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With more than 350,000 plant species recognized and new species continually being identified, it is not surprising that humans contact plants or plant-containing products daily. The nearly endless list of potential exposures leaves us with a challenging task when attempting to categorize and study potential plant-related irritants and allergens. This article focused on laying a sound framework for understanding some of the more pertinent potential irritants and allergens.

Background Patch testing is the criterion standard for diagnosis and management of allergic contact dermatitis. Limitations on the number of allergens tested can negatively impact patient care. Objective This study reports clinical practice patterns of American Contact Dermatitis Society (ACDS) members. Methods In October and November 2018, the US-based members of the ACDS received an electronic survey regarding their procedures and experiences with patch testing. We evaluated the type of practice, number of patients tested, type of screening and supplemental series, number of allergens tested, and billing and reimbursement concerns. Results There were 149 respondents; 62% use ACDS Core 80, 70% "sometimes" or "always" test with supplemental series, and 70% "sometimes" or "always" test patient products. Participants estimated that supplemental series identify relevant allergens 35% of the time. Approximately 66% most commonly test more than 81 allergens per patient, and 78% expressed concerns regarding fair reimbursement. Conclusions Most ACDS members routinely test more than 81 allergens per patient. Barriers to fair payment for beyond a fixed number of patches at any one visit may impede the diagnosis of allergic contact dermatitis, prolong suffering, and worsen outcomes.

Dermatitis is one of the most common illnesses encountered by healthcare providers and the causes are numerous. Contact dermatitis is the form of dermatitis resulting from contact with the environment, and it may be either irritant or allergic in nature. Patch testing has been the gold standard for diagnosis of allergic contact dermatitis since its formal description over 100 years ago by Jadassohn. While this diagnostic tool may seem simple to us today, there are numerous potential points for error that the practitioner must keep in mind. Patient selection, technique of patch test placement, allergen selection, patch test reading and interpretation, and patient management all must be considered. To simply apply a given set of test allergens indiscriminately and not be prepared to interpret the results accurately with patient education and management in mind would be a great failure. Conversely, with experience and the proper knowledge base some of the most complex dermatitis questions can be answered.

Background Allergic contact dermatitis is a challenging diagnostic problem in children. Although epicutaneous patch testing is the diagnostic standard for confirmation of contact sensitization, it is less used in children by dermatologists treating children, pediatric dermatologists, and pediatricians, when compared with adult practitioners. Objective The aim of the study was to create and evaluate standardization of a pediatric patch test series for children older than 6 years. Methods We surveyed dermatologists and allergists conducting epicutaneous patch testing in children attending the 2017 American Contact Dermatitis Society meeting held in Washington, DC. This was followed by discussion of collected data and consensus review by a pediatric contact dermatitis working group at the conference. Conclusions A baseline pediatric patch test panel was established through working group consensus.

Within the last 50 years, the pharmacologic market for gastric disease has grown exponentially. Currently, medical management with histamine 2 receptor antagonist and proton pump inhibitors are the mainstay of therapy over surgical intervention. These are generally regarded as safe medications, but there are growing numbers of cases documenting adverse effects, especially those manifesting in the skin. Here we review the pharmacology, common clinical applications, and adverse reactions of both histamine 2 receptor antagonists and proton pump inhibitors with a particular focus on the potential for allergic reactions including allergic contact dermatitis.

Avoidance is the principle treatment for all types of contact dermatitis. The myriad of potential hobbies and recreational activities can make recognizing and managing avocational contact dermatitis challenging. For this reason, it is important to become familiar with some of the more common irritants and allergens encountered. Key Points 1. An avocation is a recreational activity or hobby which may lead to exposure of potential cutaneous irritants and allergens. 2. Many cases of avocational contact dermatitis present as hand dermatitis. 3. Prevention is the best strategy for avocational contact dermatitis.

Patch testing is the gold standard for the diagnosis of allergic contact dermatitis (ACD). The management of patients with ACD centers on allergen avoidance. With avoidance of future exposures, the signs and symptoms of ACD should resolve. However, in practice there will be some patients that do not achieve adequate control with avoidance alone. Unfortunately, there is a dearth of literature available to guide the next steps in management of these patients with recalcitrant dermatitis. A practical approach includes reviewing the relevance of positive patch test results, considering patient adherence and ability to comply with avoidance, addressing the potential for multifactorial disease, and in select cases employing adjuvant topical and/or systemic treatment. Key points 1. Allergic contact dermatitis is a type IV (delayed) hypersensitivity reaction presenting clinically as dermatitis. 2. Patch testing is the gold standard for the diagnosis of allergic contact dermatitis. 3. Allergen avoidance protocols are the primary management tools used in treating patients with allergic contact dermatitis. 4. In patients with suboptimal clinical outcomes despite appropriate avoidance, the potential for multifactorial disease should be addressed and pharmacologic adjuvants for symptomatic control should be considered.

ObjectiveThe optimal prophylactic strategy and treatment regimen for deep venous thrombosis (DVT) in hospitalized pediatric patients is not clearly established. This study assessed the incidence, risk factors, and treatment patterns for DVT among pediatric patients admitted to a hospital ward.MethodsChildren (aged

Allergic contact dermatitis to nickel is a global health problem. Worldwide, nickel continues to be the most prevalent and relevant contact allergen detected in tested populations for the last 30 years. Thus, the need for nickel-free products is palpable. We present a sustainable resource to aid providers and consumers in locating a wide variety of nickel free alternatives.

Patients with α₁-antitrypsin (AAT) deficiency may develop cutaneous manifestations of the disorder that histologically appear as panniculitis. Algorithms consistently emphasize measuring AAT levels when both clinical and histological features of deficiency are present; however, the patient's medical history and a physical examination alone can be extremely helpful in guiding the physician to the diagnosis of AAT deficiency. We describe a patient who presented with the classic clinical findings of AAT deficiency-associated panniculitis with surprising absence of panniculitis on repeated deep incisional biopsies. We propose a triad of classic findings that should alert the clinician to check the patient's serum AAT levels, even in the absence of panniculitis on histologic evaluation. Consideration of this clinical triad may prevent delays in the diagnosis of AAT deficiency, as early lesions may not yet demonstrate subcutaneous fat involvement.

Objectives We sought to review the clinical sequelae and imaging manifestations of thoracic aortic endograft collapses and infoldings and to evaluate minimally invasive methods of repairing such collapses. Methods Two hundred twenty-one Gore endografts (Excluder, TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz) were deployed in 145 patients for treatment of pathologies including aneurysms and pseudoaneurysms, dissections, penetrating ulcers, transections, fistulae, mycotic aneurysms, and neoplastic invasions in 6 different prospective trials at a single institution from 1997 to 2007. Device collapses and infoldings were analyzed retrospectively, including review of anatomic parameters, pathologies treated, device sizing and selection, clinical sequelae, methods of repair, and outcome. Results Six device collapses and infoldings were identified. Oversized devices placed into small-diameter aortas and imperfect proximal apposition to the lesser curvature were seen in all proximal collapses, affecting patients with transections and pseudoaneurysms. Infoldings in patients undergoing dissection represented incomplete initial expansion rather than delayed collapse. Delayed collapse occurred as many as 6 years after initial successful deployment, apparently as a result of changes in the aortic configuration from aneurysmal shrinkage. Clinical manifestations ranged from life-threatening ischemia to complete lack of symptoms. Collapses requiring therapy were remedied percutaneously by bare stenting or in one case by branch vessel embolization. Conclusions Use of oversized devices in small aortas carries a risk of device failure by collapse, which can occur immediately or after years of delay. When clinically indicated, percutaneous repair can be effectively performed.

We present Canopus, the AO bench for Gemini's Multi Conjugate Adaptive Optics System (GEMS), a unique facility for the Gemini South telescope located at Cerro Pachon in Chile. The MCAO system uses five laser beacons in conjunction with different natural guide stars configurations. A deployable fold mirror located in the telescope Acquisition and Guiding Unit (A&G) sends the telescope beam to the entrance of the bench. The beam is split within Canopus into three main components: two sensing paths and the output corrected science beam. Light from the laser constellation (589nm) is directed to five Shack-Hartman wave front sensors (E2V-39 CCDs read at 800Hz). Visible light from natural guide stars is sent to three independent sensors arrays (SCPM AQ4C Avalanche Photodiodes modules in quad cell arrangement) via optical fibers mounted on independent stages and a slow focus sensor (E2V-57 back-illuminated CCD). The infrared corrected beam exits Canopus and goes to instrumentation for science. The Real Time Controller (RTC) analyses wavefront signals and correct distortions using a fast tip-tilt mirror and three deformable mirrors conjugated at different altitudes. The RTC also adjusts positioning of the laser beacon (Beam Transfer Optics fast steering array), and handles miscellaneous offloads (M1 figure, M2 tip/tilt, LGS zoom and magnification corrections, NGS probes adjustments etc.). Background optimizations run on a separate dedicated server to feed new parameters into the RTC.

As part of its Safe Aircraft Localization and Satellite Acquisition System (SALSA), Gemini is building an All Sky Camera (ASCAM) system to detect aircrafts in order to prevent propagation of the laser that could be a safety hazard for pilots and passengers. ASCAM detections, including trajectory parameters, are made available to neighbor observatories so they may compute impact parameters given their location. We present in this paper an overview of the system architecture, a description of the software solution and detection algorithm, some performance and on-sky result.

The Gemini Observatory presents the Helium Closed Cycle Cooling System that provides cooling capacity at cryogenic temperatures for instruments and detectors. It is implemented by running three independent helium closed cycle cooling circuits with several banks of compressors in parallel to continuously supply high purity helium gas to cryocoolers located about 100-120 meters apart. This poster describes how the system has been implemented, the required helium pressures and gas flow to reach cryogenic temperature, the performance it has achieved, the helium compressors and cryocoolers in use and the level of vibration the cryocoolers produce in the telescope environment. The poster also describes the new technology for cryocoolers that Gemini is considering in the development of new instruments.

The Gemini Observatory is currently in the early stages of a major upgrade of the Secondary Mirror Tip/tilt Systems (M2TS). Although these systems continue to deliver good fast-steering and chopping performance at both sites, there are persistent and occasionally time-consuming issues that need to be addressed in order for them to deliver their full potential and further reduce downtime. We present an overview of the system, outline its capabilities, and review the early commissioning process and some of the issues encountered. We describe the augmentation of the original system with data logging features which made possible some critical servo tuning work that was key in delivering improved performance. The hardware and software upgrade project to date is discussed, along with a brief overview of items it intends to address.

Background: Spindle cell hemangioma, formerly termed spindle cell hemangioendothelioma, is an uncommon benign vascular tumor. Presentation in the oral cavity is rare with only two previously reported cases. Methods: We report a case of spindle cell hemangioma that presented as an asymptomatic mass of the buccal mucosa in a 44-year-old man. Results: The tumor was a well-circumscribed vascular proliferation of spindled to epithelioid endothelial cells. Tumor cells with intracytoplasmic vascular lumens were present in several areas. Larger, ectatic, thin-walled vessels lined by a single layer of flattened endothelial cells were evident at the periphery and focally in more cellular areas. The tumor was positive for CD31 and CD34. Conclusions: Spindle cell hemangioma rarely presents in the oral cavity and needs to be considered in the differential diagnosis of oral cavity vascular tumors to avoid misdiagnosis as a more aggressive vascular tumor.

First, a status report is given for the on-going (Phase 2) instruments under construction now for Gemini. These instruments will be deployed during 2006 and 2007 at Gemini-South and collectively represent the end of an era of instrument building within the Gemini Partnership. Next, scientific applications and technical details for the next generation of "Aspen" instruments is described. These advanced future instruments will support breakthrough research in areas like extra-solar planets, dark matter, and dark energy. Gemini's ambitious adaptive optics development program in both current and future Aspen instruments is also described. Finally, a look back at some of the trials and tribulations of building instruments at Gemini is presented, with an eye toward the lessons of yesterday, how they helped mold today's program, and how they will likely impact the procurement of future instruments at Gemini.

We report a case of cardiac tamponade resulting in a death following minimally invasive direct coronary artery bypass. Despite absence of clinical symptoms at the time of hospital discharge, cardiac tamponade physiology may have been evident on close evaluation of Doppler studies of the left internal mammary artery. Performance of a predischarge transthoracic echocardiogram may have been confirmatory and lifesaving.

Bacterial infection with Staphylococcus aureus is a known trigger for worsening of atopic dermatitis (AD); the exact mechanisms by which bacterial infection worsens dermatitis are unknown.We sought to characterize the amounts of the biologically active bacterial lipoprotein lipoteichoic acid (LTA) in infected AD lesions.Eighty-nine children with clinically impetiginized lesions of AD were enrolled in this study. A lesion was graded clinically by using the Eczema Area and Severity Index (EASI), wash fluid obtained from the lesion for quantitative bacterial culture, and measurement of LTA and cytokines. The staphylococcal isolate was tested for antibiotic susceptibilities. The patients were treated with a regimen that included topical corticosteroids and systemic antibiotics, and the lesion was reanalyzed after 2 weeks.S aureus was identified in 79 of 89 children enrolled in the study. The bacterial colony-forming unit (CFU) counts correlated with the EASI lesional score (P = .04). LTA levels as high as 9.8 mug/mL were measured in the wash fluid samples, and the amounts correlated with the lesional EASI scores (P = .01) and S aureus CFU (P.001). Approximately 30% of clinically impetiginized AD lesions contained greater than 1 mug/mL LTA, amounts that exert effects on various cell types in vitro. Moreover, injection of skin tissue ex vivo with amounts of LTA found in AD lesions resulted in epidermal cytokine gene expression.Pharmacologic levels of LTA are found in many infected atopic dermatitis lesions.

A 7-YEAR-OLD, PREVIOUSLY HEALTHY WHITE girl presented with an 8-day history of blistering that had begun on the left arm and subsequently spread to the remainder of her body. The lesions were painful and pruritic. In the week before evaluation, she had been started on a regimen of cephalexin; prednisolone, 15 mg/d with taper; and ibuprofen. The presumptive diagnosis at that time was bullous impetigo. The lesions continued to progress despite the administration of corticosteroids. The patient and her family denied any recent illnesses, including upper respiratory tract infection, or new medications within the past 6 weeks. Her medical history included asthma, for which she had been taking montelukast sodium, albuterol, and fluticasone propionate for 2 years. Her family denied known allergies to medications. Immunizations were up-to-date, and there was no history of vaccination within the past 6 weeks. Findings from physical examination revealed an afebrile child with stable vital signs. Numerous tense vesicles and bullae with serous fluid resting on an erythematous base were evident on the patient’s neck, chest, back, abdomen, perineum, and extremities. In several areas the vesicles were arranged in an annular pattern at the periphery of a crusted erosion, assuming a “cluster of jewels” appearance (Figure 1 and Figure 2). There was sparing of the ocular and oral mucosa.

ObjectivesBicuspid aortic valves are associated with a poorly characterized connective tissue disorder that predisposes to aortic catastrophes. Because no criterion exists dictating the appropriate extent of aortic resection in aneurysmal disease of the bicuspid aortic valve, we studied the patterns of aortic dilation in this population.MethodsSixty-four patients with bicuspid aortic valves who underwent computed tomographic or magnetic resonance angiography and echocardiography were retrospectively identified between January 2002 and March 2006. Orthonormal 2–dimensional or 3-dimensional aortic diameters were measured at 10 levels. Agglomerative hierarchic clustering with centered correlation distance measurements and complete linkage analysis was used to detect distinct patterns of aortic dilatation.ResultsMean aortic diameter was 28.1 ± 0.7 mm at the annulus and 21.7 ± 0.4 mm at the diaphragmatic hiatus. The aorta was largest in the tubular ascending aorta (45.9 ± 1.0 mm). Compared with the descending aorta, the transverse aortic arch was also dilated (P < .01). Cluster analysis showed 4 patterns of aortic dilatation: cluster I, aortic root alone (n = 8, 13%); cluster II, tubular ascending aorta alone (n = 9, 14%); cluster III, tubular portion and transverse arch (n = 18, 28%); and, cluster IV, aortic root and tubular portion with tapering across the transverse arch (n = 29, 45%).ConclusionDistinct patterns of aortic dilatation in patients with bicuspid aortic valves call for an individualized degree of aortic replacement to minimize late aortic complications and reoperation. Patients in clusters III and IV should have transverse arch replacement (plus concomitant root replacement in cluster IV). Patients in cluster I should undergo complete aortic root replacement, whereas in patients in cluster II supracommissural ascending aortic grafting is adequate.