Discontinuation Syndrome With JAK2 Selective Agents: Case Presentation and Mechanistic Insights.

We report the first case of pacritinib-withdrawal syndrome with in vitro elucidation of underlying mechanisms.

Contemporary Neoadjuvant Therapies for High-Risk Melanoma: A Systematic Review.

Despite advances in adjuvant immuno- and targeted therapies, the risk of relapse for stage III melanoma remains high. With 43 active entries on clinicaltrials.gov (8 July 2020), there is a surge of interest in the role of contemporary therapies in the neoadjuvant setting. We conducted a systematic review of trials performed in the last decade evaluating neoadjuvant targeted, immuno- or intralesional therapy for resectable stage III or IV melanoma. Database searches of Medline, Embase, and the Cochrane Central Register of Controlled Trials were conducted from inception to 13 February 2020. Two reviewers assessed titles, abstracts, and full texts. Trials investigating contemporary neoadjuvant therapies in high-risk melanoma were included. Eight phase II trials (4 randomized and 4 single-arm) involving 450 patients reported on neoadjuvant anti-BRAF/MEK targeted therapy (3), anti-PD-1/CTLA-4 immunotherapy (3), and intralesional therapy (2). The safest and most efficacious regimens were dabrafenib/trametinib and combination ipilimumab (1 mg/kg) + nivolumab (3 mg/kg). Pathologic complete response (pCR) and adverse events were comparable. Ipilimumab + nivolumab exhibited longer RFS. Contemporary neoadjuvant therapies are not only safe, but also demonstrate remarkable pCR and RFS-outcomes which are regarded as meaningful surrogates for long-term survival. Studies defining predictors of pCR, its correlation with oncologic outcomes, and phase III trials comparing neoadjuvant therapy to standard of care will be crucial.

Physicochemical characteristics of green banana flour and its use in the development of konjac-green banana noodles.

Asian noodles typically have high glycemic index, and an unbalanced diet heavily laden with carbohydrates has been linked to weight gain and obesity. Shirataki noodles from Japan is made from konjac glucomannan (KGM) and water and is widely known for its multiple health benefits and ability to promote satiety. However, it imparts negligible nutritional value due to its low energy content. In this study, the feasibility of making low calorie, gluten-free Shirataki noodles with improved nutritional value was shown by adding green banana flour (GBF), an underutilized subproduct of low commercial value and significance in the food industry. The optimal KGM-GBF noodles (with 6% w/w KGM, 35% w/w GBF) had 27% lower total energy content, 13% lower carbohydrate content, 5.4% higher fiber content, 2% higher ash content, and 80% hardness (as measured by texture profile analysis) when compared to commercial yellow alkaline wheat noodles. Multiple regression analysis showed that KGM level was a more influential factor than GBF level on the hardness of cooked KGM-GBF noodles (P < 0.01). The compatibility of GBF with KGM in noodle making lay in GBF's high gelatinizing and pasting temperatures, which allowed optimal KGM hydration during dough formation to develop the primary network structure in the noodles. Through this study, the potential of GBF as a functional food ingredient in product processing and nutrition enhancement was demonstrated. PRACTICAL APPLICATION: The addition of green banana flour can improve the nutritional value and sensorial properties of konjac (Shirataki) noodles. This offers a gluten-free and low glycemic index alternative to wheat and starch noodles currently available commercially. A novel method of noodle-making to create KGM noodles, without the use of high alkalinity, was developed.

Performance of Gene Expression Profile Tests for Prognosis in Patients With Localized Cutaneous Melanoma: A Systematic Review and Meta-analysis.

Importance: The performance of prognostic gene expression profile (GEP) tests for cutaneous melanoma is poorly characterized. Objective: To systematically assess the performance of commercially available GEP tests in patients with American Joint Committee on Cancer (AJCC) stage I or stage II disease. Data Sources: For this systematic review and meta-analysis, comprehensive searches of PubMed/MEDLINE, Embase, and Web of Science were conducted on December 12, 2019, for English-language studies of humans without date restrictions. Study Selection: Two reviewers identified GEP external validation studies of patients with localized melanoma. After exclusion criteria were applied, 7 studies (8%; 5 assessing DecisionDx-Melanoma and 2 assessing MelaGenix) were included. Data Extraction and Synthesis: Data were extracted using an adaptation of the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS-PF). When feasible, meta-analysis using random-effects models was performed. Risk of bias and level of evidence were assessed with the Quality in Prognosis Studies tool and an adaptation of Grading of Recommendations Assessment, Development, and Evaluation. Main Outcomes and Measures: Proportion of patients with or without melanoma recurrence correctly classified by the GEP test as being at high or low risk. Results: In the 7 included studies, a total of 1450 study participants contributed data (age and sex unknown). The performance of both GEP tests varied by AJCC stage. Of patients tested with DecisionDx-Melanoma, 623 had stage I disease (6 true-positive [TP], 15 false-negative, 61 false-positive, and 541 true-negative [TN] results) and 212 had stage II disease (59 TP, 13 FN, 78 FP, and 62 TN results). Among patients with recurrence, DecisionDx-Melanoma correctly classified 29% with stage I disease and 82% with stage II disease. Among patients without recurrence, the test correctly classified 90% with stage I disease and 44% with stage II disease. Of patients tested with MelaGenix, 88 had stage I disease (7 TP, 15 FN, 15 FP, and 51 TN results) and 245 had stage II disease (59 TP, 19 FN, 95 FP, and 72 TN results). Among patients with recurrence, MelaGenix correctly classified 32% with stage I disease and 76% with stage II disease. Among patients without recurrence, the test correctly classified 77% with stage I disease and 43% with stage II disease. Conclusions and Relevance: The prognostic ability of GEP tests among patients with localized melanoma varied by AJCC stage and appeared to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients.

Number needed to biopsy ratio and diagnostic accuracy for melanoma detection.

BACKGROUND: The number needed to biopsy (NNB) ratio for melanoma diagnosis is calculated by dividing the total number of biopsies by the number of biopsied melanomas. It is the inverse of positive predictive value (PPV), which is calculated by dividing the number of biopsied melanomas by the total number of biopsies. NNB is increasingly used as a metric to compare the diagnostic accuracy of health care practitioners. OBJECTIVE: To investigate the association of NNB with the standard statistical measures of sensitivity and specificity. METHODS: We extracted published diagnostic accuracy data from 5 cross-sectional skin cancer reader studies (median [min-max] readers/study was 29 [8-511]). Because NNB is a ratio, we converted it to PPV. RESULTS: Four studies showed no association and 1 showed a negative association between PPV and sensitivity. All 5 studies showed a positive association between PPV and specificity. LIMITATIONS: Reader study data. CONCLUSIONS: An individual health care practitioner with a lower NNB is likely to have a higher specificity than one with a higher NNB, assuming they practice under similar conditions; no conclusions can be made about their relative sensitivities. We advocate for additional research to define quality metrics for melanoma detection and caution when interpreting NNB.

Systematic review of patient-oriented interventions to reduce unnecessary use of antibiotics for upper respiratory tract infections.

BACKGROUND: Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) even though most URTIs do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem globally. As physicians' prescribing behaviour is influenced by patients' expectations, there may be some opportunities to reduce antibiotic prescribing using patient-oriented interventions. We aimed to identify these interventions and to understand which ones are more effective in reducing unnecessary use of antibiotics for URTIs. METHODS: We conducted a systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL, and the Web of Science. We included English language randomized controlled trials (RCTs), quasi-RCTs, controlled before and after studies, and interrupted time series (ITS) studies. Two authors screened the abstract/titles and full texts, extracted data, and assessed study risk of bias. Where pooling was appropriate, a meta-analysis was performed by using a random-effects model. Where pooling of the data was not possible, a narrative synthesis of results was conducted. RESULTS: We included 13 studies (one ITS, one cluster RCTs, and eleven RCTs). All interventions could be classified into two major categories: delayed prescriptions (seven studies) and patient/public information and education interventions (six studies). Our meta-analysis of delayed prescription studies observed significant reductions in the use of antibiotics for URTIs (OR = 0.09, CI 0.03 to 0.23; six studies). A subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects. The studies in the patient/public information and education group varied according to their methods of delivery. Since only one or two studies were included for each method, we could not make a definite conclusion on their effectiveness. In general, booklets or pamphlets demonstrated promising effects on antibiotic prescription, if discussed by a practitioner. CONCLUSIONS: Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic prescription for URTIs. Further research is needed to investigate the costs and feasibility of implementing these interventions as part of routine clinical practice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016048007.

Anterior segment infiltration of acute lymphoblastic leukemia: case report and systematic review.

Acute lymphoblastic leukemia (ALL) relapse implies a poor prognosis and demands emergency treatment. Leukemic infiltration of the anterior segment can masquerade as intraocular inflammation; a high index of suspicion for this complication is essential. We describe a case of ocular relapse in a 2-year-old male on maintenance therapy for ALL. A systematic review of all known cases of similar leukemic infiltration of the anterior segment of the eye in ALL was performed. A total of 106 patients in 43 reports described leukemic infiltration of the eye as an initial presentation of ALL or relapse. Ocular relapse may be the first visible manifestation of systemic disease, with concurrent disease in the CNS, bone marrow, or testes. Prognosis for ALL patients with ocular relapse is poor, with death after initial presentation reported as early as 16 days. Patients with a history of ALL presenting with any sign of ocular inflammation should be assessed for relapse and leukemic infiltration. As soon as a diagnosis of relapse has been confirmed, appropriate leukemia therapy should be initiated.

Satisfaction and Awareness of Systemic Psoriasis Treatments: A National Survey Comparing Biologic and Nonbiologic Users.

BACKGROUND:: There is ongoing development of new therapies for psoriasis, including biologic and systemic agents such as interleukin-17, interleukin-23, and phosphodiesterase-4 inhibitors. The development of these agents has changed the landscape of psoriasis treatment options. OBJECTIVE:: The objective of this study was to characterize the impact of newer biologic and systemic agents approved by June 2016 on patient outcomes. We sought to evaluate and compare biologic users and nonbiologic systemic users with respect to their treatment awareness and satisfaction. METHODS:: We conducted a national Canadian survey from July to September 2016 on adult patients with moderate-to-severe psoriasis using biologic agents or nonbiologic systemic agents as their current primary treatment modality. Patients were asked to evaluate their overall satisfaction with their treatment agent and their awareness of other treatment options. Responses from biologic and nonbiologic systemic users were compared. RESULTS:: Overall, 343 participants were included (biologic users: n = 218; nonbiologic users: n = 125). Treatment satisfaction: Biologic users had a higher overall satisfaction score than nonbiologic users ( P < .001). Among nonbiologic agents, apremilast (62%) was associated with the highest satisfaction proportion. Among biologic agents, ustekinumab (77%) and adalimumab (72%) were associated with the highest proportions of satisfaction. With respect to treatment awareness, 30% of nonbiologic patients did not have enough information to form an opinion about biologics. CONCLUSIONS:: This study demonstrates the greater treatment satisfaction of biologic users compared with nonbiologic users for moderate-to-severe psoriasis. Given that nearly one-third of nonbiologic users did not have enough information to form an opinion about biologic agents, physicians may consider counselling these patients on the use of biologic agents for psoriasis management.

Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies.

BACKGROUND: Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity. OBJECTIVE: We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes. METHODS: MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes. RESULTS: Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28). CONCLUSION: Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.

Evaluating Progression-Free Survival as a Surrogate Outcome for Health-Related Quality of Life in Oncology: A Systematic Review and Quantitative Analysis.

Importance: Progression-free survival (PFS) has become a commonly used outcome to assess the efficacy of new cancer drugs. However, it is not clear if delay in progression leads to improved quality of life with or without overall survival benefit. Objective: To evaluate the association between PFS and health-related quality of life (HRQoL) in oncology through a systematic review and quantitative analysis of published randomized clinical trials. Eligible trials addressed oral, intravenous, intraperitoneal, or intrapleural chemotherapy or biological treatments, and reported PFS or health-related quality of life. Data Sources: For this systematic review and quantitative analysis of randomized clinical trials of patients with cancer, we searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 2000, through May 4, 2016. Study Selection: Paired reviewers independently screened citations, extracted data, and assessed risk of bias of included studies. Data Extraction and Synthesis: We examined the association of difference in median PFS duration (in months) between treatment groups with difference in global, physical, and emotional HRQoL scores between groups (standardized to a range of 0-100, with higher scores representing better HRQoL) using weighted simple regressions. Main Outcome and Measure: The association between PFS duration and HRQoL. Results: Of 35 960 records screened, 52 articles reporting on 38 randomized clinical trials involving 13 979 patients across 12 cancer types using 6 different HRQoL instruments were included. The mean (SD) difference in median PFS between the intervention and the control arms was 1.91 (3.35) months. The mean (SD) differences in change of HRQoL adjusted to per-month values were -0.39 (3.59) for the global domain, 0.26 (5.56) for the physical domain, and 1.08 (3.49) for the emotional domain. The slope of the association between the difference in median PFS and the difference in change for global HRQoL (n = 30 trials) was 0.12 (95% CI, -0.27 to 0.52); for physical HRQoL (n = 20 trials) it was -0.20 (95% CI, -0.62 to 0.23); and for emotional HRQoL (n = 13 trials) it was 0.78 (95% CI, -0.05 to 1.60). Conclusions and Relevance: We failed to find a significant association between PFS and HRQoL in cancer clinical trials. These findings raise questions regarding the assumption that interventions prolonging PFS also improve HRQoL in patients with cancer. Therefore, to ensure that patients are truly obtaining important benefit from cancer therapies, clinical trial investigators should measure HRQoL directly and accurately, ensuring adequate duration and follow-up.

Laparoscopic metabolic surgery for the treatment of type 2 diabetes in Asia: a scoping review and evidence-based analysis.

BACKGROUND: Laparoscopic metabolic surgery has been previously shown to be an effective treatment for obese patients with type 2 diabetes (T2DM). The objective of this scoping review is to determine the impact of metabolic surgery for the treatment of type 2 diabetes in Asia and perform an evidence-based analysis. METHODS: We performed a literature search in PubMed for research on laparoscopic metabolic surgery for the treatment of T2DM in Asia region. We classified the included studies based on the Oxford Center for Evidence Based Medicine guidelines. And performed and evidence analysis. RESULTS: In total, 205 articles were identified. 62.9% of the studies were from East Asia. The evidence of 26 studies are level I, 59 are level II. Laparoscopic sleeve gastrectomy (LSG) was the most commonly reported surgical procedure (63.1%) in Asia. The number of laparoscopic metabolic surgery for T2DM in Asian countries has increased rapidly over the last 8 years. We identified 16 studies which showed that laparoscopic metabolic surgery is an effective and safe treatment for T2DM in patients with a BMI of > 25 kg/m2 to < 35 kg/m2 in Asia. CONCLUSIONS: Our results suggest that laparoscopic metabolic surgery might be an effective and safe treatment for T2DM patients with BMI < 35 kg/m2, and that LSG is the most commonly performed surgical procedure for this in Asia.

Habitat, species richness and hantaviruses of sigmodontine rodents within the Interior Atlantic Forest, Paraguay.

Four of the nine sigmodontine tribes have species that serve as reservoirs of rodent-borne hantaviruses (RBO-HV), few have been studied in any depth. Several viruses have been associated with human cases of hantavirus pulmonary syndrome often through peridomestic exposure. Jabora (JABV) and Juquitiba (JUQV), harbored by Akodon montensis and Oligoryzomys nigripes, respectively, are endemic and sympatric in the Reserva Natural de Bosque Mbaracayú (RNBM), Paraguay, a protected area of the Interior Atlantic Forest. Rodent communities were surveyed along a 30 km stretch of the RNBM in eight vegetation classifications (Low, High, Bamboo, Riparian and Liana Forests, Bamboo Understory, Cerrado, and Meadow/Grasslands). We collected 417 rodents from which 11 species were identified; Akodon montensis was the predominant species (72%; 95%CI: 64.7%-76.3%), followed by Hylaeamys megacephalus (15% (11.2%-18.2%)) and Oligoryzomys nigripes (9% (6.6%-12.4%)). We examined the statistical associations among habitat (vegetation class) type, rodent species diversity, population structure (age, sex, and weight), and prevalence of RBO-HV antibody and/or viral RNA (Ab/RNA) or characteristic Leishmania tail lesions. Ab/RNA positive rodents were not observed in Cerrado and Low Forest. A. montensis had an overall Ab/RNA prevalence of 7.7% (4.9%-11.3%) and O. nigripes had an overall prevalence of 8.6% (1.8%-23.1%). For A. montensis, the odds of being Ab/RNA positive in High Forest was 3.73 times of the other habitats combined. There was no significant difference among age classes in the proportion of Ab/RNA positive rodents overall (p = 0.66), however, all 11 RNA-positive individuals were adult. Sex and habitat had independent prognostic value for hantaviral Ab/RNA in the study population; age, presence of tail scar/lesion (19% of the rodents) and weight did not. Adjusting for habitat, female rodents had less risk of becoming infected. Importantly, these data suggest habitat preferences of two sympatric rodent reservoirs for two endemic hantaviruses and the importance of including habitat in models of species diversity and habitat fragmentation.

Weight loss surgery for obstructive sleep apnoea with obesity in adults: a systematic review and meta-analysis protocol.

INTRODUCTION: Obstructive sleep apnoea (OSA) is caused by complete or partial obstruction of the upper airway resulting in repeated episodes of interrupted or shallow breaths. OSA is associated with significant morbidity and mortality. The prevalence is estimated to range from 3% to 7% in the general population but may be much higher. Several studies show that weight loss or bariatric surgery may have a role in treating OSA. The aim of this systematic review is to assess the safety and efficacy of randomised controlled trials (RCTs) of weight loss surgery for adults with OSA and comorbid obesity. METHODS AND ANALYSIS: A search of the Cochrane Central Register of Controlled Trials, PubMed, EMBASE and two major Chinese biomedical databases will be performed to identify related trials published as of October 2018. This study will include RCTs, comparing different types of weight loss surgery for OSA with obesity or weight loss surgery for OSA with obesity with other upper airway surgeries. The primary outcomes that will be measured are apnoea-hypopnoea index, excess weight loss and in-hospital mortality. The secondary outcomes will include duration of hospital stay, neck circumference, reoperation, waist circumference, body mass index, Epworth Sleepiness Scale score, overt complications (eg, gastric fistula, bleeding, delayed gastric emptying, wound infection), quality of life, quality of sleep and/or functionality. The systematic review will be conducted according to the recommendations as outlined by the Cochrane collaboration. ETHICS AND DISSEMINATION: The systematic review and meta-analysis will include published data available online and thus ethics approval will not be required. The findings will be disseminated and published in a peer-reviewed journal. Review updates will be conducted if there is new evidence that may cause any change in review conclusions. Any changes to the study protocol will be updated in the PROSPERO trial registry accordingly. PROSPERO REGISTRATION NUMBER: CRD42017081743.

Pediatric Wells syndrome (eosinophilic cellulitis) after vaccination: A case report and review of the literature.

A 4-year-old boy presented with erythematous vesicular plaques, ulceration, edema, and pruritus on the left foot and ankle 10 days after receiving the tetanus, diphtheria, pertussis, and polio; measles, mumps, rubella, and varicella; and hepatitis A/B vaccines. Biopsy showed eosinophilic infiltrates and flame figures, suggesting Wells syndrome. Patch testing showed a 1+ reaction to neomycin and aluminum hydroxide, with a recall reaction of Wells syndrome of the feet bilaterally. We report a rare case of pediatric Wells syndrome triggered by nonthimerosal vaccine components confirmed by patch testing.

Reporting of interventions and "standard of care" control arms in pediatric clinical trials: a quantitative analysis.

BACKGROUND: In pediatric medicine, the usual treatment received by children ("standard of care") varies across centers. Evaluations of new treatments often compare to the existing "standard of care" to determine if a treatment is more effective, has a better safety profile, or costs less. The objective of our study was to evaluate intervention and "standard of care" control arms reported in published pediatric clinical trials. METHODS: Pediatric clinical trials, published in 2014, reporting the use of a "standard of care" control arm were included. Duplicate assessment of reporting completeness was done using the 12-item TIDieR (Template for Intervention Description and Replication) checklist for both the "standard of care" control arms and intervention arms within the same published study. RESULTS: Following screening, 214 pediatric trials in diverse therapeutic areas were included. Several different terms were used to describe "standard of care." There was a significant difference between the mean reported TIDieR checklist items of "standard of care" control arms (5.81 (SD 2.13) and intervention arms (8.45 (SD 1.39, p < 0.0001). CONCLUSIONS: Reporting of intervention and "standard of care" control arms in pediatric clinical trials should be improved as current "standard of care" reporting deficiencies limit reproducibility of research and may ultimately contribute to research waste.

Association between eczema and major cardiovascular outcomes in population-based studies: a systematic review protocol.

INTRODUCTION: Chronic inflammatory diseases such as eczema (also known as atopic dermatitis) have been inconsistently linked to cardiovascular disease and stroke in both mechanistic and epidemiological studies. There is a need to review the existing epidemiological data examining the association between eczema and major cardiovascular outcomes, including angina, myocardial infarction, coronary revascularisation, heart failure, cardiac arrhythmias, stroke and cardiovascular death, in order to improve our understanding of the comorbidities of eczema. METHODS AND ANALYSIS: We will systematically review population-based studies, including cohort, case-control and cross-sectional studies, reporting on the association between eczema and cardiovascular outcomes. We will search Medline, Embase and Global Health, from their date of inception to April 2017, using a comprehensive search strategy formulated with the help of a librarian. Two reviewers will independently screen titles and abstracts in duplicate, followed by independent data extraction and quality assessment. We will group studies by the cardiovascular outcome under study and synthesise them narratively. If sufficient numbers of homogeneous studies are returned, we will perform meta-analyses to obtain pooled effect estimates. Preferred Reporting Items for Systematic Review and Meta-Analysis will be used to inform the reporting of this study. TRIAL REGISTRATION NUMBER: CRD42017060359.

Occupational Airborne Contact Dermatitis From Proton Pump Inhibitors.

Few published reports have described occupational contact dermatitis from proton pump inhibitor (PPI) exposure in the literature. We present an additional case of a 58-year-old male pharmaceutical worker with an occupational airborne allergic contact dermatitis to PPIs confirmed by patch testing. This is a novel report of workplace exposure to dexlansoprazole and esomeprazole PPIs with resultant clinical contact allergy and relevant positive patch test results to these 2 agents. A literature review of all previously reported cases of occupational contact dermatitis to PPI is summarized. The case also emphasizes the importance of even minute exposures when considering workplace accommodation.