apr18 1, article bcr2013009070, 2013. A quote from Fishers textbook on contact dermatitis is the following: if metal salts were tested close to each other a strong positive to nickel would be accompanied by false positive patch test reactions to adjacent metal salts, particularly cobalt and copper (2). Unable to load your collection due to an error, Unable to load your delegates due to an error. WebThe MELISA test a scientifically-proven test which can objectively test for the presence of titanium hypersensitivity and measure its severity. Orthopedic Analysis Trying to find LTT for titanium but cannot find - is LTT available anywhere in US for metals? Published by Elsevier Ltd. All rights reserved. 4. They can work from 8years to 15,inimum. Why don't I believe them ??? New comments are currently closed for this post. Their disadvantage is that in some individuals the HA You may be dealing with angry back syndrome from the start. MELISA is a blood test to aid the diagnosis of metal hypersensitivity. A team has devised a blood test to determine allergies to nickel and is working on developing blood tests for other allergens such as cobalt and the bone cement that is used in most implants. An exact breakdown, which includes trace amounts of metals present, is needed prior to testing, but below is a guideline. Dermatology research and practice 2012 (2012). Alas, such is not the case. After the diagnosis of RFB, the preferred approach is to remove the RFB laparoscopically [13]. 2022 Nov 23;10(12):716. doi: 10.3390/toxics10120716. -, Himmlova L., Kubies D., Hulejova H., et al. We present a case of a 28-year-old female with a chronic history of intermittent abdominal pain aggravated due to titanium allergy and retained foreign surgical body. But there isnt long-term clinical data associated with their usage, and so your dental professional is the best person to speak to about alternative options. The patient had delayed hypersensitivity reaction to nickel in the past with erythematous rash formation and severe itching. In summary, there is no official recommendation to use in vitro methodology as the testing has not been validated by multiple investigators and the FDA has not approved the testing. Eleven months prior, the patient had undergone cholecystectomy due to acute cholecystitis complicated by a liver abscess. These artificial substitutes for tooth roots are either screw, cylinder, or blade-like in form. 2022 Nov 4;8(1):51. doi: 10.1186/s40729-022-00451-1. b. Have you seen an allergist to confirm you are allergic? Although rare, metal allergies do occur and can occur with grade IV titanium as pure titanium is too brittle. This makes it an adequate metal of choice for intraosseous use in medical procedures. Lymphocyte proliferation, using Lymphocyte Transformation Testing (LTT), and cytokine release provided quantitative reactivity measurement, where a stimulation index of >2 indicated metal sensitivity. iv. The Mayo Clinic had diagnosed him with Stiff Person Syndrome. This is not only a simple and effective system, but also a very convenient one piece component that avoid all the abutments from regular titanium systems. Basketter D and Menne T. Lymphocyte transformation tests in patients with allergic contact dermatitis. 6. de Graaf, Niels PJ, et al. It also sheds light on retained foreign bodies as a possible cause of abdominal pain in patients who have gone through various surgical procedures in the past. Among different RFB, sponges are one of the most common retained foreign bodies in the abdomen, pelvis, and retroperitoneal cavities [13]. Safe for patients with metal allergies Zirconia implants are a viable option for patients who have an allergy to titanium or adhere to holistic dental principles. Wood MW, Warshaw EM. The symptoms were so severe that they interfered with the mans lifestyle. All rights reserved. The patient did not report any screening for immunodeficiency in the past. See MoreSee Less, Metal hypersensitivity and pro-inflammatory cytokine production in patients with failed orthopedic implants: A case-control study, Valentine-Thon E, Schiwara HW. Major In a pilot study, 20 patients also underwent both patch testing and a lymphocyte transformation test (LTT-MELISA) for the same metals. Symptoms can arise as acute inflammatory response, infection, abscess, or aseptic inflammation and exudative without infection in the body cavities [13]. The patients preop white blood cell (WBC) count was 5.2K/L, absolute neutrophil count was 3281 cells/L, and absolute lymphocyte count was 1284 cells/L. I have summarized her observations and suggestions below. "A retrospective study on titanium sensitivity: Patch test materials and manifestations." Many will have seen the devastating news that singer Celine Dion has been diagnosed with Stiff Person Syndrome. A triple assay technique for the evaluation of metalinduced, delayedtype hypersensitivity responses in patients with or receiving total joint arthroplasty. Sarah, a potential dental implant patient, asks:I am allergic to titanium. The patients social history is insignificant, with no smoking or alcohol consumption. True positive responses tend to persist for 7-10 days, false positives do not. aseptic osteolysis. The one we elected is from a German/Swiss based company called Z-Systems. This is why we are seeing long term immune assaults on people with titanium implants and/or replacement surgeries. WebTitanium is a reactive metal with a including titanium may mediate metal hypersen- titanium allergy, titanium release without any native oxide film thickness of about 4 12, no. doi: 10.1002/jbm.a.34721. Immediately after removal of his last palladium containing white gold crown all of his paralysis resolved.At the November 2019 meeting of the FDA's Committee Investigating Metals Used in Medical Devices, Dr. Schroeder presented Jeske's case and the cases of some of his other patients. This information is for educational purposes only. I've asked a few dentist about this problem, with the majority saying that there is no such allegic reaction to titanium. The easiest and most affordable way to clinically deliver bone graft for socket preservation. Neuro Endocrinol Lett. When exposed to oxygen, titanium oxidizes and 2003 Feb-Apr;24(1-2):57-64. Questionnaire data was processed, and the follow-up MELISA test results were compared with the results of the initial MELISA tests. Background: Sensitization to orthopaedic implant materials is an unpredictable event that might affect implant performance. If LTT-MELISA testing is to be considered, test kits, locations of laboratories offering this test and other information is available at FAQs for US Customers - MELISA. i. Her symptoms became chronic and progressed further to abdominal distension with increasing abdominal girth, fever, and several episodes of watery diarrhea. Their is such a thing as an allergy or sensitivity to Titanium. 3, pp. Hallab N J, Mikecz K, Jacobs J J. iv. She reported extensive health issues such as skin rash, hair loss, memory loss, difficulty concentrating, severe shortness of breath, hot and cold flashes, metallic taste in the mouth, abdominal bloating, joint and body aches, muscle pain and tightness, insomnia and more. This can be seen on the fact that bone attachment is usualy tighter and faster with pure ti-implants then in Ti-alloy-implants. Review our cookies information for more details. The abdominal pain is associated with titanium allergy reaction from previously inserted titanium-based surgical clips. RFB should be included in the differential diagnoses when the patient presents with acute reactions after surgical procedures. However, in the lymphocyte transformation test, the patient's lymphocytes showed markedly enhanced proliferation in vitro totitanium. Lisa: It's interesting that you have these symptoms! She reported extensive health issues such as skin rash, hair loss, memory loss, difficulty concentrating, severe shortness of breath, hot and cold flashes, metallic taste in the mouth, abdominal bloating, joint and body aches, muscle pain and tightness, insomnia and more. M. Hosoki, K. Nishigawa, T. Tajima, M. Ueda, and Y. Matsuka, Cross-sectional observational study exploring clinical risk of titanium allergy caused by dental implants, Journal of Prosthodontic Research, vol. Usually retained foreign bodies are found after complaints such as pain, infections and a palpable mass. Showed many positives at 72 and 96 hours including 14 metals and methacrylate glue. b. in vitro testing is only available for a limited number of metals; All the best! 2016;2016:15. doi: 10.1155/2016/8769347.8769347 2014;102(2):392399. Have new referral 62 year-old female smoker with focal seizure in 2017 - evaluation showed brain tumor confirmed to be malignant with primary in lung. After removal of the titanium material, fracture healing was achieved and the eczema cleared. Metals including titanium can form haptenic antigens in their ionic form upon bonding with human cell native proteins and have the ability to potentiate degranulation of basophils and mast cells [3]. She had to be hospitalized with strict isolation to wait for her medication regimen to work along with the infusion of IV fluids. MELISA is the only test that has been scientifically proven to detect titanium allergy and determine its severity. The patients past surgical history includes a tonsillectomy, an appendectomy, and cholecystectomy. The Editor-in-Chief of this journal has a copy of the written consent available for review. The International Journal of Implant Dentistry notes that due to implants' corrosion and wear, titanium alloy particles can get deposited in the surrounding tissues. This is of course important in dealing with metal implants. The CT impressions showed no signs of bowel obstruction or colitis; however, it was evident that a portion of a pigtail drainage catheter was lodged within the cecum (Figure 2). WebMELISA is a scientifically proven and clinically validated blood test that detects type-IV hypersensitivity to multiple metals at the same time. The management of any metal allergy including titanium involves removing specific offending agents and avoiding potential triggers to hypersensitivity reactions. Therefore, objective determination of metal sensitivity at preoperative assessment should be considered in planning arthroplasty intervention, as it would help the surgeon in selecting the most appropriate prosthesis for the patient and could benefit implant performance. I would emphasize the lymphocyte testing is a challenge due to delivery of viable cells and lack of FDA approval and insurance coverage. The results of the initial and follow-up MELISA tests; Percentage of patients in individual intervals of the stimulation index: green 2.0, yellow = 2.14, orange = 4.110.0, and red 10.1; comparison of the initial with the follow-up values of the stimulation indexmetals with significant differences. All my best. v. Postoperative testing may help in determining if metal allergy is responsible; There is only one test that can be used to establish titanium allergy, called the MELISA test . 1, pp. The pain was sharp and stabbing in nature and radiated from the umbilicus, and the patient rated the pain 10/10 on a scale, causing her significant discomfort. The https:// ensures that you are connecting to the (SOURCE Lymphocyte responses in patients with total hip arthroplasty, JOURNAL of ORTHOPEDIC RESEARCH 23(2), 384-391, 2005). He could breath but could not talk or actively move any muscle in his body. Usualy allergic response is seen on epidermis. The patient initially had intermittent RLQ abdominal pain accompanied by nonspecific symptoms. WebThe only current blood test for titanium allergy, a test called the MELISA(R) test, is available through Breakspear. For those affected with titanium allergy, the symptoms can be multiple and bewildering. 2004 Orthopaedic Research Society. Is there any other material used as an alternate to titanium in the implant fixtures? In most irritant reactions, intensity usually wanes between the time of patch removal and the final reading. You may be able to find those specific surgeons by contacting the manufacturerBioDent(ziterion) is in UK.Biodent Systems Biodent Systems, Suite 210, Coborn House, 3 Coborn Road, Docklands, London E3 2DA I am skeptical that the in vitro testing would facilitate a better alloy than titanium. 13, no. Do you feel that Lympocyte Transformation Tests are reasonable diagnostic alternates to patch testing for metal allergy? ii. 1, pp. I have found through the years that it is females that have these unusual allergies to metals. A question about this was submitted on Jan 9, 2013. Responses at 7-10 days after removal may help distinguish a true from false positive result. Oral Health, Dental Conditions & Treatments, Erythema (skin redness, in this case, in the tissues around the implant), Urticaria (hives that may be seen on the skin or gum surface), Eczema (itchy inflammation of the skin or gum tissue), Necrosis (death of cells or tissue, in this case, around the implant), Toxic reactions in other tissues, causing yellow nail syndrome (which can also affect the lungs and airways). This may be the situation you are facing. Department of Technology for Health, Dermatological Clinic, IRCCS Galeazzi Hospital, University of Milan, Milan 20161, Italy. In cases of documented delayed type metal hypersensitivity or when an individual has a strong belief related to this possibility, legal concerns may outweigh medical concerns; Metal allergies have been a growing concern in the general population over the past several decades. The MELISA test may be used in two ways for orthopaedic patients. Please write and tell us your outcome. Just some thoughts. You should get titanium implants bc you probably don't have an allergy to it or you can just get a zirconia based implant and have it fracture shortly after due to a reaction with fluids/water, then have someone remove it, place another, then removed, place another, etc. please note that there are many brands of implants which are used to titanium alloys in making implants so i agree with whose are believe in allergist consultation. All but one clip was removed and the patient reported resolution of most symptoms within one week of surgery. She was diagnosed with pneumonia twice followed by two sinusitis episodes from January 2020 to March 2020. 1, pp. 639644, 2020. 62, no. Systemic and topical steroids not helping. In addition, there is evidence in the dermatologic literature (1) indicating that lymphocyte transformation testing may be coming of age in terms of its usefulness to detect contact allergy not only to metals, but to other substances. His case is described in the YouTube video by Dr Scott Schroeder. In the study, 35 patients with failed orthopedic implants and 15 patients scheduled for orthopedic implant surgery were tested for metal hypersensitivity using the MELISA test. Any suggestions on the root cause? How lymphocyte-mediated metal sensitivity affects orthopaedic implant performance remains poorly understood. 15, 2019. This patient is concurrently found to have a retained pigtail catheter in the cecum discovered incidentally through radiology. Metal hypersensitivity and If a non-metal option is a consideration, then I would recommend if multiple patch tests are positive. This site needs JavaScript to work properly. The patient also started having low-grade fever, nausea, vomiting, joint pain, diffuse rash, and fatigue. "Titanium allergy is barely recognized in mainstream medicine - yet laboratories using the MELISA technology have reported that about 4% of all patients tested to titanium will be allergic to it (Valentine-Thon E., et al. Detection of chromium allergy by cellular in vitro methods. See this image and copyright information in PMC. The patients completed a special questionnaire aimed at information regarding change of health status from their last visit and determining whether the results of the initial MELISA test and recommendations based on it were beneficial for patients or not. G. Tawil, P. Tawil, and C. Irani, Zirconium implant as an alternative to titanium implant in a case of type IV titanium allergy: case report, The International Journal of Oral & Maxillofacial Implants, vol. Before Neuroendocrin Letters 2006;27:17-24. Pernicious anemia (B 12 def) sneaks up on people very slowly. Source Metals usually found in common medical grade alloys include: Cobalt chrome: cobalt, chromium, manganese, molybdenum, nickel, tungsten The titanium in the implants fuses with the jawbone, ensuring that the implant wont slip or make noise. Some symptoms include chronic dermatitis and other reactions depending on the specific organ involved [10]. Dennis K. Ledford, MD, FAAAAI 26 Its usefulness may be improved if patients are tested with chemicals relevant to their problem. 8487, 2019. The test you referred to is not actually a serum test, but a whole blood test which measures lymphocyte reactivity upon exposure to metal. However, this test has been criticized as generating false positives, and my guess would be that titanium allergy is less prevalent than that. Second, post-surgery, MELISA can be used to identify if metal hypersensitivity is responsible for any of the symptoms that have developed. Tested to NAC 80 panel and metal panel. This elevated incidence and averaged level of lymphocyte reactivity supports a metal-specific adaptive immune response and suggests involvement in the pathogenesis of poor implant performance, e.g. Vaelentin-Thon E, Mller K, Guzzi G et al. Ask The Expert Archive Main Page Another incredible case report of a woman with 18 surgical clips in her neck. 2014;293:3745. I strongly recommend zircon implants. 29, no. We describe a case of chronic abdominal pain, which is potentially complicated by retained titanium surgical clips and subsequently a retained portion of a pigtail catheter. This has been confirmed by my health care giver. Results: Sensitized individuals with an allergy displayed significantly higher lymphocyte transformation test (LTT) responses than sensitized volunteers without allergy and controls (P<0.05 and P<0.01, respectively). The clips were made of nickel and titanium, and a metal sensitivity test confirmed that he was sensitive to nickel. This can take several months. The MELISA test was validated in 2003 by Valentine-Thon and Schiwara. The clips were made of nickel and titanium, and a metal sensitivity test confirmed that he was sensitive to nickel. 2013, no. Int J Implant Dent. Metal allergies are becoming more recognized within the surgical field. Orthopedic implants heal well without complications in most patients but fail for unclear reasons in some individuals. The patient started having another episode of intermittent right lower quadrant (RLQ) pain starting in January 2020. HIGHLIGHTS SUMMARY Intolerance reaction to pure titanium implants (grade 4) is more likely a pro-inflammatory reactivity of tissue macrophages in contact with titanium oxide particles disseminated into the peri-implant tissue by tribocorrosion rather than a systemic allergic reaction. LTT-MELISA is clinically relevant for detecting and monitoring metal sensitivity. Abstract However, all the symptoms were resolved after the removal of the offending agent [57]. Our case is about a 28-year-old female presenting with a spectrum of abdominal symptoms with a complicated medical history. official website and that any information you provide is encrypted Contact Dermatitis 2005; 53:1. Dear Richard Hughes, DDS,FAAID, FAAIP.DABOI Stejskal, V. D. M., et al. Over his thirty-year career, Dr. Schroeder has encountered numerous cases involving neuromuscular and other systemic symptoms (fibromyalgia, chronic fatigue syndrome, Lupus & RA symptoms, brain fog, migraines, etc) that have dramatically improved or resolved once the offending metal was removed. We thank Dr. Guirguis, Department of Radiology, and Williamson Medical Center for their contributions in this case report. Furthermore, alternatives like absorbable sutures or even different hypoallergenic metal or plastic clips can be considered viable options to replace nickel or titanium-made surgical clips during surgery. See MoreSee Less, Rare Metallic Allergy Reaction Presentation to Cholecystectomy Surgical Clip, Many will have seen the devastating news that singer Celine Dion has been diagnosed with Stiff Person Syndrome. I also think this form of dentistry s/b considered and covered as MEDICAL. There are very few reports on hypersensitivity reactions in association with titaniumbased materials so that the existence of allergy to titanium is still put in question. P. H. Wu, J. H. Chen, and K. E. Chu, Successful endoscopic management of double iatrogenic perforations induced by endoscopic retrograde cholangiopancreatography and computed tomography-guided colon drainage, Case Reports in Gastroenterology, vol. Additionally, standard surgical instruments such as electrodes, drains/catheters, retractors, or clamps can be left unrecognized after operations, especially in the abdominal space [13]. vii. I would recommend though that you take a clifford test first on Zircon Oxide due to your allergic component. Oral saliva usualy "buffers" reaction. If medical or dental professionals suspect that you might be allergic to the titanium in your dental implant, the first step is to take diagnostic tests, such as a patch test. 2006 Dec;27 Suppl 1:31-5. 2/12/2021 cureus.com/articles/136554-diagnosis-and-management-of-a-hypersensitivity-reaction-to-titanium-containing-surgical-clips-a-case-report See MoreSee Less, Diagnosis and Management of a Hypersensitivity Reaction to Titanium-Containing Surgical Clips: A Case Report, Two weeks after gallbladder surgery, a 53-year-old man experienced constant abdominal pain in addition to nausea. A dental professional can help you treat your titanium allergy and ensure that you fill the gap in your mouth with a treatment that works for you! Have 79 year-old man with left knee replacement two years ago. The most commonly used test to diagnose a metal allergy is skin patch testing. The use of low-dose naltrexone (LDN) is also discussed. See MoreSee Less, Stiff Person Syndrome Paralysis Goes Away, "Metal hypersensitivity testing should be offered to patients before surgery to minimize the risk of implant failure", concluded this study from Charles University, Prague; "especially those with autoimmune diseases, asthma, and/or allergies." The results showed that Jeske was allergic to nickel; the screws in his feet contained 14-16% nickel. Copyright 2021 Molly S. Jain et al. But autoimmunedeficiency raised as well as the number of prothetic treatments and envireonmental influence and stress. The pigtail catheter in the cecum was removed carefully, and the foreign body was measured 10.0cm in length and 0.3cm in diameter. A positive to 14 metals is very unusual. How effective this is in detecting contact dermatitis to metal still remains somewhat undecided, but there is evidence in the literature that the test can detect delayed hypersensitivity to metals. 2021, 2022 OsseoNews, Inc. All rights reserved. In vitro testing with metal ions in solution mixed with lymphocytes from affected subjects has been suggested as means to overcome the reduced reactivity of specific metals or the reduced penetration of the metal through the keratin layer of the skin. We obtained written informed consent from the patient for the publication of this case report and accompanying images. They are real and they manifest themselves over time. 426431, 2018. say. On November 5, 2020, the embedded right colon foreign body was identified with fluoroscopic guidance (Figures 3(a) and 3(b)) and removed surgically (Figure 4). With her history of allergy to other metals in the past, a titanium allergy was suspected at this visit, and the patient promptly underwent a titanium skin patch test that turned out positive. Most likely the allergy to the other metals in the alloy. The ideal barrier membrane for most applications. Positive patch test to metal used in the implant We wanted to highlight the remarkable case of Dana Jeske, a mechanical engineer living near Seattle, who experienced intermittent paralysis for five years, before regaining his ability to walk and move his body normally after he had all metal implants taken out of his body and teeth. Clin Exp Allergy. Okamura et al. WebMELISA is a simple blood test which can separate those individuals which may suffer side-effects from metal exposure and those that will not. 81-B, no. Contact dermatitis: A practice updateUpdate 2015. Dental implants are typically made from titanium metal alloys, and in some rare cases, people may experience titanium allergy symptoms. Moreover, all her aforementioned symptoms were alleviated once the metal surgical clips were removed surgically. Phil Lieberman, M.D. This study determined the relev Clinics providing access to MELISA testing. The dr confirms thru xray that it is in properly. best of luck. Therefore a more inert Ti-alloy might be even more secure, as it interacts not that fast with the tissue. The results of a MELISA test came back negative for a titanium allergy but revealed Peters is allergic to nickel. 2. Preoperative testing may identify preexisting sensitivity but does not predict likelihood of joint failure and may help with selection of type of implant; Please enable it to take advantage of the complete set of features! Carol: keep an eye on the situation and as you already have consult with your physician. We investigated these questions by measuring lymphocyte responses to implant metals (Cr+3, Co+2, Ni+2 at 0.1 mM, and Ti+4 at 0.001 mM) in six subject groups: Group 1a = young controls, Group 1b = age matched controls, Group 2a = subjects with osteoarthritis (OA) and no history of metal sensitivity, Group 2b = OA subjects with history of metal sensitivity, Group 3a = total hip arthroplasty (THA) subjects with no to mild radiographic osteolysis, and Group 3b = THA subjects with moderate osteolysis. T. Okamura, M. Morimoto, D. Fukushima, and G. Yamane, A skin patch test for the diagnosis of titanium allergy, Journal of Dental Research, vol. It is important to diagnose RFB promptly and remove it as soon as possible due to life-threatening complications such as gastrointestinal bleeding, intestinal obstruction, and perforation [13]. a. Even low grade allergies are causing significant symptoms. The authors conclude: Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. 3. M. Tu and Y. Wu, Multiple allergies to metal alloys, Dermatologica Sinica, vol. vi. 155162, 1999. Neuroendocrinology Letters 2003; 24(1/2):57-64, Copyright 2022 MELISA Diagnostics Limited. Just wondering. WebThe patch test is considered the reference method for diagnosing contact allergy, but its use in detecting hypersensitivity to implant materials is controversial. She reported a complete resolution of all symptoms one-month postsurgery. -, Strakowska P., Beutner R., Gnyba M., Zielinski A., Scharnweber D. Electrochemically assisted deposition of hydroxyapatite on Ti6Al4V substrates covered by CVD diamond films -- Coating characterization and first cell biological results. Upon removal the pain disappeared. Lindemann M, Rietschel F, Zabel M, Grosse-Wilde H. We wanted to highlight the remarkable case of Dana Jeske, a mechanical engineer living near Seattle, who experienced intermittent paralysis for five years, before regaining his ability to walk and move his body normally after he had all metal implants taken out of his body and teeth. The German S3 guideline on titanium hypersensitivity in implant dentistry: consensus statements and recommendations. Overnight, Jeske went from being paralyzed 10-12 hours a day down to 3 hours a day. ii. zirconia has never osseointegrated to bone as titanium or titanium alloys can do. Mller-Heupt LK, Schiegnitz E, Kaya S, Jacobi-Gresser E, Kmmerer PW, Al-Nawas B. Int J Implant Dent. 12.5 microg/mL of chromium chloride and 50 ng/mL of potassium dichromate were found to be optimal to discriminate between sensitized individuals with and without allergy. It causes delayed clinical manifestations after 48 to 72 hours [10]. However, in October 2020, the patient started having new symptoms of watery, nonbloody diarrhea associated with her chronic RLQ pain. I also had titanium screws inserted into my mouth giving me alot of pain. This study is aimed at proving the clinical benefit of the MELISA test in the minimization or complete elimination of health problems in patients with confirmed ii. While nickel allergy may present as a rash or localised contact dermatitis it may also have systemic effects including chronic fatigue and muscle pain and widespread skin conditions. Tsh Normal All bld normal carol. These reactions are T cell dependent and patch testing would be the preferred method if we had reagents for each metal and if all of the metals penetrated the epithelium equally. Moreover, titanium has been described to activate macrophages through phagocytosis to cause the release of pro- and anti-inflammatory cytokines [9]. I'm with Aaron. Background: The standard assay for the detection of chromium sensitization, the patch test, does not allow discrimination between patients with and without clinical symptoms of allergy. However, THA subjects (Groups 3a & b) were >3 fold more reactive to Cr (p < 0.04), than were controls (Groups 1a & b) or OA subjects (Groups 2a & b).
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