Cross-sectional Survey of Nickel Allergy Management in the Context of Intracardiac Device Implantation

Association of nickel exposure with body mass index, waist circumference and incidence of obesity in US adults

This study aimed to detect the relationship between nickel exposure and body mass index (BMI), waist circumference and incidence of obesity in the general population of the United States. The National Health and Nutrition Examination Survey (NHANES) 2017-2018 database was utilized, and the sample comprised 1702 participants aged 18 years and above with complete urinary nickel, body mass index, and waist circumference data. Obesity was determined using BMI and waist circumference data. The multivariate linear regression and logistic regression models were utilized to detect the association between urinary nickel concentration and BMI, waist circumference, and incidence of obesity. After multivariable adjustment, the log-transformed urinary nickel concentration was inversely associated with BMI [β = -0.87; 95% confidence interval (CI): (-1.36, -0.38)] and waist circumference [β = -1.51; 95% CI: (-2.93, -0.08)]. Compared with the lowest tertile of urinary nickel, the β value and 95% CI of BMI and waist circumference for the highest tertile were β = -1.65.95% CI: (-2.85, -0.45) and β = -2.78, 95% CI: (-6.17, 0.62), respectively. The log-transformed urinary nickel concentration was also negatively associated with obesity status [adjusted odds ratio (OR) = 0.81, 95% CI: (0.64, 1.01)]. Compared with the lowest tertile of urinary nickel, the adjusted OR and 95% CI of obesity status for the highest tertile were OR = 0.64 and 95% CI: (0.37, 1.12). Smooth curve fitting and the generalized additive model indicated that elevated urinary nickel concentration was associated with decreased BMI, waist circumference, and incidence of obesity. The negative association was consistent and robust in different subgroups, according to stratified analysis. This study found that nickel exposure may be negatively associated with BMI, waist circumference and incidence of obesity in US Adults.

Mediation Effect of Body Mass Index on the Association of Urinary Nickel Exposure with Serum Lipid Profiles

The objective of this study was to determine the relationship of urinary nickel (U-Ni) exposure to serum lipid profiles and the mediation effect of body mass index (BMI) in a US general population. We analyzed the cross-sectional data from 3517 participants in the National Health and Nutrition Examination Survey (NHANES) (2017-March 2020). Multivariable linear regression and restricted cubic spline (RCS) regression were conducted to explore the association of U-Ni with four serum lipids and four lipids-derived indicators. Mediation analysis was performed to examine the effect of BMI on the relationship between U-Ni levels and serum lipid profiles. Compared with the lowest quartile, the β with 95% confidence intervals (CIs) in the highest quartile were - 12.83 (- 19.42, - 6.25) for total cholesterol (TC) (P for trend < 0.001), - 12.76 (- 19.78, - 5.74) for non-high-density lipoprotein cholesterol (non-HDL-C) (P for trend = 0.001) and - 0.29 (- 0.51, - 0.07) for TC/HDL-C (P for trend = 0.007) in the fully adjusted model. RCS plots showed the linear association of log₂-transformed U-Ni levels with TC, non-HDL-C and TC/HDL-C (P for nonlinearity = 0.294, 0.152, and 0.087, respectively). Besides, BMI decreased monotonically in correlation with increasing U-Ni levels (P for trend < 0.001). Mediation analysis revealed that BMI significantly mediated the relationship of U-Ni to TC, non-HDL-C and TC/HDL-C with mediated proportions of 11.17%, 22.20% and 36.44%, respectively. In summary, our findings suggest that BMI mediates the negative association of U-Ni with TC, non-HDL-C, and TC/HDL-C in the US general population.

Transcatheter closure of perimembranous ventricular septal defect using a novel fully bioabsorbable occluder: multicenter randomized controlled trial

Although the use of bioabsorbable occluder is expected to reduce the risk of metal occluder-related complications, it has not been approved due to incomplete degradation and new complications. Novel fully bioabsorbable occluders were designed to overcome such limitations. The aim of this study was to investigate the efficacy and safety of a fully biodegradable occluder in patients with ventricular septal defects. 125 patients with perimembranous ventricular septal defect (VSD) larger than 3 mm were screened from April 2019 to January 2020 in seven centers. 108 patients were enrolled and randomized into the bioabsorbable occluder group (n = 54 patients) and nitinol occluder group (n = 54). A non-inferiority design was utilized and all patients underwent transcatheter device occlusion. Outcomes were analyzed with a 24-month follow-up. All patients were successfully implanted and completed the trial. No residual shunt >2 mm was observed during follow-up. Transthoracic echocardiography showed a hyperechoic area corresponding to the bioabsorbable occluder which decreased primarily during the first year after implantation and disappeared within 24 months. Postprocedural arrhythmia was the only occluder-related complication with an incidence of 5.56% and 14.81% for the bioabsorbable and nitinol groups, respectively (P = 0.112). The incidence of sustained conduction block was lower in the bioabsorbable occluder group (0/54 vs. 6/54, P = 0.036) at 24-month follow-up. In conclusion, the novel fully bioabsorbable occluder can be successfully and safely implanted under echocardiography guidance and reduce the incidence of sustained postprocedural arrythmia. The efficacy and safety of this fully biodegradable occluder are non-inferior to that of a traditional nitinol one.

Urinary Nickel Was Associated with the Prevalence of Diabetes: Results from NHANES

The study aimed to investigate the association between nickel exposure and the presence of diabetes (DM). The participants were analyzed from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018. Urinary nickel exposure was measured using inductively coupled-plasma mass spectrometry. DM was diagnosed based on the WHO standards. The association between nickel and DM or fasting glucose was examined using multivariable linear regression models and logistic regression models. A total of 1899 participants (933 men and 966 women) were included in our study, of whom 342 (18.0%) were diagnosed with DM. There was a significant positive association between nickel level and DM (OR: 1.27, 95%CI: 1.04-1.56) after adjusting for potential confounding factors. Comparing with the lowest quartile, the highest quartile independently increased a 0.66-fold higher risk of DM (OR: 1.66, 95%CI: 1.13-2.44]). In addition, nickel exposure was independently related to the level of fasting glucose. The exposure to nickel was associated with a higher risk of DM in general population.

Association between the urinary nickel and the diastolic blood pressure in general population

AIM

To investigate the association of the level of nickel and blood pressure (BP) level in a general population.

METHODS

A total of 2201 participants were enrolled from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018. Urinary nickel level was measured using inductively coupled-plasma mass spectrometry. Multivariable linear regressions were performed to explore the associations between nickel and systolic BP and diastolic BP. Restricted cubic splines were used to explore the nonlinearity.

RESULTS

Per one-fold increase of nickel was associated with a 0.67-unit decrease of diastolic BP (β -0.67, 95 % confidence interval [CI] [-1.15, -0.18]; p = 0.007). Comparing with the lowest quartile, the highest quartile decreased 2.21-unit diastolic BP (β -2.21, 95 % CI [-3.84, -0.59]; p = 0.007). Restricted cubic spline confirmed the relationship was linear. Subgroup analysis found that the association was only significant in population without hypertension.

CONCLUSIONS

The urinary nickel, as a long-term exposure biomarker, was associated with the diastolic BP in individuals without hypertension.

Efficacy and safety of a parylene-coated occluder for atrial septal defect: a prospective, multi-center, randomized controlled clinical trial

Background:

Nitinol-containing devices are widely used in clinical practice. However, there are concerns about nickel release after nitinol-containing device implantation. This study aimed to compare the efficacy and safety of a parylene-coated occluder vs. a traditional nitinol-containing device for atrial septal defect (ASD).

Methods:

One-hundred-and-eight patients with ASD were prospectively enrolled and randomly assigned to either the trial group to receive a parylene-coated occluder (n = 54) or the control group to receive a traditional occluder (n = 54). The plugging success rate at 6 months after device implantation and the pre- and post-implantation serum nickel levels were compared between the two groups. A non-inferiority design was used to prove that the therapeutic effect of the parylene-coated device was non-inferior to that of the traditional device. The Cochran–Mantel–Haenszel chi-squared test with adjustment for central effects was used for the comparison between groups.

Results:

At 6 months after implantation, successful ASD closure was achieved in 52 of 53 patients (98.11%) in both the trial and control groups (95% confidence interval (CI): [−4.90, 5.16]) based on per-protocol set analysis. The absolute value of the lower limit of the 95% CI was 4.90%, which was less than the specified non-inferiority margin of 8%. No deaths or severe complications occurred during 6 months of follow-up. The serum nickel levels were significantly increased at 2 weeks and reached the maximum value at 1 month after implantation in the control group (P < 0.05 vs. baseline). In the trial group, there was no significant difference in the serum nickel level before vs. after device implantation (P > 0.05).

Conclusions:

The efficacy of a parylene-coated ASD occluder is non-inferior to that of a traditional uncoated ASD occluder. The parylene-coated occluder prevents nickel release after device implantation and may be an alternative for ASD, especially in patients with a nickel allergy.

Allergy Considerations in Implanted Neuromodulation Devices

OBJECTIVES

Allergic reactions are rare and poorly understood complications of neuromodulation device implantation. There are currently no guidelines for management of allergic reactions to these devices and their components. Here we review the published cases of allergic reactions to implanted neuromodulatory devices and leverage the experiences of other specialties that deal with similar complications to formulate recommendations for prevention and management.

MATERIALS AND METHODS

A review and assessment of the literature.

RESULTS

Allergic reactions to a number of implantable devices have been observed and published. In dentistry and orthopedics, metals such as nickel are the most frequent cause of allergic reactions. In interventional cardiology, where devices closely resemble neuromodulatory devices, titanium, silicone, and polyurethanes are the most common causes of allergic reactions. In neurosurgery, allergic reactions to implantable neuromodulatory devices are rare, and we summarize 13 cases published to date. Such allergic reactions generally present as local dermatitis, erythema, and pruritus, which can be difficult to distinguish from surgical site infection. In one published case, symptoms resolved with corticosteroid treatment, but all other cases required explantation. The successful reimplantation with a modified device was reported in some cases.

CONCLUSIONS

Patients should be screened for a personal history of contact allergy before implantation procedures. A multidisciplinary approach to suspected cases of postoperative allergic reactions involving collaboration between neurosurgeons and other implanting physicians, dermatologists or allergists, and device manufacturers is recommended. In cases where an allergic reaction is suspected, an infectious etiology should be ruled out first. Clinical suspicion can then be supported with the use of patch testing, interpreted by an experienced dermatologist or allergist. If patch testing supports an allergic etiology, the implanting physician and the device manufacturer can work together to modify the device for safe reimplantation.