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Background: Cobalt was recently identified in a leather couch responsible for dermatitis. Cobalt content/release in leather in the United States is unknown. We evaluated leather for cobalt content/release and investigated screening methods for identifying cobalt in leather., Methods: One hundred thirty-one leather swatches were screened for cobalt content/release with X-ray fluorescence (XRF) spectrometry and cobalt indicator solution (CIS). Samples with positive screens and 1 negative control were analyzed using inductively-coupled plasma mass spectrometry (ICPMS)., Results: CIS showed that 5 of 131 samples contained cobalt, subsequently found to be between 1 and 190 parts per million (ppm) when evaluated with ICPMS. The XRF analysis showed that 6 samples contained >5% cobalt, subsequently found to contain greater than 300 ppm cobalt by ICPMS. 7 of 12 tested swatches contained cobalt in excess of 100 ppm. One sample contained greater than 1000 ppm cobalt. The prevalence of swatches containing cobalt at levels in excess of 190 ppm was at least 5% (n = 7; total, N = 131)., Discussion: Some leather consumer goods contain and release cobalt. Cobalt indicator solution is a poor screening test for cobalt in leather while XRF screening may be effective. Leather is a new source of cobalt exposure. Exposures to metal allergens are changing in ways that impact clinical decision making.

Background: Several studies have shown nickel and cobalt release from jewellery by using spot tests, but the metal composition of jewellery is largely unknown., Objectives: To evaluate the metal composition of a large worldwide sample of mainly inexpensive jewellery items, and investigate the release of nickel, cobalt and lead from a subsample by using EN 1811:1998-required methods., Methods: A total of 956 metallic jewellery components were examined with X-ray fluorescence spectroscopy. A subsample of 96 jewellery items purchased in the United States were investigated for nickel, cobalt and lead release by the use of artificial sweat immersion and plasma optical emission spectroscopy., Results: Eighteen elements were detected. The 10 most frequently occurring were, in order of frequency, copper, iron, zinc, nickel, silver, chromium, tin, manganese, lead, and cobalt. Release of nickel was noted from 79 of the 96 US samples (0.01-98 µg/cm(2) /week), release of cobalt from 35 samples (0.02-0.5 µg/cm(2) /week), and release of lead from 37 samples (0.03-2718 µg/cm(2) /week)., Conclusions: We present here a comprehensive list of the most frequently encountered metals in jewellery and fashion accessories. Different allergenic and non-allergenic metals are utilized. We also report the frequent release of nickel, cobalt and lead from these objects, despite legislative restrictions., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: With the increased implementation of ultrasound in medical education, it is important to continually improve instructional methods. In this study, we demonstrate that by augmenting the traditional methods of instructor demonstration and student practice on a healthy volunteer with additional modalities, such as didactic presentation, simulated pathologic cases, and simulated procedures, students gain a more comprehensive understanding of and confidence in ultrasound technique and pathology., Methods: A multimodal curriculum was developed and applied to head and neck ultrasound sessions of our institution's Ultrasound Symposium. Participants were asked to fill out surveys rating each instructional modality as well as preinstructional and postinstructional confidence. The survey results were divided into a group of first- and second-year medical students who had previous ultrasound training and a group of third- and fourth-year students who were ultrasound "naïve.", Results: The survey showed that the first- and second-year student group (n = 8) had an average preinstructional confidence of 4.14/10 compared to 1.44/10 in the third- and fourth-year student group (n = 9) (P = .003). Following the instructional sessions, the students' confidence increased respectively to 8.14/10 and 7.78/10 (P= .53), showing a 4.00 (96%) increase in the first- and second-year group and a 6.34 (440%) increase in the third- and fourth-year group. The combined results of all student teaching modality ratings showed that instructor demonstration was rated the highest (9.47) and computerized simulation lowest (8.25)., Conclusions: Overall, our study shows that multimodal ultrasound instruction was beneficial in increasing both ultrasound-trained and ultrasound-naïve medical students' confidence in head and neck ultrasound., (© 2015 by the American Institute of Ultrasound in Medicine.)

Background: Nickel is the most common allergen detected by patch testing in children. There is an increasing number of cases in children who have not had exposure to piercing. Although the clinical relevance of nickel patch test reactions in children is sometimes uncertain, continued vigilance to identify new sources of nickel exposure in this age group is important. Recent case reports have described allergic nickel contact dermatitis in children following exposure to toys, but the magnitude of this problem is unknown., Objective: The aim of this study was to evaluate nickel and cobalt release from children's toys., Methods: We purchased 212 toys in 18 different retail and online stores in the United States and Denmark. Nickel and cobalt release was tested using the dimethylglyoxime and cobalt screening spot tests., Results: A total of 73 toys (34.4%) released nickel, and none released cobalt., Conclusions: Toys are a commonly overlooked source of nickel exposure and sensitization. Therefore, dermatologists, allergists, and pediatricians should consider the role of toys in their evaluation of children with dermatitis, and the parents of children with positive nickel patch test reactions should be told that toys may release nickel and be a potential chemical source in the manifestation of allergic contact dermatitis.

Background: Hair dye products constitute an important source of allergen exposure, and contribute importantly to allergic contact dermatitis in consumers and hairdressers., Objectives: To evaluate the presence of potent contact sensitizers in oxidative hair dye products intended for home use on the US market., Methods: Ingredient labels of 107 hair dyes from 10 major brands were examined and used to assess the prevalence of hair dye substances known to be potent contact sensitizers., Results: One hundred and six of 107 (99%) products contained at least one potent sensitizer, and the average product contained six (range 0-11). p-Phenylenediamine (PPD) was found in 83 products (78%), but resorcinol (89%), m-aminophenol (75%), p-aminophenol (60%) and toluene-2,5-diamine (21%) were also frequently identified., Conclusions: Potent contact sensitizers were almost universally included in the hair dyes investigated in the United States. Although PPD is a common allergen, resorcinol and m-aminophenol were found more frequently. In total, 30 potent sensitizers were found. Clinicians should consider other allergens in addition to PPD when evaluating patients with suspected hair dye allergy., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Box jellyfish are highly venomous and numerous possible treatments for envenomation have already been reported in the published literature. The hand of a 55-year-old scuba diver was stung in the Gulf of Guinea resulting in two crops of coalescing vesicles with intense pain and lymphadenopathy. Traditional therapies such as hot water, cold packs and acetic acid were ineffective. Symptoms were rapidly relieved after the application of a lemon-oil emulsion balm. Treatments for jellyfish envenomation generally aim to either denature the jellyfish venom or prevent the discharge of the venom. Lemon-oil emulsion therapy has not yet been reported in the published literature but may be an economical and novel treatment for box jellyfish envenomation.

Background: Cosmetic skin lightening is practiced worldwide. Mercury is a well-documented melanotoxin added to some lightening products. However, mercury can cause many dermatologic, renal, and neurologic problems. The Food and Drug Administration limits the amount of mercury in cosmetic products to trace amounts, 1 ppm., Objective: The objective of this study was to quantitatively evaluate a large international sample of lightening products for mercury content, focusing on products available to US consumers either online or in stores., Methods: A total of 549 skin-lightening products, manufactured in 32 countries, were purchased online in the United States, Taiwan, and Japan and in stores in the United States, China, Taiwan, Thailand, Japan, and Sri Lanka. Cosmetics were screened for mercury content above 200 ppm using a low-cost portable x-ray fluorescence spectrometer., Results: Of the 549 tested products, 6.0% (n = 33) contained mercury above 1000 ppm. In all, 45% of mercury-containing samples contained mercury in excess of 10,000 ppm. Of lightening products purchased in the United States, 3.3% were found to contain mercury in excess of 1000 ppm., Limitations: Our study did not evaluate creams for other melanosuppressive ingredients. Only 1 sample of each product was tested., Conclusion: Our study confirms the national and global presence of mercury in skin-lightening products., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Standardization of patch testing has been difficult to achieve., Objectives: This study aimed to identify physical variations in patch test systems that could affect delivery of allergens., Methods: We compared the volume, depth, and contact area of 21 patch test delivery systems. We also filled a variety of patch test systems with different volumes of liquid (ferrous chloride) and petrolatum (disperse blue) allergens to investigate coverage and extrusion., Results: The depth of chambers varied from minimal to greater than 1 mm. Mean areas ranged from 50 to almost 350 mm2. In most chambers, even the largest volume of liquid (40 μL) seemed to be completely contained by each product's absorbent material. The amount of petrolatum required to provide 100% coverage ranged from 15 to 45 μL. The dose delivered, as defined by mg per cm2, varied more than 2-fold across the systems., Conclusions: There are considerable differences across various patch tests. Different patch test systems likely do not deliver the same dose of allergen if the same volume of excipient is applied. Appreciating the differences between different patch test systems may help refine recommendations for the amount of allergens that should be applied to different patch test systems.

Purpose of Review: We are widely exposed to metal allergens in our daily doings. As exposures constantly changes because of fashion trends and technological developments, there is a need for a continuous update of patch testers. An overview of consumer metal exposure studies that have been published in 2012 and 2013 is provided as well as lists of common metal exposures., Recent Findings: Nickel release in concentrations that cause nickel allergy and contact dermatitis is seen from laptop computers. Cobalt is found in leather as a dye and may cause chronic dermatitis. Chromium is used as a dye and for tanning in leather items and is found in nearly all shoes and released from a high proportion., Summary: New consumer items should continuously be considered and investigated for metal release when patients with positive patch test results to metal allergens are evaluated.

Background: The common practice of preparing patch tests in advance has recently been called into question by researchers. It has been established that fragrance compounds are volatile and their testing efficacy may be affected by storage conditions and preparation. Allergens in fragrance mix I rapidly decrease in concentration after preapplication to test chambers., Objectives: This study aimed to investigate the volatility of hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC) in petrolatum when stored in test chambers and to explore the correlation between vapor pressure and allergen loss in petrolatum during preparation and storage., Methods: Standardized HICC in petrolatum was prepared and stored in IQ Chambers and Finn Chambers with covers at 5°C, 25°C, and 35°C, and concentration was analyzed at intervals for up to 9 days using gel permeation chromatography., Results: Changes in HICC concentrations were not statistically significant at 8 hours at 5°C, 25°C, and 35°C. After 9 days, HICC concentrations were found to fall approximately 30% when stored at 35°C, 10% at 25°C, and less than 5% at 5°C. There was no significant difference between IQ and Finn chambers., Conclusions: Hydroxyisohexyl 3-cyclohexene carboxaldehyde concentrations are more stable in petrolatum than many other studied fragrance allergens, but HICC is still at risk for decreasing concentration when exposed to ambient air or heat for prolonged periods.

Background: Nickel is widely used in coins; nickel may cause contact allergy and allergic contact dermatitis in those who handle them., Objectives: To investigate alloy use, coin composition and nickel and cobalt release for a worldwide selection of currently circulating coins., Materials and Methods: Eight hundred and fifty coins of 361 different denominations or issues from 52 countries were collected and analysed with X-ray fluorescence spectrometry and nickel and cobalt spot tests., Results: Copper-nickel was the most frequently identified coin alloy, being observed in 100 denominations (28%), followed by aluminium-bronze (62, 17%). In total, 239 denominations released nickel (28%). Coins from Bolivia, Brazil and Costa Rica did not release nickel. Fewer than one-third of the denominations or issues from China, India, the euro area and Indonesia released nickel. In the United States, the Russian Federation, Japan, and Mexico, one-third or more of the denominations released nickel., Conclusions: This worldwide selection of circulating coins covered countries with 75% of the world population, and shows that the majority of the world population lives in countries where coins release nickel. Pertinently, ∼ 40% of circulating coin denominations do not release nickel., (© 2012 John Wiley & Sons A/S.)

Background: p-tert-Butylphenol-formaldehyde resin (PTBP-FR) is a common component of glues used in the manufacturing of many plastic, electronic, rubber, wood and leather products. Two main allergens of PTBP-FR have been described., Objectives: To determine the concentrations of the two main allergens of PTBP-FR in diagnostic patch testing preparations and PTBP-FR available to glue and adhesive manufacturers., Methods:   Nuclear magnetic resonance spectrometry was used to confirm the identity and determine the purity of reference materials. High-pressure liquid chromatography was used to analyse patch test preparations and commercially available PTBP-FR., Results: In the PTBP-FR in analysed patch test preparations the highest concentration of the allergenic dimer 4-tert-butyl-2-(5-tert-butyl-2-hydroxy-3-hydroxymethyl-benzyloxymethyl)-6-hydroxymethylphenol found was 1·79% and the lowest 0·21%. The highest concentration of the allergenic dimer 4-tert-butyl-2-(5-tert-butyl-2-hydroxy-benzyloxymethyl)-6-hydroxymethylphenol found in PTBP-FR of analysed patch test preparations was 0·50% and the lowest concentration found was 0·04%. In commercially available PTBP-FR the highest concentration of 4-tert-butyl-2-(5-tert-butyl-2-hydroxy-3-hydroxymethyl-benzyloxymethyl)-6-hydroxymethylphenol found was 3·7% and the highest concentration of 4-tert-butyl-2-(5-tert-butyl-2-hydroxy-benzyloxymethyl)-6-hydroxymethylphenol found was 1·1%. In three PTBP-FR samples neither allergen could be detected., Conclusions: Our data suggest that reporting resin concentration in petrolatum is not predictive of a consistent concentration of the two main allergens of PTBP-FR. The 10-fold difference in allergen concentration between different patch test preparations has significant ramifications for maintaining consistent dose of delivered allergen. The results of this study reinforce the need for patch test product standardization in the contact dermatitis community., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Background: China and Thailand produce large amounts of jewellery that are sold domestically and abroad., Objective: To identify nickel release and metal content in earrings purchased in China and Thailand., Methods: A total of 557 earrings were randomly purchased from vendors in 11 markets located in Beijing, Chengdu, Bangkok, Patong Beach, and Hat Yai. Earrings were subjected to dimethylglyoxime (DMG) tests and 26 of the DMG negative earrings were further evaluated qualitatively for major and minor metal content using X-ray fluorescence spectrometry., Results: A total of 314 Chinese earrings (31.5%) and 243 Thai earrings (29.2%) were DMG test positive. Three (11.5%) of 29 DMG negative earrings contained nickel as a major component; 7 (26.9%) of 29 DMG negative earrings contained nickel as a minor component., Discussion: Excessive nickel release was frequent. This may contribute to the high prevalence of nickel allergy in both countries. Increased public education together with the adoption of a regulatory intervention in Thailand may be warranted. In China, enforcement of the 2002 Chinese National Standard GB 11887 may assist in reducing sensitization. These initiatives may eventually result in decreased morbidity among the Chinese and Thai citizens, but can potentially benefit recipient countries of these important earring producing countries.