A Review of Natural‐Rubber Latex Allergy in Health Care Workers

Comparative Assessment of Hypersensitivity Reactions on Use of Latex and Nitrile Gloves Among General Dental Practitioners: A Cross-Sectional Study

Background  Latex gloves are used more frequently by dental, medical, and other health workers and their allergy has also increased as a result, dentists are frequently exposed to latex or nitrile gloves for extended periods. This prolonged exposure often leads to local symptoms such as itching and erythema rashes. However, some dentists experience more severe systemic reactions, including swelling, wheezing, breathlessness, and even an increase in blood pressure. Latex gloves have recently been replaced with nitrile gloves, powder-free latex gloves, and other preventive measures to avoid allergies. Latex allergies are more common than nitrile allergies, as they are hypoallergic with properties such as tear-resistant and provide an equivalent level of defense against various dental materials and procedures. Women experience more allergic reactions than men. Not only are dentists exposed to this allergy but the patient can also be exposed during the procedure. This study aimed to assess hypersensitive reactions to the use of latex and nitrile gloves among general dentist practitioners and dental students. Methods A cross-sectional study was conducted in Wardha, Maharashtra, India, to evaluate allergic reactions to latex and nitrile gloves among general dental practitioners and dental students at college. A questionnaire-based study was conducted with a sample size of 356. The self-administered survey inquiries about glove compliance, the time they wear the gloves, regular glove use, and problems related to latex or nitrile contact. In addition, dentists and dental students' personal histories of allergies to medications, dental materials, disinfectants, or other chemicals were noted, as well as signs and symptoms they experienced from prolonged contact with gloves. Result The total number of responses collected was 356. The investigated dentists were 274 and 82 were students, out of which 122 (34.3%) were male and 234 (65.7%) were female. Responses showed that 224 (62.92%) used latex gloves, and 132 (37.08%) used nitrile gloves. Among 356 participants 175 showed symptoms by the use of both latex and nitrile gloves, out of which 85.14% showed allergy to latex and 14.85% to nitrile gloves. All 175 individuals showed type IV hypersensitivity, and none of them showed type I. Conclusion Latex gloves are not the only option for dentists who experience itching when wearing gloves; they can also use powered-free latex gloves and nitrile gloves or take precautions such as not using oil-based cream, washing their hands, or taking pharmaceuticals such as cetirizine, pheniramine maleate, etc. However, when symptoms worsen and include erythema, swelling, wheezing, and in some cases, anaphylactic shock may occur they tend to use alternative gloves.

New Insight into Rubber Composites Based on Graphene Nanoplatelets, Electrolyte Iron Particles, and Their Hybrid for Stretchable Magnetic Materials

New and soft composites with good mechanical stretchability are constantly addressed in the literature due to their use in various industrial applications such as soft robotics. The stretchable magnetic materials presented in this work show a promising magnetic effect of up to 28% and improved magnetic sensitivity. The composites are soft in nature and possess hardness below 65. These composites were prepared by mixing silicone rubber with fillers such as graphene nanoplatelets (GNP), electrolyte-iron particles (EIP), and their hybrid via solution mixing. The final composites were cured at room temperature for 24 h and their isotropic and anisotropic properties were studied and presented. The mechanical properties under compressive and tensile strain were studied in detail. The results show that the compressive modulus was 1.73 MPa (control) and increased to 3.7 MPa (GNP) at 15 per hundred parts of rubber (phr), 3.2 MPa (EIP), and 4.3 MPa (hybrid) at 80 phr. Similarly, the mechanical stretchability was 112% (control) and increased to 186% (GNP) at 15 phr, 134% (EIP), and 136% (hybrid) at 60 phr. Thus, GNP emerges as a superior reinforcing filler with high stiffness, a high compressive modulus, and high mechanical stretchability. However, the GNP did not show mechanical sensitivity under a magnetic field. Therefore, the hybrids containing GNP and EIP were considered and an improved mechanical performance with magnetic sensitivity was noticed and reported. The mechanism involves the orientation of EIP under a magnetic field causing a magnetic effect, which is 28% for EIP and 5% for hybrid.

Poly(cis-1,4-isoprene)-cleavage enzymes from natural rubber-utilizing bacteria

Natural rubber and synthetic poly(cis-1,4-isoprene) are used industrially in the world. Microbial utilization for the isoprene rubbers has been reported in gram-positive and gram-negative bacteria. Poly(cis-1,4-isoprene)-cleavage enzymes that are secreted by rubber-utilizing bacteria cleave the poly(cis-1,4-isoprene) chain to generate low-molecular-weight oligo(cis-1,4-isoprene) derivatives containing aldehyde and ketone groups. The resulting products are converted to the compounds including carboxyl groups, which could then be further catabolized through β-oxidation pathway. One of poly(cis-1,4-isoprene)-cleavage enzymes is latex-clearing protein (Lcp) that was found in gram-positive rubber degraders including Streptomyces, Gordonia, Rhodococcus, and Nocardia species. The other one is rubber oxygenase A and B (RoxA/RoxB) which have been identified from gram-negative rubber degraders such as Steroidobacter cummioxidans and Rhizobacter gummiphilus. Recently, the transcriptional regulation mechanisms for Lcp-coding genes in gram-positive bacteria have been characterized. Here, the current knowledge of genes and enzymes for the isoprene rubber catabolism were summarized.

Metabolic and taxonomic insights into the Gram-negative natural rubber degrading bacterium Steroidobacter cummioxidans sp. nov., strain 35Y

The pathway of rubber (poly [cis-1,4-isoprene]) catabolism is well documented for Gram-positive rubber degraders but only little information exists for Gram-negative species. The first documented potent rubber degrading Gram-negative strain is Xanthomonas sp. strain 35Y that uses extracellular rubber oxygenases for the initial cleavage of the polyisoprene molecule. However, neither the exact phylogenetic position of Xanthomonas sp. strain 35Y nor the catabolic pathway of the primary polyisoprene cleavage products have been investigated. In this contribution, we started to address both these issues by a comprehensive taxonomic characterization and by the analysis of the draft genome sequence of strain 35Y. Evaluation of the 16S rRNA gene sequence pointed to a borderline taxonomic position of strain 35Y as a novel species of the genus Steroidobacter. Further, substantial differences in the genotypic properties of strain 35Y and the members of the genus Steroidobacter, including average nucleotide identity (ANI) and in silico DNA-DNA hybridization (DDH), resolved the taxonomic position of strain 35Y and suggested its positioning as a novel species of the genus Steroidobacter. This was further confirmed by comparative analysis of physiological and biochemical features of strain 35Y with other members of the genus Steroidobacter. Thus, we conclude that strain 35Y represents a novel species of the genus Steroidobacter, for which we propose the designation Steroidobacter cummioxidans sp. nov., strain 35YT. A comprehensive analysis of the draft genome of S. cummioxidans strain 35Y revealed similarities but also substantial differences to rubber degrading Gram-positive counterparts. In particular, the putative transporters for the uptake of polyisoprene cleavage products differ from Gram-positive rubber degrading species. The draft genome sequence of S. cummioxidans strain 35Y will be useful for researchers to experimentally verify the predicted similarities and differences in the pathways of polyisoprene catabolism in Gram-positive and Gram-negative rubber degrading species.

Teaching Incision and Drainage: Perceived Educational Value of Abscess Models

OBJECTIVES

Incision and drainage (I&D) of skin abscesses is an important procedural skill for pediatric emergency medicine providers. Practical skills training using simulation provides an opportunity to learn and gain confidence with this invasive procedure. Our objective was to assess the perceived educational value of 2 versions of an abscess model as part of an educational workshop for teaching I&D.

METHODS

A combined didactic and practical skills workshop was developed for use at 2 national conferences. The didactic content was created through an iterative process. To facilitate hands-on training, 2 versions of an abscess model were created: 1 constructed from a negative mold and the other using a 3-dimensional printer. Participants were surveyed regarding prior experience with I&D, procedural confidence, and perceptions of the educational utility of the models.

RESULTS

Seventy physicians and 75 nurse practitioners participated in the study. Procedural confidence improved after training using each version of the model, with the greatest improvements noted among novice learners. Ninety-four percent of physicians, and 99% of nurse practitioners rated the respective models as either "educational" or "very educational," and 97% and 100%, respectively, would recommend the abscess models to others.

CONCLUSIONS

A combined didactic and practical skills educational workshop using novel abscess models was effective at improving learners' confidence. Our novel models provide an effective strategy for teaching procedural skills such as I&D and demonstrate a novel use of 3-dimensional printers in medical education. Further study is needed to determine if these educational gains translate into improvement in clinical performance or patient outcomes.

Identification and practical management of latex allergy in occupational settings

Allergy to natural rubber latex (NRL) from Hevea brasiliensis is a relevant occupational health hazard. The use of gloves and products manufactured with latex and environmental allergen exposure in the work environment are risks factors for the development of occupational allergy among different job categories. Healthcare workers have been the most commonly affected, but other professions with exposure to latex products such as hairdressers, cleaners, food handlers and those making natural rubber latex (NRL) products are also at risk of developing occupational allergy. Clinical manifestations of IgE-mediated latex allergy can range from troublesome skin disorders to life-threatening systemic reactions. It is very important to identify the occupational allergic diseases in their early stages in order to implement avoidance strategies. For this purpose, the interventions for prevention should emphasize the importance of latex allergy awareness and surveillance among exposed workforces.

Drug allergies and implications for dental practice

Adverse reactions to medications prescribed or administered in dental practice can be worrying. Most of these reactions are somewhat predictable based on the pharmacodynamic properties of the drug. Others, such as allergic and pseudoallergic reactions, are generally unpredictable and unrelated to normal drug action. This article will review immune and nonimmune-mediated mechanisms that account for allergic and related reactions to the particular drug classes commonly used in dentistry. The appropriate management of these reactions will also be addressed.

Tolerogenic dendritic cells derived from donors with natural rubber latex allergy modulate allergen-specific T-cell responses and IgE production

Natural rubber latex (NRL; Hevea brasiliensis) allergy is an IgE-mediated reaction to latex proteins. When latex glove exposure is the main sensitizing agent, Hev b 5 is one of the major allergens. Dendritic cells (DC), the main antigen presenting cells, modulated with pharmacological agents can restore tolerance in several experimental models, including allergy. In the current study, we aimed to generate DC with tolerogenic properties from NRL-allergic patients and evaluate their ability to modulate allergen-specific T and B cell responses. Here we show that dexamethasone-treated DC (dxDC) differentiated into a subset of DC, characterized by low expression of MHC class II, CD40, CD80, CD86 and CD83 molecules. Compared with LPS-matured DC, dxDC secreted lower IL-12 and higher IL-10 after CD40L activation, and induced lower alloantigenic T cell proliferation. We also show that dxDC pulsed with the dominant Hev b 5 T-cell epitope peptide, Hev b 5_46–65^, inhibited both proliferation of Hev b 5-specific T-cell lines and the production of Hev b 5-specific IgE. Additionally, dxDC induced a subpopulation of IL-10-producing regulatory T cells that suppressed proliferation of Hev b 5-primed T cells. In conclusion, dxDC generated from NRL-allergic patients can modulate allergen-specific T-cell responses and IgE production, supporting their potential use in allergen-specific immunotherapy.

Wearing ambidextrous vinyl gloves does not impair manual dexterity

Universal precautions mandate that health care workers wear gloves to prevent the unintended spread of bloodborne pathogens. Gloves may affect manual dexterity, generally delaying task completion. Our previous study showed that wearing the wrong size latex surgical glove degraded manual dexterity. The use of non-sterile and non-latex gloves may limit certain risks and be more cost-effective. However, such gloves may produce different results. We hypothesized that ambidextrous vinyl examination gloves would degrade manual dexterity compared with bare hands. We studied 20 random subjects from a medical environment. Subjects performed a standard battery of Grooved Pegboard tasks while bare-handed, wearing ambidextrous non-sterile vinyl gloves that were their preferred size, a size too small, and a size too large. The order was randomized with a Latin Square design to minimize the effects of time, boredom, and fatigue on the subjects. Subjects were also invited to comment on the fit of different size gloves. Wearing vinyl gloves of both the preferred size and a size up or down failed to affect manual dexterity vs. bare hands on time to insert pegs, and pegs dropped during insertion or removal. In contrast, the time to remove pegs was reduced by wearing preferred size vinyl gloves compared with performing the task with bare hands (P<0.05). Subjects reported a generally poor fit in all sizes. Vinyl gloves that were too small caused significant hand discomfort. Vinyl gloves surprisingly do not degrade manual dexterity even when worn in ill-fitting sizes. Wearing a preferred size vinyl glove vs. bare hands may improve dexterity in selected tasks. Choosing a comfortable, large size seems the best strategy when the preferred size is unavailable. Thinner vinyl gloves may improve grip and may not degrade touch as much as latex surgical gloves and may thus represent a reasonable choice for selected tasks.

Latex medical gloves: time for a reappraisal

Many hospitals have implemented policies to restrict or ban the use of devices made of natural rubber latex (NRL) in healthcare as precautionary measures against the perceived risk of NRL allergy. Changes in glove technology, progress in measuring the specific allergenic potential of gloves and a dramatic decrease in the prevalence of NRL allergies after interventions and education prompted us to revisit the basis for justifiable glove selection policies. The published Anglophone literature from 1990 to 2010 was reviewed for original articles and reviews dealing with the barrier and performance properties of NRL and synthetic gloves and the role of glove powder. The review shows that NRL medical gloves, when compared with synthetic gloves, tend to be stronger, more flexible and better accepted by clinicians. The introduction of powder-free gloves has been associated with reductions in protein content and associated allergies. Recently, new methods to quantify clinically relevant NRL allergens have enabled the identification of gloves with low allergenic potential. The use of low-protein, low-allergenic, powder-free gloves is associated with a significant decrease in the prevalence of type I allergic reactions to NRL among healthcare workers. Given the excellent barrier properties and operating characteristics, dramatically reduced incidences of allergic reactions, availability of specific tests for selection of low-allergen gloves, competitive costs and low environmental impact, the use of NRL gloves within the hospital environment warrants reappraisal.

Hev b 6.01 and Hev b 5 induce pro-inflammatory cytokines and chemokines from peripheral blood mononuclear cells in latex allergy

BACKGROUND

Hev b 6.01 (prohevein) and Hev b 5 [acidic natural rubber latex (NRL) protein] are major IgE-binding allergens in NRL allergy.

OBJECTIVE

To examine allergen-specific cytokine and chemokine responses in NRL-allergic patients.

METHODS

Fourteen NRL-allergic patients and 10 healthy controls participated in the study. Hev b 6.01 and Hev b 5 were purified under non-denaturating conditions by chromatographic methods. Specific IgE antibodies were measured by ELISA and proliferation of peripheral blood mononuclear cells (PBMC) by (3)H-thymidine incorporation assay. Allergen-specific induction of cytokine and chemokine mRNA in PBMC was measured by real-time PCR and protein levels by ELISA. Surface expression of chemokine receptors was analysed by flow cytometry.

RESULTS

Twelve (86%) NRL-allergic patients had positive skin prick test reactions and IgE antibodies against Hev b 6.01, but less than 30% responded to Hev b 5. Cell proliferation against Hev b 6.01, but not against Hev b 5, was significantly increased. Both allergens elicited significantly higher expression of pro-inflammatory and T-helper type 2 cytokines (TNF, IL-12p40, IL-13) and chemokines (CCL3, CCL4, CCL20) in the NRL-allergic patients than in controls. Interestingly, mRNA expression of the regulatory cytokine TGF-beta1 was reduced, whereas IL-10 expression was enhanced after allergen stimulations in patients with NRL allergy. Finally, the NRL-allergic patients showed increased CCR4 expression on CD3(+)CD8(-) T cells and decreased CXCR3 expression on CD3(+)CD8(+) T cells.

CONCLUSION

Allergen-specific induction of cytokines and chemokines in PBMC and chemokine receptor expression on circulating T cells may contribute to the pathogenesis of NRL allergy.

Occupational allergy to latex among loom tuners in a textile factory

BACKGROUND

Occupational allergy to latex is generally reported from occupational groups such as health care workers; however, few reports derive from other occupational settings.

METHODS

Two male subjects working as loom tuners in a textile manufacturing plant developed severe allergic reactions during the cutting and weaving of elastic bands, initially not suspected to contain latex constituents. Clinical evaluation and lung function tests were supplemented by skin prick testing, specific IgE evaluation and basophil activation assays with extracted elastic bands.

RESULTS

Both workers presented with rhinitis, episodes of tight chest and itchy eyes. Initial spirometry was normal with no significant reversibility; however, a histamine challenge test was positive in one worker. Skin prick testing to a battery of common inhalant allergens was negative; however, raised IgE levels were detected to latex using ImmunoCAP. On further testing, the specific IgE response was directed mainly to the major latex allergens rHev b 5, rHev b 6.01, rHev b 6.02 and nHev b 13. Basophils of the two workers, but not the unaffected control subjects, were strongly activated by extracts of the elastic and the cutting dust material.

CONCLUSIONS

Workers are at high risk of becoming sensitised to latex allergens when exposed to excessive dust produced by loom tuning machines. Latex sensitisation should therefore be considered in workers developing unexplained work-related allergic reactions (including asthma) associated with unlabelled materials in the textile industry.

Occupational risk factors for asthma among nurses and related healthcare professionals in an international study

OBJECTIVE

The authors examined the relations between self-reported work tasks, use of cleaning products and latex glove use with new-onset asthma among nurses and other healthcare workers in the European Community Respiratory Health Survey (ECRHS II).

METHODS

In a random population sample of adults from 22 European sites, 332 participants reported working in nursing and other related healthcare jobs during the nine-year ECRHS II follow-up period and responded to a supplemental questionnaire about their principal work settings, occupational tasks, products used at work and respiratory symptoms. Poisson regression models with robust error variances were used to compare the risk of new-onset asthma among healthcare workers with each exposure to that of respondents who reported professional or administrative occupations during the entire follow-up period (n = 2481).

RESULTS

Twenty (6%) healthcare workers and 131 (5%) members of the referent population reported new-onset asthma. Compared to the referent group, the authors observed increased risks among hospital technicians (RR 4.63; 95% CI 1.87 to 11.5) and among those using ammonia and/or bleach at work (RR 2.16; 95% CI 1.03 to 4.53).

CONCLUSIONS

In the ECRHS II cohort, hospital technicians and other healthcare workers experience increased risks of new-onset current asthma, possibly due to specific products used at work.

Latex specific IgE: performance characteristics of the IMMULITE 2000 3gAllergy assay compared with skin testing

BACKGROUND

In the absence of a US Food and Drug Administration (FDA)-cleared latex skin testing reagent, in vitro tests remain important for the diagnosis of latex allergy.

OBJECTIVE

To evaluate the performance characteristics of IMMULITE 2000 3gAllergy (Immulite), a third-generation, FDA-cleared, continuous random-access immunoanalyzer, for the quantification of latex specific IgE.

METHODS

Stored serum samples (N = 201) from patients classified as having positive or negative latex puncture skin test results were measured for latex specific IgE levels using Immulite, and these data were compared with historical results from 3 second-generation, FDA-cleared IgE antilatex assays (AlaSTAT [Ala], AutoCAP [CAP], and HY*TEC enzyme immunoassay [HT]).

RESULTS

The diagnostic performances of the CAP, Ala, and Immulite assays (> or = 0.35 kU/L cutoff value) were equivalent in sensitivity and specificity (P > .05). The HT assay (> or = 0.05 kU/L cutoff value) was more sensitive and less specific (P < .05). Immulite (> or = 0.10 kU/L cutoff value) had greater sensitivity than Ala and CAP and greater specificity than HT (P < .05 for both). Diagnostic efficiency was greater for Immulite than for CAP, Ala, and HT (P < .05).

CONCLUSIONS

The Immulite system is superior in diagnostic performance, especially at the 0.10 kU/L or greater cutoff level, for the diagnosis of latex allergy compared with older, second-generation assays. Immulite still misclassifies 15.5% of puncture skin test-positive individuals as negative for latex specific IgE. Compared with second-generation assays, Immulite represents a technological advance, with enhanced speed and less operator intervention.

Differential expression of allergens on the internal and external surfaces of latex surgical gloves

BACKGROUND

Differences in latex allergen sensitization profiles have been described between children undergoing repeated surgical interventions and health care workers. The purpose of this study was to determine whether such sensitization profiles are associated with differences in the expression of latex allergen between the internal and external surfaces of surgical gloves.

METHODS

Extracts were obtained from whole surgical gloves as well as from their external and internal surfaces. The extracts were centrifuged, filtered, concentrated, dialyzed and lyophilized. The protein profile of the extracts was analyzed using hydrophobic interaction chromatography (HIC) and sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Immunoblotting was performed using sera from two patients with confirmed latex allergy. Latex recombinant allergen-specific IgE in these two patients was determined using a fluorescence enzyme immunoassay (FEIA) method. Latex allergen quantification was determined on both glove surfaces using an ELISA method.

RESULTS

HIC and SDS-PAGE showed qualitative and quantitative differences in proteins between the internal and external glove surfaces, with the former being much richer in proteins. Immunoblotting of glove extracts using sera from two latex-allergic health workers showed differences between glove surface extracts. ELISA quantification of latex allergens demonstrated that the internal glove surface had high amounts of Hev b 5 and Hev b 6.02 whereas the external surface showed Hev b 1, Hev b 3, and Hev b 6.02.

CONCLUSIONS

Our results reveal substantial differences in the composition of latex allergen profiles between the internal and external surfaces of surgical latex gloves, which may suggest a relationship between latex allergen localization and sensitization routes in different risk groups.

Increased incidence of latex allergy in children with allergic diseases in Japan

The incidence of latex allergy is increasing in Japanese adults. However, the changing incidence of latex allergy in children with or without allergic diseases has not been reported in detail. After obtaining written informed consent from parents, Japanese children under 14 years of age were studied. In total, 776 non-atopic children, 802 children with allergic rhinitis (AR), 706 children with bronchial asthma (BA) and 844 children with atopic eczema/dermatitis syndrome (AEDS) were asked about symptoms of latex allergy, and tested by serum latex-specific IgE, skin prick test to latex allergen and latex-glove-wearing test between 2001 and 2003. All the patients were outpatients at Ujitakeda Hospital, while the non-atopic children were children of the staff of Ujitakeda Hospital or Unitika Ltd. This was a retrospective study. The incidence of latex allergy in 2001/2002/2003 was 1.4/3.1/4.7% in non-atopic children, 3.1/5.1/9.1% in AR patients, 3.6/6.5/10.3% in BA patients and 6.1/11.3/15.9% in AEDS patients, respectively. Moreover, although no cases of anaphylactic shock were noted in allergic patients in 2001, two and eight cases were noted in 2002 and 2003, respectively. These results indicate that the incidence of latex allergy is increasing in paediatric patients with allergic diseases. A latex-reduced environment may be desirable in future.

Latex allergy and skin

PURPOSE OF REVIEW

In this review we address the prevalence and outcome of latex allergy in health care workers (HCWs). Recent findings in natural rubber latex (NRL) allergens and trials of specific immunotherapy (SIT) are also of interest.

RECENT FINDINGS

A study involving skin prick test (SPT) screening in HCWs in Russia and adjacent countries found a prevalence of latex allergy of 1.9%. Questionnaire studies performed in Wales and in the USA identified prevalence rates of about 0.6%. An intervention undertaken at the Mayo Clinic, in which only gloves with low or undetectable allergen levels were allowed, reduced markedly the incidence of NRL allergy. Two studies, one from Finland and another from Ohio, showed that outcomes in latex-allergic HCWs are generally good. A study involving SPT screening showed that 6% of construction workers had latex allergy. A questionnaire study among allergists practicing in the USA showed that 62% performed latex SPT and 6% reported anaphylaxis, which mostly occurred while using a homemade SPT solution. Hev b 2, Hev b 5, Hev b 6.01 and Hev b 13 produced positive SPT reactions in over 60% of latex-allergic individuals. Topical application of NRL in a murine model of protein contact dermatitis caused a striking increase in prohevein-specific (Hev b 6.01) immunoglobulin E levels, together with a T-helper-2 type dermatitis. A placebo-controlled SIT trial with NRL extract alleviated cutaneous symptoms but caused some systemic reactions in latex-allergic patients.

SUMMARY

Low prevalence rates suggest that the peak of the latex allergy epidemic has already passed in HCWs. Hospital-wide interventions requiring use of low-allergen gloves reduce sensitization and changing gloves to nonlatex ones, or even using low-allergen latex gloves, in the affected individuals appears to confer adequate secondary prevention. In the USA there is an urgent need for standardized latex SPT reagent. Hev b 5 and Hev b 6.01 are major in vivo NRL allergens. Findings in mice suggest that NRL proteins eluting from latex gloves may also cause hand eczema in humans. SIT with NRL extract must still be considered an experimental treatment.