm, or trunk (P values ≤ .0474). Overall, 55.5% of reactions were currently clinically relevant; this percentage significantly increased over time (from 44.1% in 1994-1996 to 51.6% in 2013-2014 [P < .0001]). The rate of occupational relatedness was 3.7% overall, with a significant decrease over time (from 7.9% in 1994-1996 to 1.9% in 2013-2014 [P < .0001]). Jewelry was the most common source of nickel contact. LIMITATIONS: Tertiary referral population. CONCLUSIONS: Nickel allergy is of substantial public health importance in North America. The frequency of nickel sensitivity in patients referred for patch testing has significantly increased over a 20-year period.

Nickel dermatitis from earrings 15 years after EU directive implementation: a clinical-epidemiological study and a market survey in Rome, Italy.

BACKGROUND: Nickel (Ni) dermatitis remains a highly prevalent allergic condition in Italy. There is a continuous need for clinical and epidemiological surveillance to evaluate whether or not European Ni Directive has been effective in contact allergy prevention. OBJECTIVES: To assess the prevalence of Ni dermatitis among patch-tested patients and self-interviewed school students and to analyse Ni release from earlobe jewellery. METHODS: Results of patch tests performed in 2006-2007, 2015-2016 and 2017-2018 were retrieved. A questionnaire was compiled by 315 secondary school students. Ni release from earring parts was analysed with the EN1811:2015 method. RESULTS: A significant time trend of decreasing Ni positivity from 2006-2007 to 2017-2018 was observed both in the overall population (44.1% in 2006-2007, 33.0% in 2015-2016, 31.6% in 2017-2018, P < 0.0001) and in female patients (P < 0.0001). Conversely, change was not significant in males (P = 0.16). Decrease was significant for all age groups, except for those aged >60 years (P = 0.51). Among 242 students who reported earring use, 130 (54%) reported symptoms at earlobes, mostly associated with jewellery of materials other than gold and silver (59% of those with earlobe symptoms). Ni release exceeded the migration limit in 4/21 (20%) earring parts. CONCLUSIONS: A high prevalence of Ni dermatitis and earlobe symptoms were found in Rome. A decreasing time trend was noted, with a significant decline in Ni sensitivity compared to the situation observed right after Ni Directive implementation. This most likely represents the consequence of reduced Ni content in earring parts, although a major care in the use of Ni-containing objects could contribute to explain these findings.

Nickel allergy and allergic contact dermatitis: A clinical review of immunology, epidemiology, exposure, and treatment.

Nickel is the most frequent cause of contact allergy worldwide and has been studied extensively. This clinical review provides an updated overview of the epidemiology, exposure sources, methods for exposure quantification, skin deposition and penetration, immunology, diagnosis, thresholds for sensitization and elicitation, clinical pictures, prevention, and treatment. The implementation of a nickel regulation in Europe led to a decrease in the prevalence of nickel allergy, and changes in the clinical picture and disease severity. Nevertheless, the prevalences of nickel allergy in the European general population are approximately 8% to 19% in adults and 8% to 10% in children and adolescents, with a strong female predominance. Well-known consumer items such as jewellery and metal in clothing are still the main causes of nickel allergy and dermatitis, although a wide range of items for both private and occupational use may cause dermatitis. Allergic nickel dermatitis may be localized to the nickel exposure site, be more widespread, or present as hand eczema. Today, efficient methods for exposure quantification exist, and new insights regarding associated risk factors and immunological mechanisms underlying the disease have been obtained. Nevertheless, questions remain in relation to the pathogenesis, the persistent high prevalence, and the treatment of severe cases.

Causative exposures and temporal development of cobalt allergy in Denmark between 2002 and 2017.

BACKGROUND: Cobalt contact allergy is common, but clinical relevance is often difficult to determine. OBJECTIVES: To examine the aetiology, prevalence and clinical characteristics of cobalt-allergic patients who were patch tested between 2002 and 2017 at the Department of Dermatology and Allergy, Herlev-Gentofte Hospital. METHODS: Patch test data, along with patient characteristics and causative exposures, from all adult dermatitis patients seen and tested between 2002 and 2017 were analysed. Associations were tested with the χ 2 test and logistic regression. RESULTS: A total of 13 475 adults aged 18 to 99 years were patch tested. The overall prevalence of cobalt allergy and the prevalence of isolated cobalt allergy were 3.3% and 1.5%, respectively. The prevalence of isolated cobalt allergy decreased from 2.4% in 2006 to 2009 to 1.1% in 2014 to 2017 (Ptrend = 0.00003). Leather exposure as a relevant cause of allergic cobalt dermatitis increased from 3.7% in 2002 to 2009 to 8.3% in 2010 to 2017 (P = 0.04). The current clinical relevance of positive patch test reactions, that is, a positive reaction to cobalt combined with a history of current skin exposure to a source of cobalt, was 20.1%. CONCLUSIONS: We conclude that cobalt allergy is relatively common, but causative exposures are largely unknown, and the proportion of positive patch test reactions with clinical relevance is low. It is therefore currently unclear how we can better protect consumers and workers from cobalt exposure.

Assessing the validity of self-reported history of rash caused by metal or jewellery.

BACKGROUND: The use of metal-containing bio-devices is becoming increasingly common. Self-reported history of dermatitis with metal exposure is not established as being predictive for metal allergy. OBJECTIVES: To assess the validity of two screening questions addressing metal allergy. METHODS: At Massachusetts General Hospital Contact Dermatitis Clinic, 2132 consecutive patients were asked either 'Do you get rashes when jewellery touches your skin' (Q1; N = 1816) or 'Do you get rashes when metal touches your skin?' (Q2; N = 316) before being patch tested. RESULTS: Testing showed that 20% of subjects had positive reactions to nickel, 7.4% had positive reactions to cobalt, and 5.8% had positive reactions to chromium. Q1 was 40% sensitive (95%CI: 35-45%). The positive predictive value (PPV) was 51%, and the negative predictive value (NPV) was 82%. Q2 was 77% sensitive (95%CI: 68-84%). The PPV was 71%, and the NPV was 84%. Q2 was 37% more sensitive than Q1 (p < 0.0001), with a higher relative risk (RR) (4.75, p < 0.001) than Q1 (RR = 3.01, p < 0.001). CONCLUSIONS: Patient-reported metal allergy, although not perfect, is a reasonable method for metal allergy screening to help identify those needing further objective evaluation by patch testing.

Approach to the jewelry aficionado.

Children's and teens' frequent use of inexpensive "costume" jewelry exposes them to a variety of contact allergens. Greater use heightens the risk of developing allergic contact dermatitis, especially in the setting of body piercings. Several clinical pearls, prevention strategies, and avoidance alternatives are provided in this article to guide clinicians and patients in the management of jewelry-related allergic contact dermatitis.

A Modified String Technique for Atraumatic Ring Removal.

BACKGROUND: We describe a modified string technique for ring removal from an edematous finger, a critical step in the initial treatment of a patient with upper-extremity trauma. TECHNIQUE: This technique involves multiple sutures looped around the ring to provide differential tension on the ring as it is advanced distally over a lubricated digit. With the use of an assistant, the ring can be advanced in caterpillar fashion without sliding back proximal when the direct pressure is released as a result of edema. CONCLUSIONS: This multisuture technique adds to the armamentarium of methods for ring removal in the setting of upper-extremity trauma without reverting to alternate techniques for cutting or shattering the ring.

[Coiling method combined with bloodletting from the corpus cavernosum for penile incarceration with a metal ring: A case report and literature review].

OBJECTIVE: To explore the treatment of penile incarceration with a metal ring. METHODS: Based on our experience in the successful management of a case of penile incarceration with a metal ring by coiling and bloodletting from the corpus cavernosum, we reviewed the relevant literature and analyzed the indications, advantages and disadvantages of different methods for the treatment of penile incarceration with a circular foreign body. RESULTS: The clamping and cutting methods were non-invasive, fast, effective, and with few complications, which could be applied to the treatment of penile strangulation at all levels. However, clamping was not desirable enough for a hard metal ring and the cutting method took a longer time and might increase the risk of unnecessary damage to the penile skin, urethra and cavernous body. Prepuce edema decompression and the thin tube-coiling method, with the advantages of minimal invasiveness, simple operation and no need of special tools, were suitable for penile strangulation injury under level 3, but might cause penile skin injury and potential postoperative erectile dysfunction. Surgical resection, as an invasive procedure, could be applied to severe penile strangulation at level 4 or 5. CONCLUSIONS: The principle for the treatment of penile incarceration with a circular foreign body is to remove the foreign object as soon as possible and not to add secondary damage.

Nickel allergy in a Danish population 25 years after the first nickel regulation.

BACKGROUND: Nickel in metallic items has been regulated in Denmark since 1990; however, 10% of young Danish women are still sensitized to nickel. There is a need for continuous surveillance of the effect of regulation. OBJECTIVES: To identify current self-reported metallic exposures leading to dermatitis in nickel-allergic patients, and the minimum contact time needed for dermatitis to occur. METHODS: A questionnaire was sent to all patients who reacted positively to nickel sulfate 5% pet. within the last 5 years at the Department of Dermatology and Allergy, Gentofte Hospital. RESULTS: The response rate was 63.2%. Earrings were the foremost cause of dermatitis after the EU Nickel Directive had been implemented, followed by other jewellery, buttons on clothing, belt buckles, and wrist watches. Dermatitis reactions within 10 min of contact were reported by 21.4% of patients, and dermatitis reactions within 30 min of contact were reported by 30.7% of patients. CONCLUSIONS: Nickel exposures that led to the implementation of a nickel regulation seem to persist. The durations of contact with metallic items to fall under the current REACH regulation of nickel correspond well with the results of this study.

Occurrence of Dental Injuries and Periodontal Complications in Tongue-piercing Jewellery Users.

PURPOSE: Tongue piercing (TP) has been gaining in popularity, mainly among adolescents and young adults, and there has been a corresponding increase in reports of dental injury and adverse effects on periodontal tissue due to TP jewellery. The purpose of this study was to assess the type and prevalence of dental injury and periodontal complications in a group of Slovenian adolescents and young adults with TP in comparison with a control group. MATERIALS AND METHODS: This case-control study included 17 subjects with TP (study group) and 28 subjects without TP (control group). Subjects were clinically examined for dental injuries, as classified according to Andreasen. Periodontal complications were evaluated using an estimation of clinical attachment loss (CAL) and gingival recession (GR). Differences in categorical variables were analyzed using the chi-squared or Fisher's exact test as appropriate. Differences between the groups in numerical variables were analyzed with the Mann-Whitney U-test. A multiple logistic regression model was built to test the association between dental injuries and TP when controlling for cofounders, namely age and gender of study participants. The significance level was set at α = 0.05 (two-tailed). RESULTS: Subjects with TP had 12.2 higher odds of dental injury (CI = 2.2-67.7, p = 0.004) compared with subjects without TP. Enamel fractures were more prevalent in the study group (p = 0.002). Frequencies of other dental injuries in the two groups were similar. GR was significantly associated with TP (p = 0.008), while differences in CAL between the groups were not statistically significant. CONCLUSION: Subjects with tongue piercing had more dental injuries and gingival recession.

[When love becomes eternal: Two embedded rings, a case report]. / Quand l'amour devient éternel : l'intégration sous-cutanée de deux bagues, un cas clinique.

Embedded ring injury is a rare condition often associated with mental illness or cognitive disorders. Clinical presentation varies from simple oedema to serious neurovascular deficits. We report the unusual case of a 69-year-old woman presenting with two embedded ring injuries. The rings had been in place for over 20 years, however she had no past medical history of psychiatric or neurological disorder. A non-invasive approach was decided to treat the patient by simply cutting the rings allowing to resolve the situation without further morbidity.

The "Jewelry Addict": Allergic Contact Dermatitis from Repetitive Multiple Children's Jewelry Exposures.

A 9-year-old girl with atopic dermatitis developed persistent plaques on the lips, hands, and fingers that were unresponsive to topical steroids. Her mother reported that she was "addicted" to costume jewelry and developed rashes in reaction to a number of adornments, ranging from rubber bracelets to costume metal jewelry and belt buckles. A careful history of jewelry exposures was taken and patch testing was performed to identify allergenic sources. Patch testing revealed allergy to nickel, gold, and thiuram mix. The case illustrates the importance of investigating a range of different types of allergens when evaluating for jewelry sensitivity in children with frequent use of accessories, including rubber jewelry, plastics, dyed yarns, beads, metals, and ceramics. This article provides an overview of jewelry allergies and the potential allergens requiring screening.

Localized cutaneous argyria: Report of two patients and literature review.

BackgroundLocalized cutaneous argyria is a rare skin condition caused by direct contact with silver or silver particles. It presents as asymptomatic gray or blue-gray macules that appear similar to blue nevi. Histologic features include brown-colored or black-colored silver granules in the basement membrane and dermis, most commonly surrounding eccrine glands, elastic fibers, and collagen fibrils. The condition is most frequently observed in individuals who are regularly exposed to small silver particles, such as silversmiths and welders. However, localized cutaneous argyria has also been associated with acupuncture needles, silver earrings, and topical medications containing silver nitrate. Although the condition is benign, patients who are concerned about the cosmetic features of localized cutaneous argyria may benefit from laser therapy.PurposeWe describe the clinical and pathologic findings of two women who developed localized cutaneous argyria. We also review the characteristics of other patients with localized cutaneous argyria and summarize the differential diagnosis and treatment options for this condition.Materials and methodsThe features of two women with localized cutaneous argyria are presented. Using PubMed, the following terms were searched and relevant citations assessed: acquired localized argyria, acupuncture, argyria, argyrosis, colloidal silver, cutaneous argyria, and localized cutaneous argyria. In addition, the literature on localized cutaneous argyria is reviewed.ResultsTwo women presented with small, asymptomatic blue-gray macules appearing at sites directly adjacent to ear piercings. A punch biopsy was performed on one woman. Microscopic examination revealed a yellowish-brown colored granular material found adjacent to elastic fibers. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of localized cutaneous argyria was established. The second woman did not undergo a biopsy. However, the clinical presentation was highly suggestive of localized cutaneous argyria. Both women were reassured of the benign nature of the condition and agreed to return for clinical follow-up if they observed any changes in the appearance of the lesions.

Tooth Decorations and Modifications ­ Current Trends and Clinical Implications.

Since earliest times, humans have felt the need to modify and beautify their bodies. Adornments in the form of tooth decorations have featured around the world for generations and continue to evolve. This paper describes current and forthcoming trends. It explores the use of tooth jewels, 'dental grills' and tooth tattoos which are not yet common in the UK, but are currently trending in the United States of America. This article reviews the literature and aims to describe the clinical effects each tooth decoration has on the dentition, along with appropriate management strategies. Owing to the lack of good quality studies, it is difficult to determine accurate effects on the dentition, but dental practitioners should focus on conservative and preventive management strategies. Clinical relevance: This paper describes modern day tooth decorations, explores the possible effects on oral health and suggests management strategies.