Religious Allergic Contact Dermatitis

Henna, derived from a combination of natural leaves and coloring additives, is a common decorative dye traditionally used in many Islamic religious celebrations. Para‐phenylenediamine (PPD), a major component of black henna tattoo, is a strong sensitizer and common allergen. We report a case of severe connubial allergic contact dermatitis after black henna heterotransfer in a girl.     

Retinal disease in the C3 glomerulopathies and the risk of impaired vision

Background: Dense deposit disease and atypical hemolytic uremic syndrome are often caused by Complement Factor H (CFH) mutations. This study describes the retinal abnormalities in dense deposit disease and, for the first time, atypical haemolytic uremic syndrome. It also reviews our understanding of drusen pathogenesis and their relevance for glomerular disease. Methods: Six individuals with dense deposit disease and one with atypical haemolytic uremic syndrome were studied from 2 to 40 years after presentation. Five had renal transplants. All four who had genetic testing had CFH mutations. Individuals underwent ophthalmological review and retinal photography, and in some cases, optical coherence tomography, and further tests of retinal function. Results: All subjects with dense deposit disease had impaired night vision and retinal drusen or whitish-yellow deposits. Retinal atrophy, pigmentation, and hemorrhage were common. In late disease, peripheral vision was restricted, central vision was distorted, and there were scotoma from sub-retinal choroidal neovascular membranes and atypical serous retinopathy. Drusen were present but less prominent in the young person with atypical uremic syndrome due to a heterozygous CFH mutation. Conclusions: Drusen are common in forms of C3 glomerulopathy caused by compound heterozygous or heterozygous CFH mutations. They are useful diagnostically but also impair vision. Drusen have an identical composition to glomerular deposits. They are also identical to the drusen of age-related macular degeneration, and may respond to the same treatments. Individuals with a C3 glomerulopathy should be assessed ophthalmologically at diagnosis, and monitored regularly for vision-threatening complications.     

Prognostic tools for hypertrophic scar formation based on fundamental differences in systemic immunity

Unpredictable hypertrophic scarring (HS) occurs after approximately 35% of all surgical procedures and causes significant physical and psychological complaints. Parallel to the need to understanding the mechanisms underlying HS formation, a prognostic tool is needed. The objective was to determine whether (systemic) immunological differences exist between patients who develop HS and those who develop normotrophic scars (NS) and to assess whether those differences can be used to identify patients prone to developing HS. A prospective cohort study with NS and HS groups in which (a) cytokine release by peripheral blood mononuclear cells (PBMC) and (b) the irritation threshold (IT) after an irritant (sodium lauryl sulphate) patch test was evaluated. Univariate regression analysis of PBMC cytokine secretion showed that low MCP‐1, IL‐8, IL‐18 and IL‐23 levels have a strong correlation with HS (P < .010‐0.004; AUC = 0.790‐0.883). Notably, combinations of two or three cytokines (TNF‐a, MCP‐1 and IL‐23; AUC: 0.942, Nagelkerke R²: 0.727) showed an improved AUC indicating a better correlation with HS than single cytokine analysis. These combination models produce good prognostic results over a broad probability range (sensitivity: 93.8%, specificity 86.7%, accuracy 90,25% between probability 0.3 and 0.7). Furthermore, the HS group had a lower IT than the NS group and an accuracy of 68%. In conclusion, very fundamental immunological differences exist between individuals who develop HS and those who do not, whereas the cytokine assay forms the basis of a predictive prognostic test for HS formation, the less invasive, easily performed irritant skin patch test is more accessible for daily practice.     

Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data

ObjectiveTo evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA).MethodsWe evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012–2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage—overall and within the older (≥65), working-age (18–64) and pediatric (<18) subpopulations—using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends.ResultsOverall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014–2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13–1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29–2.23). The increase was almost entirely attributable to increased Medicaid coverage.ConclusionIn the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.