Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

Allergic contact dermatitis caused by dipropylene glycol diacrylate in the Omnipod® insulin pump

BACKGROUND

Cases of allergic contact dermatitis (ACD) caused by isobornyl acrylate (IBOA) in the Omnipod® insulin pump have previously been reported.

OBJECTIVES

To present three cases of patients with ACD caused by a new allergen in the pump, and results from chemical analyses.

METHODS

Omnipod pumps from different batches were analysed by gas chromatography-mass spectrometry. Aimed testing, with the department's medical device (MD) series and substances identified in the pump including dipropylene glycol diacrylate (DPGDA) at 0·01% and 0·1% in petrolatum (pet.), was performed. Patch testing also included extracts from the device, the adhesive patch as is, and allergens from baseline series.

RESULTS

All patients tested positive to 0·1% DPGDA in pet., and two patients additionally to a 0·01% concentration. DPGDA was found in extracts of the Omnipod pumps brought by the patients. An Omnipod pump from an earlier batch contained tripropylene glycol diacrylate, IBOA, N,N-dimethylacrylamide, di(ethylene glycol)ethyl ether acrylate (DEGEA) but no DPGDA. One of the patients reacted positively to all of these allergens except DEGEA, which was not tested.

CONCLUSIONS

When suspecting ACD to MDs, DPGDA at 0·1% in pet. should be tested. The contents of Omnipod have changed over time. Patch testing with updated test series and relevance assessment of positive reactions is a delicate task. Children, with lifelong use of MDs, risk contracting many allergies with potential cross-allergies. A question should be raised as to whether these low molecular weight acrylates should be used at all in devices constantly worn on the skin.

Validation of questionnaire algorithm based on repeated open application testing with the constituents of fragrance mix II: the EDEN Fragrance Study

BACKGROUND

In a European study on contact allergy in the general population, it has been hypothesized that the combination of contact allergy to a fragrance together with a history indicating dermatitis at exposure and thereafter subsequent avoidance of scented products implied a diagnosis of allergic contact dermatitis.

OBJECTIVES

The primary aim of this study was to validate this hypothesis/algorithm. The secondary aim was to investigate whether there was any association between the outcome of the recent repeated open application test (ROAT) and the patch test reactivity.

METHODS

One hundred nine subjects with and without contact allergy to fragrance mix II (FM II) were recruited. Volunteers from six European dermatology clinics participated in the study including a patch test and a ROAT.

RESULTS

Twenty-four positive ROAT reactions were noted in total including 20 of those 32 with contact allergy to FM II. None of the volunteers reacted to the vehicle (P < 0.001). More individuals with a positive algorithm had positive ROATs when compared with those with a negative algorithm. However, the difference was not statistically significant (P = 0.12). The lower the patch test concentration eliciting a positive test reaction, the more likely was a positive ROAT and the more likely that the positive ROAT appeared early during the investigative period.

CONCLUSIONS

The algorithm used in this study was not validated but it was indicated in this ROAT setup. The stronger the patch test reactivity the more likely was a positive ROAT and the more likely it was that the positive ROAT appeared early during the application period.

Hand strength and dexterity in individuals with hand eczema

BACKGROUND

Patients with hand eczema often describe symptoms such as pain, clumsiness and difficulty flexing their fingers, thus impairing the function of the hand.

OBJECTIVE

The aim of this study was to investigate whether hand eczema is associated with a measurable impairment of hand strength and dexterity. We also studied the relationship between hand function and the ability to perform activities of daily living (ADL), pain level and quality of life measured with the Dermatology Life Quality Index (DLQI).

METHODS

Twenty-one participants with ongoing hand eczema were examined with well-established methods for measuring hand grip strength, pinch strength and dexterity. A questionnaire was designed to investigate perceived ability to perform ADL. The participants were also asked to grade their current pain level, and the DLQI was used to assess the participants' quality of life. A group of 12 participants was reinvestigated when healed.

RESULTS

The participants demonstrated a significant improvement in all functional tests when healed. There was a strong correlation between ADL and both dexterity and hand grip strength. There was also a strong correlation between ADL and pain. All participants reported some difficulty performing ADL.

CONCLUSIONS

Our results suggest that ongoing hand eczema may lead to a measurable decrease of strength and dexterity of the hand, leading to an impairment of the ability to perform ADL and consequently to a poorer quality of life.

The epidemic of methylisothiazolinone contact allergy in Europe: follow-up on changing exposures

BACKGROUND

Methylisothiazolinone (MI) has caused an unprecedented epidemic of contact allergy in Europe and elsewhere. Subsequently, regulatory action has been taken, at least in Europe, aiming at reducing risk of MI sensitization.

OBJECTIVE

To follow-up on the prevalence of contact allergy to MI in consecutively patch tested patients and assess the spectrum of products containing MI or methylchloroisothiazolinone (MCI)/MI in patients positive to MI which elicited current allergic contact dermatitis.

METHODS

A cross-sectional survey was performed in 2016 and 2017, including all adult patients patch tested with the baseline series (including MI 0.2% aq.) between 1 May and 31 October at 14 centres in 11 European countries. Patients with positive reactions (+ to +++) to MI were further examined regarding history, clinical characteristics and eliciting products, which were categorized into 34 types and 4 classes (leave-on, rinse-off, household, occupational). The results were compared with the reference year 2015.

RESULTS

A total of 317 patients, n = 202 of 4278 tested in 2016 (4.72%) and n = 115 of 3879 tested in 2017 (2.96%), had positive reactions to MI; the previous result from 2015 was 5.97% (P < 0.0001). The share of currently relevant contact allergy among all positive reactions declined significantly as well (P = 0.0032). Concerning product classes, a relative decline of leave-on and a relative increase of rinse-off and household products was noted.

CONCLUSION

The prevalence of MI contact allergy decreased by 50% from 2015 to 2017. As a consequence of regulation, the share of cosmetics products (leave-on in particular) eliciting allergic contact dermatitis is decreasing. The chosen method of analysing causative products in sensitized patients has proven useful to monitor effects of intervention.

Abstract P1-07-14: Real-life analysis evaluating &gt;1000 N0/N1mi estrogen receptor (ER)+ breast cancer patients for whom treatment decisions incorporated the 21-gene recurrence score (RS) result: Clinical outcomes with median follow up of &gt; 9 years

Background: The 21-gene Recurrence Score (RS) Assay (Oncotype DX®) is a validated prognosticator and predictive of chemotherapy (CT) benefit in patients with hormone receptor (HR)+ human epidermal growth factor receptor 2 (HER2)-negative breast cancer. In Israel, the RS assay has been reimbursed by Clalit Health Services (CHS, the largest HMO in Israel) since 2006, and the assay is widely used in eligible estrogen receptor (ER)+ patients. Notably, ER+ breast cancer patients have a protracted risk of recurrence with approximately half of all distant recurrences occurring after 5 years from diagnosis. The goal of the current ongoing analysis was to investigate early (≤5 years) and late (&gt;5 years) distant recurrence in N0/N1mi ER+ HER2-negative breast cancer patients who were RS-tested through CHS.

Methods: This analysis of the CHS registry included breast cancer patients with ER+ HER2-negative N0/N1mi disease who underwent RS testing from 1/2006 (CHS approval of the assay) through 1/2009. Data sources included CHS claims arms (for patient/tumor characteristics), Teva Pharmaceuticals (for tumor characteristics, RS result), and medical records (for treatment/recurrence/survival). The study was approved by the institutional review boards of the CHS Community Division and was granted a waiver for obtaining patient consent.

Results: The analysis included 1026 patients with median (interquartile range) follow up of 9.3 (8.8-10.2) years. Most patients were females (99%). Median (range) age was 59 (25-84) years; 92% had N0 and 8% had N1mi disease; 14%, 52%, and 16% had grade 1, 2, and 3 tumors, respectively (grade information was not available for 18% of patients); median (range) tumor size was 1.5 (0.3-6.5) cm. The majority of patients (78%) had invasive ductal carcinoma and 12% had invasive lobular carcinoma. Overall, 489 patients (48%) had RS&lt;18, 434 (42%) had RS 18-30, and 103 (10%) had RS≥31. The use of adjuvant CT was consistent with the RS result: 3%, 27%, and 90% of RS&lt;18, RS 18-30, and RS≥31 patients, respectively. Overall, 25 distant recurrences were reported within 5 years of RS testing: 5 (1.0%) in RS&lt;18 patients, 9 (2.1%) in RS 18-30 patients, and 11 (10.6%) in RS≥31 patients. In the first 5 years, breast cancer-specific death was reported in 8 patients including 3 (0.7%) with RS 18-30 and 5 (4.9%) with RS≥31 results. Among N0 patients with RS 11-25 who did not receive adjuvant CT (n = 540), 5 (0.9%) distant recurrences and one (0.2%) breast cancer death were reported within 5 years of RS testing. Analysis of 'late' recurrences and breast cancer-specific death (from 5 to 9.3 years of follow-up) is ongoing.

Conclusions: These will be the first late recurrence data from over 1000 patients for whom the RS result was used in real-life clinical decision making. Consistent with previous analyses of the CHS registry, CT use was appropriately based on the RS result, and the recurrence/survival outcomes (for the first 5 years) demonstrated the prognostic performance of the RS. Distant recurrence and breast cancer death data beyond 5 years will be presented at the meeting.

Citation Format: Stemmer SM, Rizel S, Steiner M, Geffen DB, Soussan-Gutman L, Bareket-Samish A, McCullough D, Svedman C, Nisenbaum B, Ryvo L, Peretz T, Fried G, Rosengarten O, Liebermann N, Ben Baruch N. Real-life analysis evaluating &gt;1000 N0/N1mi estrogen receptor (ER)+ breast cancer patients for whom treatment decisions incorporated the 21-gene recurrence score (RS) result: Clinical outcomes with median follow up of &gt; 9 years [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-14.

Abstract P6-09-08: Real-world clinical experience and outcomes in patients with early-stage breast cancer (EBC) treated according to the 21-gene recurrence score® (RS) result

Evaluating the merits of a genomic assay includes measuring analytic and clinical validity, and establishing clinical utility—a property that is not consistently defined. One definition of clinical utility that has gained traction is “the balance of benefits and harms associated with the use of the test in practice” [Genet Med. 2015; doi:10.1038/gim.2015.173].

The 21-gene RS assay is the only assay clinically validated for both prognosis and prediction of chemotherapy (CT) benefit in patients with node-negative (N0) or node-positive (N+), ER+, HER2− EBC. The original clinical validation studies were prospectively designed using archived tissue from legacy trials that had long-term outcomes (NSABP B-14 and B-20, TransATAC, and SWOG 8814). With 10+ years of the RS assay in clinical use, we now have real-world, prospective outcomes for patients with N0 or N+ disease that meet the aforementioned definition of clinical utility.

Here we summarize the growing body of clinical evidence including the original validation studies, prospective outcomes-based trials, and analyses from two large, real-world registries in which patients were treated based on RS results: the US SEER and Clalit Health Services registries.

The US SEER registry is a population-based cancer surveillance program that covers 30% of the US population and includes 40,134 N0 and 4,691 N+ patients with RS results. The Clalit Health Services registry, from the largest HMO in Israel, has 2,028 N0 and micrometastatic (Nmi) patients who were uniformly tested and had complete treatment information. In the SEER and Clalit cohorts, the distribution of RS results were similar for N0/Nmi and N+ patients: 54% and 57% low (&lt;18), 38% and 36% intermediate (18-30), and 8% and 7% high (≥31), respectively. 5-year outcomes by RS group show that patients with low RS results of any nodal status (N0/Nmi/N1-3) had similar outcomes (Table). Outcomes by RS group and age or grade were also similar for patients with low RS results of any nodal status.

5-y BC-specific Mortality (95% CI) SEER RegistriesClalit Registry N0a (N=38,568)Known CT use (% of N)N+b (N=4,691)Known CT use (% of N)N0/Nmic (N=2,028)Known CT use (% of N)RS &lt;180.4% (0.3%-0.6%)7%1.0% (0.5%-2.0%)23%0.0% (0.0%-0.0%)2%RS 18-301.4% (1.1%-1.7%)34%2.3% (1.3%-4.1%)47%1.1% (0.5%-2.1%)25%RS ≥314.4% (3.4%-5.6%)69%14.3% (8.4%-23.8%)75%6.8% (4.1%-11.2%)88%a. Includes patients 40-84 years of age only (HR+, HER2−, nonmetastatic EBC). b. Includes Nmi and up to three positive nodes [N+(mi,1-3)]. c. Includes 1,815 (89%) N0 and 213 (11%) Nmi.

In summary, after 10+ years of clinical use, the 21-gene RS assay has now amassed a body of clinical evidence from &gt;50,000 patients that confirms the original clinical validation results and supports its clinical utility. The assay identifies patients with low RS results who can be safely and effectively treated with hormonal therapy alone and spared the toxicity of CT exposure. In aggregate, these data support the clinical utility of the 21-gene RS assay and its value to physicians and patients by providing information based on individual tumor biology that they can use to tailor treatment.

Citation Format: Sing AP, Rothney M, Svedman C, Shak S, Baehner FL. Real-world clinical experience and outcomes in patients with early-stage breast cancer (EBC) treated according to the 21-gene recurrence score® (RS) result [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-08.

Abstract P2-07-01: Association of TILs with clinical parameters, recurrence score, and prognosis in patients with early HER2-negative breast cancer (BC) – A translational analysis of the prospective WSG planB trial

Introduction:

Tumor-infiltrating lymphocytes (TILs) have been associated with prognosis and with chemotherapy response among patients with BC, particularly in presence of high-risk features. The WSG planB trial randomized 2448 patients with HER2- N0/1 BC for comparison of anthracycline-free (6xTC) vs. standard anthracycline-taxane chemotherapy (4xEC-4xDoc). Recurrence Score® (RS) was incorporated for risk stratification in hormone receptor positive (HR+) BC. The present analysis focuses on the correlation of TILs with clinical/pathological parameters and their prognostic impact among planB patients.

Methods:

Stromal TILs were evaluated using a pathologist and two-observer approach. Three independent observers evaluated digital sections on H&E staining as previously suggested (Salgado et al., Ann Oncol. 2014); the median of the three values (TILmed) was used for statistical analysis. Spearman correlations of TILmed with clinical/pathological parameters (including central KI67 expression, quantitative ER measurements, nodal involvement, and RS) and univariate impact on event-free survival (EFS) were analyzed.

Results:

Our analysis included 300 patients with HR- and 1124 patients with HR+ HER2- BC. Both in HR- and HR+ BC, a significant association between TILmed and (i) central grading (correlation coefficient r=0.147, p=0.012 and r=0.195, p&lt;0.001, respectively) and (ii) central Ki67 expression (r=0.202, p=0.001 and r=0.152 and p&lt;0.001) was observed. Among HR+ cases, a significant association between TILmed and quantitative ER measurements (r=-0.412, p=0.041) and RS (r=0.190, p&lt;0.001) was found. Furthermore, univariate Cox analysis revealed a significant association between TILmed (coded as fractional rank) and event-free survival (EFS). The hazard ratio of 75th to 25th percentile was 1.58 (95%CI: 1.06-2.36, p=0.025). This impact was not separately significant in HR subgroups due to lack of events

Conclusion:

In this dataset, presence of stromal TILs was moderately associated with clinical features of high-risk breast cancer (including RS) and decreased EFS. TILs will be evaluated as a prognostic or predictive factor (in multivariate and subgroup analyses) when the outcome results are evaluated after prolonged follow up. Furthermore, an updated analysis including the complete planB dataset will be presented.

Citation Format: Liedtke C, Gluz O, Heinisch F, Feuerhake F, Kreipe HH, Clemens M, Nuding B, Kraemer S, Reimer T, Svedman C, Shak S, Nitz U, Kates RE, Harbeck N, Christgen M. Association of TILs with clinical parameters, recurrence score, and prognosis in patients with early HER2-negative breast cancer (BC) – A translational analysis of the prospective WSG planB trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-07-01.

Abstract P6-05-11: Run-in phase of prospective WSG-ADAPT HR+/HER2- trial demonstrates feasibility of early endocrine sensitivity prediction by recurrence score and conventional parameters in clinical routine

Background: Despite promising evidence regarding outcome prediction, endocrine sensitivity, as determined by proliferation response to short-term preoperative endocrine therapy, is currently not included in adjuvant chemotherapy decisions in early HR+/HER2- breast cancer (BC).

Methods: The prospective WSG-ADAPT HR+/HER2- trial includes early BC patients with 0-3 positive LN who are candidates for adjuvant chemotherapy based on clinical-pathological criteria alone; it aims to spare chemotherapy in a substantial proportion utilizing a combination of genomic assessment by Oncotype DX and endocrine sensitivity testing. All patients received 3-week preoperative endocrine induction therapy (ET): aromatase inhibitors (AI) if postmenopausal, tamoxifen if premenopausal. Patients with low (0-11) Recurrence Score (RS) or intermediate RS (12-25) and ET response (centrally tested, post-therapy Ki-67 &lt;10%) are recommended to forego adjuvant chemotherapy (“low-risk” patients). Distribution of RS, responder percentages in each group, and impacts of RS, ET regimen, and initial Ki-67 on post-therapy Ki-67 are reported here.

Results: As of 6/2013, 380 patients from 30 study centers had been enrolled in the ADAPT HR+/HER2- trial. Median age was 54 years. At first pre-planned analysis (5/2013), paired Ki-67 measurements (pre-/post-therapy) were available in 241 patients; RS was available in 208 cases (201 with paired Ki-67). RS was low in 21.6%, intermediate in 57.7%, and high in 20.7%; the respective risk group responder percentages (post-treatment Ki 67 &lt;10%) were 84.1%, 73.9%, and 40.0% (p&lt;0.001 when comparing low/intermediate vs. high, chi-square). In particular, these percentages support the pre-trial estimate of &gt;70% endocrine responders in the intermediate genomic risk group, who could potentially be spared adjuvant chemotherapy. Median Ki 67 level decreases (as percentage of pre-treatment value) were 25% in premenopausal patients (tamoxifen, n = 101) vs. 75% in postmenopausal patients (AI, n = 115) (p&lt;0.001, Mann-Whitney); median decreases by RS group were similar, 61% (low), 53% (intermediate) and 56% (high), respectively (p = 0.81, Kruskal-Wallis). In linear regression, pre-treatment Ki-67, endocrine regimen/menopausal status, and RS were all independent predictors for post-treatment Ki 67. Final run-in-phase analysis and validation will be presented after completion of endocrine induction therapy in 400 patients.

Conclusions: The Run-In Phase of the WSG ADAPT HR+/HER2- trial confirms trial design estimates of RS and proliferation response to induction ET. It indicates that the multicenter prospective ADAPT concept combining static and dynamic biomarker assessment for individualized therapy decisions in early BC is feasible. Proliferation response was strongly associated with therapy group (AI/post-menopausal vs. tamoxifen/pre-menopausal). Survival non-inferiority of intermediate Recurrence Score proliferation responders vs. low Recurrence Score patients (active control) will be tested in the ADAPT main phase to determine if adjuvant chemotherapy can be spared in 70% of patients with 0-3 positive LN classified as “intermediate risk” by conventional factors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-11.

Stability of fragrance patch test preparations applied in test chambers

BACKGROUND

Petrolatum patch test preparations are for practical reasons often applied in test chambers in advance, several hours or even days before the patient is tested. As many fragrance compounds are volatile it may be suspected that petrolatum preparations applied in test chambers are not stable over time.

OBJECTIVES

To investigate the stability of petrolatum preparations of the seven chemically defined components in the fragrance mix (FM I) when stored in test chambers.

METHODS

Samples of petrolatum preparations applied in test chambers stored at room temperature and in a refrigerator for between 4 and 144 h were analysed using liquid chromatographic methods.

RESULTS

The concentration decreased by ≥ 20% within 8 h in four of seven preparations stored in Finn chambers at room temperature. When stored in a refrigerator only the preparation of cinnamal had decreased by ≥ 20% within 24 h. The stability of preparations of cinnamal stored in IQ chambers with a plastic cover was slightly better, but like the preparations applied in Finn chambers, the concentration decreased by ≥ 20% within 4 h at room temperature and within 24 h in a refrigerator. Cinnamal and cinnamyl alcohol were found to be more stable when analysed as ingredients in FM I compared with when analysed in individual preparations.

CONCLUSIONS

Within a couple of hours several fragrance allergens evaporate from test chambers to an extent that may affect the outcome of the patch test. Application to the test chambers should be performed as close to the patch test occasion as possible and storage in a refrigerator is recommended.

High frequency of contact allergy to gold in patients with endovascular coronary stents

BACKGROUND

Stent implantation is an effective method for treatment of atherosclerotic disease. Factors predisposing to in-stent restenosis are still largely unknown. Contact allergy to metal ions eluted from the stent has been suggested to be a risk factor.

OBJECTIVES

To explore whether there is a possible induction of contact allergy to metals used in stents among patients with a stainless steel stent containing nickel (Ni stent) and patients with a gold-plated stent (Au stent).

METHODS

Adults (n = 484) treated with coronary stent implantation participated in the study with patch testing. The study design was retrospective and cross-sectional with no assessment of contact allergy before stenting. Age- and sex-matched patch-tested patients with dermatitis (n = 447) served as controls.

RESULTS

Of Au-stented patients, 54 of 146 (37%) were allergic to gold compared with 85 of 447 (19%) controls (P < 0.001). Within the stented population there were no statistically significant differences in contact allergy to gold or nickel between Ni-stented and Au-stented patients. In multivariate models where other risk factors for contact allergy to gold were considered, the Au stent showed a trend towards statistical significance (odds ratio 1.43, 95% confidence interval 0.95-2.16; P = 0.09).

CONCLUSIONS

As the frequency of contact allergy to gold is higher in stented patients independent of stent type it suggests a previous sensitization. However, several pieces of circumstantial evidence as well as statistical analysis indicate the possibility of sensitization in the coronary vessel by the Au stent. Ni stents and Au stents should not be ruled out as risk factors for induction of contact allergy to these metals.

The utilization of new oncology drugs: A global perspective

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Background: A number of new innovative cancer drugs have recently been approved or are in the process of being approved. We have analysed the access and uptake of 65 oncology drugs in 25 countries (19 European countries, Australia, Canada, Japan, New Zealand, South Africa and the USA) over a 10 year period based on sales data provided by IMS Health. Methods: We calculated an index of number of patients treated based on sales per inhabitant or per person who died from a specific cancer type. The age composition (vintage) of the drug arsenal used was calculated based on sales for cancer drugs introduced before 1995; between 1995–1999, 2000–2002 and after 2002 respectively. The vintage of the drug arsenal used was also analysed in relation to different economic and health care system characteristics. We performed three types of analysis of the effect of cancer drug vintage on cancer survival and mortality using difference-in-difference research designs. Results: Different patterns of uptake were seen in the countries studied, both with respect to speed of uptake and level of use. Fast uptake of most new drugs was seen in Austria, France, Switzerland, Spain and the USA, and slow uptake as well as low usage was seen in Poland, Hungary, New Zealand, South Africa and the UK. For some of the most recently approved drugs the variation in uptake is especially marked. The vintage of the cancer drug “arsenal” used also differs significantly between countries. Nearly half (44%) of the observed improvement in the two-year cancer survival rate between 1992 and 2000 at 50 USA cancer centres could be attributed to the use of newer cancer drugs. Around one sixth (14% − 19%) of the inter-country differences in 5-year cancer survival rates across 5 major European countries is due to differences in the uptake of newer drugs (post-1985) in each country. Nearly one third (30%) of the decline in cancer mortality rates seen during the period 1995 –2003, could be accounted for by the use of newer drugs. The observed decrease in mortality of 16% would have been only 11% if newer drugs had not been used. Conclusions: Patient access to innovative cancer drugs varies significantly between countries affecting mortality rates, and further research is needed into the determinants and consequences of these variations.

No significant financial relationships to disclose.

The use of innovative oncology drugs in Europe

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Background: A number of new innovative cancer drugs have recently been approved or are in the process of being approved. Rapid patient access to new innovative drugs is important as it may lead to improved survival. Methods: We have analysed the access and uptake of new oncology drugs in 19 European countries over a 15 year period based on sales data provided by IMS Health. In the study we focus on select, “targeted” drugs that have been introduced over the last 10 years: rituximab, trastuzumab and imatinib. We have also analysed data to assess the composition of the drug “arsenal” used in the selected countries based on % of total sales for cancer drugs introduced before 1993; between1993–1998 and after 1999. Results: We see different patterns of uptake in countries studied, both with respect to speed and level of usage, in relation to use per person dying of the specific cancers.. Fast uptake is seen in Austria, Switzerland and Spain, and slow uptake as well as low usage is seen in Poland, Hungary, Norway and the UK. For example, trastuzumab uptake indicates that countries with the fastest uptake treat the majority of HER2 over expressing metastatic breast cancer patients within 2–3 years after introduction while countries with slow uptake still after 5 years seem to have a large proportion of patients not receiving trastuzumab treatment. On the other hand, for a drug like imatinib the uptake has been more rapid and uniform in most countries. The composition of the cancer drug “arsenal” used also differs significantly in between countries. Conclusions: Patient access to innovative cancer drugs varies significantly between European countries.

[Table: see text]

Contact allergy to gold in patients with gold-plated intracoronary stents

An increasingly common and effective method for the treatment of atherosclerotic disease in the coronary arteries is percutaneous transluminal coronary angioplasty (PTCA) and stenting. The stents are made of different metals. An increased rate of restenosis when using gold-plated stents has been shown. Contact allergy to gold is common in many countries. Recently, a study has shown an increased rate of contact allergy to nickel among patients with restenosis and a nickel-containing stent. The aims of our study were to investigate whether there was an increased rate of contact allergy to gold among patients with gold-plated stents and if this increased the risk of restenosis. 22 patients who had received a gold-plated stent were patch tested. An age- and sex-matched population of 88 patients, previously patch tested because of a suspected contact dermatitis, served as controls. In the stent group, 10/22 (45.5%) had a contact allergy to gold, in the control group 18/88 (20.5%); the difference is statistically significant (P = 0.04). There was no significant difference regarding frequency of restenosis. Our study indicates that there is a risk of sensitizing the patient when implanting a gold-plated stent. Further studies are needed to confirm these results and to evaluate whether there is an increased risk of restenosis.

Ulcus vulvae acutum, a rare diagnosis to keep in mind

Genital ulceration is today often thought to be caused by herpes simplex. In this case report, a rare differential diagnosis, ulcus vulvae acutum is described, probably caused by Epstein-Barr virus (EB-virus).

Contact allergy to isoeugenol and its derivatives: problems with allergen substitution

A total of 2261 (808 male, 1453 female) consecutive patients attending contact dermatitis clinics were patch tested to isoeugenol and its derivatives listed in the EU Inventory of Fragrance Ingredients. Positive reactions were found to isoeugenol in 40, transisoeugenol in 40, isoeugenyl acetate in 19, isoeugenyl benzoate in 4, isoeugenyl phenylacetate in 16, isoeugenyl methyl ether in 6 and benzyl isoeugenyl ether in 2 patients. There was a concomitant reaction to isoeugenol in 36/40 of those positive to transisoeugenol, 13/19 of those to isoeugenyl acetate, 3/4 of those to isoeugenyl benzoate and 15/16 of those to isoeugenyl phenylacetate but in none of those 6 positive to isoeugenyl methyl ether and in neither of those 2 positive to benzyl isoeugenyl ether. Concomitant contact allergy between isoeugenol and its derivatives may occur through chemical cross-reactivity or local skin metabolism of the derivatives. It is more commonly observed with the esters rather than the ethers. Isoeugenyl acetate has been proposed as an alternative to isoeugenol, but there is a high degree of concomitant reactivity with isoeugenol.

Citral a fragrance allergen and irritant

Citral is a well known contact allergen and a contact irritant. Routine patch testing in the past may have been restricted because of possible irritant (IR) patch test responses. 586 consecutive patients, with hand eczema, were patch tested with a selection of fragrances including citral 2% petrolatum and the European standard series. 28 of the patients showed a positive patch test reaction (+ to +++) to citral and 82 at least 1 IR patch test reaction and no positive patch test reaction to citral. A statistically significant association between a positive patch test reaction to citral and positive patch test reactions to other fragrances compared with IR reactions (n = 82) was established. The difference regarding fragrance history found between those with IR and positive reactions to citral was not significant. Citral could be an allergen and/or irritant, worthy of further more extensive studies.

Hydroxyisohexyl 3-cyclohexene carboxaldehyde- known as Lyral®: quantitative aspects and risk assessment of an important fragrance allergen

Hydroxyisohexyl 3-cyclohexene carboxaldehyde, also known as Lyral, is a fragrance ingredient identified as the cause of contact allergic reactions in 2-3% of eczema patients undergoing patch testing. Lyral has been included in the standard patch test series in many clinics due to its importance as an allergen. It has been used without restrictions in cosmetic products, until now. In the present study, the dose-response relationship of Lyral contact allergy was studied with doses relevant for normal exposure in cosmetic products. 18 eczema patients, who previously had given a positive patch test to Lyral 5% petrolatum, were included along with 7 control subjects. All cases were tested with a serial dilution of Lyral in ethanol 6% to 6 p.p.m and subjected to a 2-week, repeated open application test with a low dose of Lyral in ethanol. In the case of no reaction, this was followed by another 2 weeks of testing with a higher dose. The test was performed at the volar aspect of the forearm. In 16 of 18 cases (89%), a positive use test developed, 11 reacting to the low and 5 to the high concentration. None reacted to the vehicle control of ethanol applied to the contralateral arm. All controls were negative to both the test solutions of Lyral and the ethanol control. The difference between the test and the control group was statistically significant (Fisher's test, P < 0.001). It is concluded that Lyral at the current usage levels is inducing sensitization in the community. The same levels were shown to elicit allergic contact dermatitis in almost all sensitized individuals. A significant reduction in usage concentrations is recommended to prevent contact allergic reactions.

The fragrance hand immersion study - an experimental model simulating real-life exposure for allergic contact dermatitis on the hands

Recently, we showed that 10 x 2% of consecutively patch-tested hand eczema patients had a positive patch test to a selection of fragrances containing fragrances relevant to hand exposure. In this study, we used repeated skin exposure to a patch test-positive fragrance allergen in patients previously diagnosed with hand eczema to explore whether immersion of fingers in a solution with or without the patch-test-positive fragrance allergen would cause or exacerbate hand eczema on the exposed finger. The study was double blinded and randomized. All participants had a positive patch test to either hydroxycitronellal or Lyral (hydroxyisohexyl 3-cyclohexene carboxaldehyde). Each participant immersed a finger from each hand, once a day, in a solution containing the fragrance allergen or placebo. During the first 2 weeks, the concentration of fragrance allergen in the solution was low (approximately 10 p.p.m.), whilst during the following 2 weeks, the concentration was relatively high (approximately 250 p.p.m.), imitating real-life exposure to a household product like dishwashing liquid diluted in water and the undiluted product, respectively. Evaluation was made using a clinical scale and laser Doppler flow meter. 3 of 15 hand eczema patients developed eczema on the finger immersed in the fragrance-containing solution, 3 of 15 on the placebo finger and 3 of 15 on both fingers. Using this experimental exposure model simulating real-life exposure, we found no association between immersion of a finger in a solution containing fragrance and development of clinically visible eczema on the finger in 15 participants previously diagnosed with hand eczema and with a positive patch test to the fragrance in question.

Deodorants: an experimental provocation study with hydroxycitronellal

Axillary dermatitis is a common problem, particularly in individuals with contact allergy to fragrances. Many individuals suspect their deodorant to be the causal product of their fragrance allergy. It has been shown that deodorants containing cinnamic aldehyde (cinnamal) can elicit axillary dermatitis in patients sensitized to this substance. The aim of the present investigation was to evaluate the importance of hydroxycitronellal used in deodorants for the development of axillary dermatitis, when applied by individuals with and without contact allergy to this fragrance chemical. Patch tests with deodorants and ethanolic solutions containing hydroxycitronellal, as well as repeated open application tests (ROAT) with roll-on deodorants with and without hydroxycitronellal at different concentrations, were performed in 14 dermatitis patients, 7 with and 7 without contact allergy to hydroxycitronellal. A positive ROAT was noted only in the patients hypersensitive to hydroxycitronellal (P < 0.001) and only in the axilla to which the deodorants containing hydroxycitronellal had been applied (P < 0.001). Deodorants containing hydroxycitronellal in the concentration range of 0.032-0.32% used twice daily on healthy skin in individuals hypersensitive to hydroxycitronellal can elicit axillary dermatitis in a few weeks.

Skin mini-erosion technique for monitoring metabolites in interstitial fluid: its feasibility demonstrated by OGTT results in diabetic and non-diabetic subjects

The aim of this study was to evaluate a new interstitial fluid (IF) sampling technique and its application in diabetology. IF and venous whole blood were sampled serially during an oral glucose tolerance test (OGTT) on days 1 and 3 after formation of a mini-erosion in eight non-diabetic controls and eight Type 2 diabetic subjects. Glucose, lactate, glycerol, 3-hydroxybutyrate and insulin were assayed in IF and plasma. With solitary exceptions, the IF sample volumes were in excess of those required for measurement of all five substances. However, mean IF sampling rates differed significantly both between the non-diabetic and diabetic groups and between days 1 and 3 (p < 0.001 in all cases). In both groups, the OGTT curves of glucose, glycerol and 3-hydroxybutyrate were similar to the respective curves for plasma, whereas for lactate concentrations they were markedly greater in IF than in plasma (40% and 93% in the control group and 57% and 100% greater in the diabetic group on days 1 and 3, respectively). The reverse was true of insulin concentrations in the non-diabetic group, which were 57% and 74% lower in IF than in plasma on days 1 and 3, respectively. In the non-diabetic group, the baseline (pre-OGTT) insulin level in IF increased from 49 +/- 22% (SD) of that in plasma on day 1 to 74 +/- 19% of that in plasma on day 3 (p=0.005). Sampling site re-epithelialization was rapid. In conclusion, the feasibility of transdermal sampling of IF via a skin mini-erosion has been demonstrated in both diabetic and non-diabetic subjects.

The veno-arteriolar reflex in venous leg ulcer patients studied by laser Doppler imaging

Posture-induced microcirculatory changes in the lower leg were studied in venous leg ulcer patients and in control subjects by means of laser Doppler imaging (LDI), a technique which allows almost real-time mapping of the perfusion from a distance, each perfusion value constituting the mean of a number of measurements at separate sites. LDI values for intact skin with the subject supine were 0.39 (0.32, 0.47) V [geometric mean (gm -SD, gm +SD)] and 0.32 (0.15, 0.70) V in two age groups of controls and 0.91 (0.66, 1.24) V in patients (NS). Values were 2.04 (1.25, 3.35) V for skin at the ulcer margin, and 1.44 (0.72, 2.88) V in the ulcer proper. With the lower leg passively dependent, lower LDI values were obtained at all sites in all groups, the reduction in intact skin value being 62 +/- 11% (arithmetic mean +/- SD) (p < 0.01) in the younger controls, 43 +/- 24% (p < 0.01) in the older controls and 62 +/- 19% (p < 0.001) in the patient group, and the reduction in ulcer values being 45 +/- 27% (p < 0.05) for the margin and 52 +/- 23% (p < 0.001) for the ulcer proper. Thus, a high degree of postural vasoconstriction was present overall, even in the ulcer itself. Vasomotor tone in the skin of the lower leg was assessed by topical application of methyl nicotinate, a vasodilator. The skin perfusion value (supine position, no stimulus) was 71 +/- 31% (p < 0.01) of the drug-induced (assumed peak) hyperaemia value [0.60 (0.30, 1.10) V] in patients and 24 +/- 25% (p < 0.001) of the hyperaemia value (1.30 (0.64, 2.62) V] in the controls. It would appear that in ulcer patients the veno-arteriolar reflex, despite being comparable in magnitude to that in controls, may nonetheless be insufficient to reduce tone during dependency to a level similar to that in healthy controls.

Skin mini-erosion sampling technique: feasibility study with regard to serial glucose measurement

PURPOSE

To describe a dermally non-invasive serial sampling technique and to test its clinical feasibility with regard to glucose measurement.

METHODS

A standardized skin mini-erosion devoid of the epidermal barrier, and covered by an artificial one, was formed by a suctioning technique. Interstitial fluid (IF) was extracted serially by brief application of negative pressure, and its glucose content compared with that in capillary or venous blood samples.

RESULTS

The procedure caused no discomfort. The epidermis regenerated rapidly after experimentation. There were no complications. In non-diabetic subjects (n = 13) the mean of all IF values measured daily for 6 days was 6.2 +/- 0.1 mmol/l (+/-SE). The corresponding capillary blood glucose value was 5.6 +/- 0.1 mmol/l, and the venous glucose value was 5.4 +/- 0.1 mmol/l. The differences between IF glucose values and invasive control values remained within narrow limits throughout. The 2SD limits of agreement for the differences were 1.44 mmol/l (IF vs. capillary blood samples) and 1.76 mmol/l (IF vs venous samples) respectively. The OGTT curves suggested glucose kinetics to be similar in IF and in capillary blood. In diabetic subjects, the mean of IF values determined serially during one day was 15.3 +/- 1.0 mmol/l (range, 6.7-21.8 mmol/l), and the corresponding mean capillary value was 12.0 +/- 0.9 mmol/l (range, 3.3-17.2 mmol/l). The ICC for all paired photometric observations was 0.948.

CONCLUSIONS

The results suggest the new sampling technique to be a feasible approach for clinical and experimental purposes. A functionally integrated sampling patch is entering the clinical testing stage.

Laser Doppler imaging of skin microcirculation

Laser Doppler imaging (LDI), a new technique which allows measurement of skin blood perfusion at a distance from the skin surface, was assessed methodologically in healthy volunteers. Each skin LDI value was based on virtually real-time measurements obtained from a number of discrete measuring sites. In scans made along the circumference of the lower arm, valid figures for LDI (as distinct from no output at all) were obtained in 8/8 measurements at 0 degrees inclination, and in 16/16 measurements at 7 degrees, 14 degrees, 22 degrees, 30 degrees and 38 degrees, respectively. Beyond this inclination a numerical output was obtained in only 9/16 of measurements at an inclination of 48 degrees, in 7/16 at 69 degrees, and in no more than 1/16 at 90 degrees. Values obtained at angles of inclination greater than 38 degrees fell within the relatively narrow range of values obtained at lesser angles of inclination. The findings are of interest since measuring sites of clinical importance may not be flat. Variability of measurement (coefficient of variation in per cent) was studied in the lower leg by performing LDI and conventional laser Doppler flowmetry (LDF) concomitantly. The coefficient of variation for measurements in one subject at rest was 13% for LDI vs. 19% for LDF, the corresponding interindividual coefficient of variation values being 25% vs. 28%. In response to heating, finger pulp perfusion increased by 55% as measured by LDI (p = 0.0051) and by 44% (p = 0.0756) as measured by LDF. In summary, the findings contribute to the validation of LDI for skin perfusion measurement.