Specific immunotherapy for severe latex allergy

We studied 4 patients (3 adult females + 13y old boy) with latex allergy. All patients had anaphylaxis related with latex and oral-latex-fruit syndrome. All 3 females had severe symptoms in the workplace. The boy had spina bifida with 9 previous surgeries and needed further surgical interventions. Positive skin prick tests (SPT), the presence of serum latex specific IgE (CAP-RAST, Pharmacia-Upjohn, Sweden- class 3 in the 3 females and class 4 in the boy) demonstrated the sensitisation. All 4 patients were treated with specific immunotherapy (SIT) with aqueous extract (ALK-ALK-ABELLO SA, Spain) administered subcutaneously at the hospital, by a modified rush schedule. A maintenance dose (MD) of 0.35_g protein was established according to the magnitude of local reactions (LRs). In one patient a higher dose induced the appearance of a systemic reaction (SR) 40 min after administration, which promptly remitted with treatment. After reaching MD, all 3 females remained assymptomatic at workplace. A challenge test with latex gloves was performed. Two months after MD was reached 2 females had no symptoms and one other had mild symptoms of rhinoconjunctivitis. The boy was subjected to a surgical intervention with no allergic reaction. We also observed a reduction on skin reactivity to latex in all patients by prick tests. We consider SIT with latex to be highly effective, safe and well tolerated provided we use this dose of the allergenic extract.

Severe allergy in a pregnant woman after vaginal examination with a latex glove

Recently case reports about latex allergy were increased. We have experienced severe latex allergy in a pregnant women after vaginal examination with a latex glove. A 33-year-old woman, 38 weeks pregenant, was hospitalized for management of fetal IUGR. She underwent a vaginal examination with a latex glove and soon developed severe anaphylactic reactions. Although two hours later her condition had remarkably improved, regular uterine contractions appeared, and fetal cardiotocogram showed late decelerations. So emergency cesarean section was performed under the situation without using any latex products. She delivered a male infant weighing 2,227 g (-2.21 SD) at 38 weeks gestation. His Apgar score was 5 points at 1 min and 8 points at 5 min. The latex-specific IgE of this patient was high and IgE for banana, avocado and kiwi were also positive. These foods showed cross-reactions with latex, but she had no history of allergic reactions against these foods. She had a history of atopic reactions and of atopic dermatitis while working as a nurse at the ICU. It is thought that this patient was in the high-risk group.

Minimizing latex exposure and allergy. How to avoid or reduce sensitization in the healthcare setting

Healthcare professionals with long-term exposure to natural rubber latex products and patients who undergo multiple operations are at high risk for latex allergy. The clinical spectrum of this allergy ranges from self-limited contact urticaria to involvement of multiple organ systems in anaphylaxis. In this article, Dr Muller explores the roots of the latex allergy epidemic and offers insight into the manufacturing process of latex gloves. She also presents a clinical approach to prevent or ameliorate sensitization and manage allergic symptoms.

The mechanical and microbiological integrity of surgical gloves

BACKGROUND

Several manufacturers supply surgical gloves that have been individually tested (IT) for leaks. Other manufacturers supply gloves in which sample gloves from each batch are tested for leaks (batch tested: BT). The latter brands may be rejected by surgeons because of presumed increased risk of wound infection and staff exposure to patient pathogens. The influence of differences between glove brands on performance in surgery has not been extensively studied. The aims of the present study were to test the mechanical and microbiological integrity of IT compared to BT gloves.

METHODS

A total of 110 unused gloves from each of an IT and a BT brand were tested for leaks, first, by observation of water-jets from water-filled gloves and second, by measuring electrical resistance between inside and outside the glove surfaces, to give a baseline measure. A total of 304 IT and 280 BT gloves were then similarly leak-tested after 98 clean surgical procedures. The hands and gloves of scrub team members were cultured postsurgery.

RESULTS

A total of 1/110 BT and 0/110 IT unused gloves contained leaks (NS, Fisher's exact test). Operative perforation rates were lower for BT compared with IT (8/280 cf. 22/304; P < 0.05 Fisher's exact test). There was no bias in types of operations or scrub team members to account for the difference. Growth of normal skin flora was found on virtually every wearer's hands post-operatively. Similar bacteria were frequently cultured from the outside of gloves at the conclusion of surgery (111/152 pairs IT cf. 122/140 pairs BT; P < 0.01, Fisher's exact test).

CONCLUSION

This study provides evidence that the clinical performance of BT gloves is no different to IT gloves. There was no significant difference in mechanical leak rates for unused gloves. Paradoxically, although IT gloves were more likely to show macro-perforations after surgery, the incidence of contamination on the surface of BT gloves was greater, possibly reflecting a qualitative difference in glove material. This study suggests that both types of gloves develop microporosity during use, which may allow transfer of bacteria from the surgeon's skin to the surface of the glove.

[A successfully treated case of intraoperative latex anaphylaxis during abdominal aorta aneurysm resection]

We experienced resuscitation from latex anaphylaxis induced by surgical gloves during elective abdominal aorta aneurysm resection in a low risk adult with latex allergy. The patient developed severe circulatory collapse 10 minutes after the start of surgery. Although administration of dopamine, norepinephrine, and a large amount of fluid could not normalize this circulatory collapse, but addition of famotidine and chlorpheniramine could restore blood pressure. After resuscitation, we decided to postpone the operation. The re-operation was planned in the latex free setting one month later. All products, containing latex, had been excluded from operating room one day before the re-operation, and the patient entered operating room earlier than other patients to avoid latex-polluted powder from surgical gloves of other staffs. Y-shaped graft replacement was performed, and the perioperative course was uneventful. Latex is the second leading cause of intraoperative anaphylaxis, and the high-risk cases could be easily detected through the questionnaires, focusing on latex and other tropical fruits allergy. Moreover, because it is easy to get latex-free products, we recommend that a set of latex free products should be prepared at least for a high-risk case of latex allergy.

Occupational asthma from natural rubber latex. Specific inhalation challenge test and evolution

BACKGROUND

Natural rubber latex (NRL) is the most frequent cause of occupational respiratory problems in hospital workers.

OBJECTIVE

To describe the diagnostic methodology, including the specific inhalation challenge (SIC), used on patients diagnosed as having occupational asthma due to NRL in our Allergy Department during a 6-year period from 1989 to 1995.

METHODS

In 19 patients diagnosed as having occupational asthma due to NRL, clinical severity was assessed with a combined score for symptoms and medication use. Skin prick tests with aeroallergens, latex, papain, kiwi and chestnut, total IgE, serum-specific latex IgE, respiratory function study, methacholine test, specific conjunctival test, and SIC test with latex were done.

RESULTS

All but three patients worked in hospitals. All presented urticaria and rhinoconjunctivitis, and six also suffered anaphylaxis, usually preceded by asthma. Clinical fruit allergy was present in eight patients. The latency period was variable (0.25-27 years). The intensity of symptoms was low to moderate. Specific IgE, skin prick, and conjunctival tests to latex were positive in all cases. SICs were done in 12 patients. All of them presented isolated immediate reactions. No adverse reactions were observed. Duration of follow-up ranged from 1 to 7 years. Twenty-six percent of the patients kept their job, 26% changed jobs but remained in health care, and 48% switched to jobs unrelated to health care. Only 16% were free of symptoms without treatment, while 32% needed bronchodilators and 52% needed inhaled steroids. The specific bronchial challenge test was safe, but it did not predict the course of the illness. Duration of exposure and intensity of symptoms did correlate with prognosis, however.

CONCLUSIONS

NRL acts as a common aerollergen. Minor symptoms often precede occupational asthma. The SIC test was safe in the hands of trained technicians. Occupational asthma due to NRL seems to have a poor prognosis.

Management of dental patients with allergies to natural rubber latex

Reports of serious allergic reaction to natural rubber latex (NRL) are not uncommon in dentistry. The prevalence of Type I allergies in high-risk patient groups can range as high as 17% for health care professionals and over 50% in patients with spina bifida. A Type IV allergy to NRL chemical additives, also known as allergic contact dermatitis, is common in health care professions. To safeguard patients and coworkers, dentists must learn to recognize patients and workers at risk for NRL allergies, identify the associated symptoms, implement preventive measures, and encourage thorough diagnostics and management. This article reviews the latest advances in NRL allergies, particularly as they apply in dentistry.

Minimizing the risks of latex allergy: the effectiveness of written information

BACKGROUND

Latex allergy has been identified as an occupational risk for the dental profession. This study assessed whether identified latex-allergic dental personnel changed their practices after receiving verbal and written information about the management of latex allergy.

METHODS

A survey conducted at the 1998 Australian Dental Association Congress identified 157 dental personnel with clinical latex allergy, or at high risk from latex exposure. The workplace implications were then explained to them by a consultant allergist. Four weeks later, follow up written information on latex allergy was mailed out. The information sheet outlined possible symptoms and cross-reactions, implications for the workplace, hand care advice and management strategies to reduce latex exposure in the workplace. After six weeks, a questionnaire, designed to assess whether appropriate steps to reduce latex exposure had been taken, was mailed out.

RESULTS

Seventy per cent of the questionnaires were returned. All respondents felt the information was easy to understand and informative. While 50 per cent of respondents indicated that they had changed to powder-free or non-latex gloves, only five respondents were fully compliant with all instructions.

CONCLUSION

Compliance with instructions regarding minimizing exposure to latex in a group of latex-allergic dental personnel was poor.

Reducing the hazards of exposure to cornstarch glove powder

Latex allergy has received considerable attention during the past decade. The occurrence of latex allergy in health care workers is higher than in the general population. Latex gloves are the most frequent form of exposure that health care workers have to natural rubber latex; therefore, the relationship between gloves and latex allergies, has been well studied. Scientific evidence supports the link between glove powder and the occurrence of latex allergies, as well as the development of postoperative complications in surgical patients. This article describes how a multihospital system, which is the seventh largest not-for-profit health care corporation in the nation and includes 35 ORs, successfully eliminated powdered gloves from the environment.

An unusual case of a postoperative bone cyst

We describe an unusual case of a postoperative bone cyst resulting from a retained fragment of surgical glove. We highlight some of the problems associated with gloves and suggest ways of safeguarding against similar complications.

Latex allergy: the perspective from the surgical suite

Latex allergy in the perioperative setting presents unique challenges to the health care system. Specific needs of the latex-sensitive patient are paramount, but consideration must also include the impact on health care workers vis-a-vis latex sensitization, environmental allergen control, and barrier protection against blood-borne pathogens. It has been well documented that the greatest source of latex aeroallergen in the surgical setting is latex gloves (both sterile and nonsterile). Levels of latex aeroallergen correlate strongly with use of high-allergen and powdered gloves, total number of gloves used, and the hours of activity in a given environment. A significant reduction in aeroallergen (>10-fold) can be achieved by switching to low-allergen gloves. Ready availability of and encouragement to use nonlatex alternatives when appropriate can further reduce exposure to latex allergens. Since 1998, the Food and Drug Administration has required all medical devices (or their packaging) that contain natural rubber latex to be so labeled. In addition, industry has responded with a host of latex-free products for use in patient care. This has helped eliminate a great deal of confusion about which products are safe for use with latex-sensitive individuals. However, despite significant efforts to educate the public and the health care industry regarding latex allergies, considerable misinformation persists. Provision of a completely latex-free environment in most surgical suites may be unrealistic, but every effort should be made to minimize the unnecessary exposure of patients and health care workers to latex allergens in this high-risk arena.

Latex sensitization in dental students using powder-free gloves low in latex protein:a cross-sectional study

In Germany, employers must provide low-protein, powder-free gloves. This study was carried out to determine the current prevalence of latex sensitization in dental students using these gloves and to compare our results with a study of the same design dating from 1990/1991 at our university. A cross-sectional study was performed by questionnaire, prick testing and determination of specific IgE antibodies. 226 of 403 dental students underwent prick testing with a panel of 8 aero-allergens, 1 commercially available latex extract and 5 high-ammonia accelerator-free latex fluids. 39 of 226 dental students (17.3%) had a positive prick test response to at least 1 of the 6 latex substances tested. The prick test positivity was similar in preclinical education (semester 1-6) and in clinical education (semester 7-10), at 17.1% and 17.4%, respectively. In 9 of 32 persons with positive prick tests, specific IgE antibodies to latex could be detected. Within the past 10 years, prick test positivity increased from 8.7% to 17.3%. 14 students (6.2%) reported a history of glove intolerance, 3 of them (1.3%) showing a positive prick test to latex. By the use of low-protein, powder-free gloves less students with glove intolerance were observed. The observed reactions to between 1 and 3 of 6 latex substances tested may indicate a decrease in intensity and spectrum of sensitization. Additionally non-occupational sensitization may be of importance.

Prevalence of adverse reactions to latex gloves in Korean operating room nurses

This study was conducted to determine the prevalence rate of adverse reactions to latex gloves. Among hospital personnel working in operating rooms, 41.4% reported adverse reactions to latex. Especially among OR nurses, the prevalence rate of adverse reactions was 80.3%, and that of latex allergy was 9.8%. Common symptoms were rash, skin itching, dizziness, and eye itching. Atopics had more latex allergy than the non-atopics. There was no difference in the incidence rate of latex allergy among the five gloves by the prick test. But with the exposure test, ordinary gloves had a higher latex allergy incidence than hypoallergenic gloves.

Health effects associated with medical glove use

Adverse reactions to medical gloves represent an important public health issue. Accordingly, there is increasing interest in understanding the information reported to the US Food and Drug Administration (FDA) describing health effects associated with the use of medical gloves. This article provides a retrospective analysis and summary of health effects associated with medical glove use reported to the FDA. The FDA's medical device adverse event databases were searched via computer using keywords to identify reports of reactions associated with any type of medical glove. Demographic and clinical information abstracted from these reports was used to perform frequency and trend analyses. The reported medical glove-related events, including the noted trends in reporting, suggest the need for further study and continued monitoring of such reports.

Latex allergy: a health care problem of epidemic proportions

Latex allergy is one of the major health concerns of the decade. The induction of latex allergy commonly occurs after exposure of skin or mucous membrane to natural rubber latex. It is usually a type I, immediate hypersensitivity reaction mediated by IgE which can range from mild skin erythema to anaphylaxis and death. To manage latex allergy appropriately, prompt and correct diagnosis is essential. This depends primarily on clinical history, latex specific IgE RAST (in vitro) and skin prick test (in vivo). It affects people who are frequently exposed to products made of natural rubber latex, such as, health care workers, workers in the rubber industry and those who have had multiple surgical operations. The prevalence in the general population was estimated at 0.7% in a population study in France, but this can be higher in health care workers (up to 17%) and in patients with spina bifida to almost 65%. Prevention strategies should therefore target at risk population, rather than the population as a whole. At present this primarily involves providing non-powdered latex gloves in hospitals and primary health care centres. However, once latex allergy has been established, the situation becomes more complicated. Health care workers either have to be moved to a latex free environment or in extreme circumstances may have to give up their occupation. For patients undergoing operations most hospitals have adopted a latex free protocol. It is important that this is understood and followed by every member of the staff. Those who have had serious adverse reactions should wear Medi-Alert bracelets and in exceptional circumstances may need to keep epinephrine injections on their person. Future strategies focus on the reduction of allergens during latex manufacture, development of suitable non latex gloves and immunotherapy including desensitisation of latex allergic individuals and development of candidate vaccine.

An investigation of the effect of prolonged glove wearing on the hand skin health of dental healthcare workers

OBJECTIVES

Glove wearing during patient treatment has been central to dental surgery infection control for over 15 years. However, little is known about the cutaneous effects of glove wearing on the hands of dental healthcare workers (DHCWs). The objective of this project was to assess the hand skin health of DHCWs before and after wearing gloves of two types and to compare this with a control group of non-DHCWs.

METHODS

Following a mailing to all dentists in the West of Scotland, 50 DHCWs who wore gloves during dental treatment procedures for a minimum of 8h daily for at least 4 days per week were invited to participate in the project. The control group comprised 25 subjects who did not routinely use surgical or examination gloves. Hands were assessed by clinical examination and by transepidermal water loss at baseline, 1 month and 3 months.

RESULTS

Of the 50 DHCWs, 26 wore a non-powdered latex glove (Microtouch Powder-free: Johnson and Johnson, Arligton, TX, US), and 24 wore a nitrile glove (Hartalega SDN BHD, Malaysia) from the time of the baseline examination until the 3-month examination. No differences were observed in hand skin health between the control group and the DHCWs at baseline, nor between those wearing the latex or nitrile gloves during the 3 month period of the study.

CONCLUSION

It is concluded that the hand skin health of the DHCWs examined were no different from those of a control group of non-DHCWs, and that the wearing of the two types of gloves used in the 3 month study had no significant effect.

Data dependent systems technique: a methodology with an application to human systems

The objective of this paper is to introduce the application of Data Dependent Systems (DDS) methodology to the field of ergonomics. Many current techniques in ergonomics utilize static models, which can have significant limitations. DDS is a stochastic modelling and analysis technique that can be used to capture the dynamics of a system through quantitative analysis of the available data. DDS has been successfully applied to the analysis of manufacturing processes and the surfaces generated by those processes. In this research, DDS was used to analyse time-based hand-skin temperature data for the evaluation of two types of glove liners to be used underneath latex gloves. DDS was able to capture the differences between the two glove liners and the two subjects. The implications of the results and the potential of the DDS methodology are discussed.

[Skin reactions to dental materials]

In dentistry, contact with a wide range of both irritants and contact allergens pose an important occupational hazard. It is important to understand the resulting clinical skin symptoms and their causes to prevent further exposition and to avoid serious problems that may lead to an incompatibility with the dentist profession.

Latex allergy: are you at risk?

The prevalence of latex allergies in healthcare workers has significantly increased over the past 2 decades. Increases in exposure to latex products in healthcare environments are related primarily to the use of gloves for barrier protection. In the early 1980s, with the implementation of universal precautions and appropriate healthcare worker protection, latex glove use dramatically rose in many countries. Manufacturing techniques and additional factories for latex gloves were developed to meet the tremendous demand. As a result of new "fast-track" production processes, some of the latex gloves had variant amounts of powder and allergen content. Synthetic materials, such as polyvinyl, polyurethanes, nitrile, and neoprene, are being used to manufacture medical gloves. Some hospitals and clinics have adopted the use of these alternatives to provide a "latex-free" healthcare environment. Risk reduction and prevention strategies are being implemented in many countries. Latex sensitivity and allergy can present as variable clinical reactions including contact dermatitis, rhinoconjuctivitis, asthma, and anaphylaxis. Some healthcare providers who have coexisting risk factors, such as atopy and food allergies (chestnuts, bananas, avocados, passion fruit, celery, potatoes, and peaches), are at an even greater risk for severe allergic reactions following repeated latex exposure. This journal course will provide an overview of the information available related to latex allergy in healthcare workers.