Anaphylactic reaction to "Heartwise"

Pregnancy and urinary diversion

In most children or premenopausal women who need urinary diversion, the underlying disease is benign. After the problems associated with urinary incontinence have been resolved, and patients have reached puberty, sexuality and fertility become more significant. In women with urinary diversion, numerous influencing factors exist, including, but not limited to, the underlying disease and form of urinary diversion. The authors' center has a large expertise in urinary diversion, although the number of cases with pregnancies is limited. This article uses this prior experience and data from a literature review to provide guidance for urologists, obstetricians, general practitioners, and patients to aid decision making in pregnancies after urinary diversion.

Latex allergy in children on home mechanical ventilation

STUDY OBJECTIVE

Determining the incidence of latex allergy in children receiving home mechanical ventilation.

BACKGROUND

The prevalence of latex allergy in the general population ranges from 0.1 to 1.0%. However, in patients with spina bifida and other chronic medical conditions associated with repeated exposure to latex, the prevalence may be as high as 60%. Children receiving home mechanical ventilation are frequently exposed to latex products. Therefore, we hypothesized that these children would be at increased risk for latex allergy.

DESIGN

Fifty-seven children receiving home mechanical ventilation (31 boys, 26 girls; mean [+/- SD] age, 7.8+/-6.6 years; range, 0.3 to 23.2 years) were enrolled. A radioallergosorbent test (RAST) for latex was administered and serum IgE levels were obtained in all patients.

RESULTS

Seventeen patients (29.8%) were found to have a positive RAST for latex. Patients with latex allergy had required mechanical ventilation for an average of 6.1+/-4.1 years vs. 5.5+/-5.4 years (p = 0.69; not significant) in those without latex allergy. Eleven of 17 patients (64.7%) had elevated serum IgE levels in the group with latex allergy vs only 14 of 40 patients (35.0%) in the group with a negative latex RAST (p = 0.04; odds ratio, 3.4).

CONCLUSION

We conclude that there is a high incidence of latex allergy in children requiring home mechanical ventilation. We speculate that screening all children receiving home mechanical ventilation may lead to the identification of patients with previously undiagnosed latex allergy and the prevention of untoward reactions from exposure to latex.

Risky business: pre-powdered gloves or powder-free gloves in the operating suite?

Two of the emerging issues for the health-care sector in the 1990s are occupational health and safety, and iatrogenic issues. Both of these issues are implicated in the use of pre-powdered latex gloves. Hospital health-care workers are exposed to latex in many ways: gloves, intravenous sets, ventilator circuits, dental products, resuscitation equipment, anaesthetic equipment. Post-operative complications, delayed wound healing, scar formation, and the potential for misdiagnosis, in the presence of starch powder, have been well documented in the literature with the need for through glove rinsing prior to surgery. Another route for glove powder to enter wounds is through a barrier breach. For an institution to ensure it provides the most durable and effective barrier for healthcare worker protection and patient safety, knowledge is needed regarding the various factors which lead to glove barrier failure. The primary aim of the study was to evaluate the in-use durability of the surgical gloves in current use against powder-free gloves. Descriptive statistics were used to analyse the data, in addition a cost analysis was calculated. The results of this study demonstrated clinically important differences between existing glove products in terms of barrier quality.

Raising eyebrows: problems that get anesthesiologists' attention

There are many clinical situations of concern that may be unique to pediatric anesthesiologists. The author discusses four of the more common presentations: asthma, cystic fibrosis, anterior mediastinal masses, and latex allergy. Many such issues can be resolved before surgery by consultation with members of the operating team. Some issues may require additional input from nonsurgical pediatric specialists. By maintaining good communication between the anesthesiologist and the surgeon, delays and cancellations can be minimized and patient care enhanced.

Latex allergy and the podiatric surgeon

Latex allergy in recent years has become a more visible problem in the medical community. There are certain populations found to be at greater risk for this problem. Those with myelodysplasia, congenital urinary anomalies, and a history of a significant number of prior surgeries are particularly at risk, followed less commonly by health care workers and the general population. A detailed patient history is the most reliable predictor of latex sensitivity. There are various immunological and serological screening tests on the market, which are not always reliable predictors of allergy or readily available to the physician. This article reviews the current literature on latex allergy and provides insight into populations at risk, the type of allergic response seen, predictors of sensitivity, management of patients with latex allergy, and measures to prevent it.

Latex allergy

Coined the next major health concern of the decade, allergy to natural rubber latex affects people routinely exposed to rubber products. Groups at highest risk include health care workers, rubber industry workers, and persons who have undergone multiple surgical procedures, especially those with spina bifida. Allergy to latex is a type I, immediate, IgE-mediated reaction, which can lead to anaphylaxis and death. Much of latex research is published in allergy journals. Dermatologists may not be aware of the prevalence, symptoms, risks, diagnosis, and treatment of latex allergy. These topics are the subject of this review. Research concerning antigenic proteins, as well as sources of latex alternatives, is also summarized. (J Am Acad Dermatol 1998;39:1-24.)

LEARNING OBJECTIVE

At the completion of this learning activity, participants should have a clear understanding of the history, biology, epidemiology, mechanism, clinical characteristics, diagnostic work-up, and treatment of latex allergy. Readers should also have a greater understanding of multiple potential allergenic latex proteins and their importance in preventing future latex-sensitization.

On the allergenicity of Hev b 1 among health care workers and patients with spina bifida allergic to natural rubber latex

BACKGROUND

Recent studies have caused much controversy about the prevalence of IgE antibodies to Hev b 1 among health care workers (HCWs) and patients with spina bifida (SB) who are allergic to latex. This investigation was carried out to verify the results reported.

METHOD

Serum samples from 140 patients with SB as well as from 105 HCWs allergic to latex were tested by enzyme allergosorbest test (EAST) and EAST-inhibition assay to evaluate the rate and degree of sensitization to highly purified Hev b 1.

RESULTS

Eighty-one percent of patients with SB who were allergic to latex had IgE antibodies against Hev b 1. The prevalence of anti-Hev b 1 antibodies among HCWs allergic to latex was 52.3%. In 15 of 33 serum samples from patients with SB that were randomly tested, the IgE binding to commercial latex allergens could be completely inhibited by Hev b 1; in only six cases was the maximum inhibition of IgE binding to latex by Hev b 1 less than 50%. Testing two monoclonal anti-Hev b 1 antibodies with extracts of five brands of latex gloves revealed a predominant presence of Hev b 1 protein as a monomer or its aggregates. Molecular analysis of human leukocyte antigen-D region genes DRB and DQB1 suggested no statistically significant correlation between the human leukocyte antigen alleles tested and IgE responsiveness to Hev b 1.

CONCLUSIONS

Our results indicate that Hev b 1 not only makes significant contributions to the IgE binding to latex, but it is also the unique sensitizer in about 45% of patients with SB who are allergic to latex.

Determination of independent risk factors and comparative analysis of diagnostic methods for immediate type latex allergy in spina bifida patients

BACKGROUND

Development of allergy to natural rubber latex in spina bifida patients is determined by several risk factors, such as age, number of interventions and atopic disease that are, however, interdependent. Furthermore, several diagnostic procedures have been analysed, but a comprehensive analysis of their diagnostic significance is lacking.

OBJECTIVE

To determine the independent major risk factor(s) for development of natural rubber latex allergy and the most valuable diagnostic procedure.

METHODS

In aselectively collected spina bifida patients, we correlated existing natural rubber latex allergy with age, sex, atopy and the number of hospitalizations and of surgical interventions in appropriately matched subgroups. Allergy to natural rubber latex was established by application of a latex glove fragment on the skin. Skin-prick tests with glove eluate, a natural latex extract and a commercial latex extract were carried out as were specific IgE measurements by radioimmuno assay (RAST-CAP). The results of the latex application test are compared with the other diagnostic methods.

RESULTS

Out of 74 fully evaluated patients, 17 had a positive application test. The number of surgical interventions correlates strongly with the presence of natural rubber latex allergy (P<0.0002), independent of age, sex and presence of atopy. Skin-prick tests with unstandardized allergens made from known high allergenic latex gloves represent the most sensitive diagnostic method, with the highest negative predictive value and a specificity of 0.95. RAST-CAP was the next best method with a specificity of 0.93, a sensitivity of 0.89 and a negative predictive value of 0.97.

CONCLUSION

The number of surgical interventions is the major independent determining factor for allergy to natural rubber latex in spina bifida patients. Unstandardized skin-prick tests are the most sensitive and specific diagnostic tool, but RAST-CAP is almost equally performant and therefore a valid alternative.

HLA class II antigens DR4 and DQ8 are associated with allergy to hevein, a major allergen of Hevea latex

In this study we investigated the relationship between HLA class II alleles and the IgE-specific immune response to the 4.7 kDa polypeptide hevein of Hevea brasiliensis, a major latex allergen, 51 individuals with immediate-type latex allergy and 90 controls were examined for the polymorphisms in exon 2 of HLA-DRB1, 3, 4, 5 and DQB1 by sequence-specific oligonucleotide probe typing. 35 (69%) out of 51 latex-sensitized subjects showed positive hevein-specific IgE values. Analysis of the HLA data among these 35 subjects revealed increased phenotype frequencies for DR4 (22/35, 63%) and DQ8 (18/35, 51%) when compared with those in the 16 hevein-negative but latex-positive subjects (DR4: 2/16, 13%, p = 0.0009, Pc = 0.047; DQ8: 0/16, p = 0.0003, pc = 0.018) and with healthy controls (DR4: 22/90, 24%, p = 0.00012, pc = 0.013; DQ8: 16/89, 18%, p = 0.0003, pc = 0.036). Finally the DR4-DQ8 haplotype frequency was significantly elevated in hevein-positives when compared with hevein-negatives (51% vs. 0, p = 0.0003, pc = 0.034) or controls (51% vs. 18%, p = 0.0002, pc = 0.045) The present data suggest DR4 and DQ8 to be operating jointly as susceptibility factor for the allergy to hevein.

The relationship between latex skin prick test responses and clinical allergic responses

BACKGROUND

Allergic responses to latex have been reported more frequently in the past 5 years. Although commercial skin prick test solutions are available and can be used in the diagnosis of latex allergy in some countries, the characteristics of patients sensitized to latex relative to their skin test responses have not been reported.

OBJECTIVE

The purpose of this study is to relate the clinical characteristics of patients with latex sensitivity to the size of their latex skin prick test response.

METHODS

A retrospective review of patients who were attending a hospital-based allergy and asthma clinic and who had positive skin test responses to a commercial latex skin test solution was undertaken.

RESULTS

Of 47 patients who had skin test responses to latex, 36 had a mean wheal diameter at least 3 mm greater than the negative control (diluent). Sixty-eight percent were health care workers. There was a positive association between the size of skin test response and severity of latex-induced symptoms (p < 0.001). A history of banana sensitivity was also associated with larger skin test responses (p < 0.05).

CONCLUSION

The size of the skin prick test response to latex solution that is commercially available in Canada reflects the severity of latex-induced clinical allergic responses.

Latex anaphylaxis: report of occurrence in two pediatric surgical patients and review of the literature

This report describes two cases of intraoperative anaphylaxis in children sensitized to latex. Both children were undergoing nonurological procedures and, despite numerous previous operations, neither had a history of unusual reaction or anaphylaxis during surgery. The problem of latex allergy is discussed with review of the current literature and suggestions for management.

A cluster of anaphylactic reactions in children with spina bifida during general anesthesia: epidemiologic features, risk factors, and latex hypersensitivity

BACKGROUND

Anaphylactic reactions (ARs) in high-risk pediatric patients undergoing general anesthesia, especially those with spina bifida, have been attributed to anesthetics, muscle relaxants, antimicrobials, ethylene oxide, and latex.

METHODS

To identify risk factors for AR during general anesthesia and to investigate the role of latex allergy, we studied epidemiologic and immunologic characteristics of patients with ARs during general anesthesia during a 13-month cluster of such reactions at Children's Hospital of Wisconsin (case patients). Patients with AR were compared with patients with spina bifida undergoing uneventful general anesthesia during the same period (control patients). For each case patient and control patient, we conducted a chart review; a parental interview; skin prick testing with latex, anesthetics, aeroallergens, and banana extract; ELISA and RAST for latex-specific IgE; a total serum IgE; and an ELISA for IgE antibody to ethylene oxide.

RESULTS

Anaphylactic reactions occurred exclusively in patients with spina bifida (n = 10) or patients with a congenital urinary tract anomaly (n = 1). Case-patients were more likely than control patients to have a history of asthma (p = 0.002), rubber contact allergy (p = 0.001), food allergy (p = 0.001), rash caused by adhesive tape (p = 0.05), daily rectal disimpaction (p < 0.001), nine or more prior surgical procedures (p < 0.002), latex-specific IgE (p = 0.027), or elevated total serum IgE levels (p = 0.002). Multivariate analysis identified non-white race, rubber contact allergy, history of food allergy, and nine or more surgical procedures as significant independent risk factors. Logistic model equation identified the predicted probability of AR with a sensitivity, specificity, and positive predictive value of 82%, 97%, and 82%, respectively.

CONCLUSIONS

These findings demonstrate that atopy, especially symptomatic latex allergy, is associated with AR during anesthesia in patients with spina bifida. Until a standardized latex test is available, a medical history of immediate rubber contact allergy, non-white race, food allergy, or nine or more prior surgical procedures can identify patients with spina bifida at highest risk for ARs. A complete history, including rubber contact and food allergy, should be compiled on all patients with spina bifida before surgery.

Glove-related skin symptoms among operating theatre and dental care unit personnel (I). Interview investigation

233 employees in hospital and dental care participated in an interview investigation on glove-related skin complaints. 37% (87/233) reported skin symptoms related to glove use. 2% (4/233) reported localized contact urticaria provoked by latex gloves, 10% (23/233) hand eczema and 24% (56/233) unclassifiable skin intolerance reactions from gloves. Another 2% (4/233) reported facial irritation from gloves. Glove-related skin symptoms were thus reported by more than 1/3 of the personnel and the reported glove-provoked contact urticaria constituted 5% (4/87) of the intolerance reactions.