Latex Allergy: Where Are We Now and How Did We Get There?

Characteristics of Litigations Involving Contact Dermatitis: An Exploratory Analysis

Background: Contact dermatitis (CD) is one of the most common skin disorders, occurring in >20% of patients worldwide. Estimated cost burden for CD in the United States approaches $1 billion annually. Objective: To describe characteristics of litigation among patients with CD. Methods: Westlaw legal database for U.S. lawsuits was queried for lawsuits between the years 1983 and 2021 containing the keywords "dermatitis or eczema." Each lawsuit associated with CD was analyzed by plaintiff demographics, verdict, prosecution reason, payouts, and allergen implicated. Results: Of 98 cases, 61 met the inclusion criteria. Verdicts issued favored plaintiffs (42.6%) more than defendants (32.8%) with the remaining cases decided through settlements. If payout occurred, the mean was $246,310 (standard deviation [SD] = $798,536), the median was $20,000 (Q1 = $8,500, Q3 = $88,725, interquartile range = $80,225). The top reason for litigation was toxic exposure (n = 38, 62.2%), and common contact allergens associated with lawsuits were latex (n = 4, 20%), surgical tape (n = 4, 20%), and beauty products (n = 4, 20%). Conclusion: Common allergens associated with lawsuits include latex, surgical tape, and beauty products. Most CD cases adjudicated in the United States since 1983 are associated with toxic exposures.

Latex Allergy in Children

Notwithstanding the efforts made in the last decades to mitigate the consequences of natural rubber latex allergy, this disease continues to be a major health problem, especially in developing countries. The categories of patients with greater and frequent exposure to latex (such as health care professionals and, in the pediatric field, subjects who undergo repeated surgery, e.g., those suffering from spina bifida and urogenital malformations) have an increased risk of developing sensitization and allergy to latex. Herein we provide an overview of the current knowledge and practical recommendations with a focus on epidemiology, diagnostics, and management (including both prevention and therapy) in order to guide a correct recognition and containment of this potentially fatal condition.

Recent development of biodegradable synthetic rubbers and bio-based rubbers using sustainable materials from biological sources

Rubber is an amorphous hyperelastic polymer which is widely used in this modern era. Natural rubber is considered the ultimate rubber in terms of mechanical performance, but over the years, some limitations and challenges in natural rubber cultivation that could result in serious shortages in the supply chain had been identified. Since then, the search for alternatives including new natural and synthetic rubbers has been rather intense. The initiative to explore new sources of natural rubber which started during the 1940s has been reignited recently due to the increasing demand for natural rubber. The commercialization of natural rubber from the Parthenium argentatum and Taraxacum kok-saghyz species, with the cooperation from rubber product manufacturing companies, has somewhat improved the sustainability of the natural rubber supply chain. Meanwhile, the high demand for synthetic rubber drastically increases the rate of depletion of fossil fuels and amplifies the adverse environmental effect of overexploitation of fossil fuels. Moreover, rubber and plastic products disposal have been a major issue for many decades, causing environmental pollution and the expansion of landfills. Sustainable synthetic rubber products could be realized through the incorporation of materials from biological sources. They are renewable, low cost, and most importantly, biodegradable in nature. In this review, brief introduction to natural and synthetic rubbers, challenges in the rubber industry, alternatives to conventional natural rubber, and recent advances in biodegradable and/or bio-based synthetic rubbers are discussed. The effect of incorporating various types of biologically sourced materials in the synthetic rubbers are also elaborated in detail.

Secondary prevention of latex allergy

PURPOSE OF REVIEW

The present review addresses the secondary prevention in healthcare worker, healthcare setting, and in patients outside the healthcare setting.

RECENT FINDINGS

There is sufficient knowledge of the broad aetiology of latex allergy for secondary preventive programmes to be widely adopted. Currently, avoidance of latex-containing surgical products is mandatory in the care of sensitized patients. They should also have a list of occult sources of natural rubber latex exposure and cross-reacting fruits. During all health-care procedures latex allergic patients should be treated in a 'latex-free' environment. Specific sublingual immunotherapy has been suggested as a suitable therapeutic option. It can be offered, in addition to symptomatic treatment, to selected patients, when avoidance measures are not feasible or effective. The use of omalizumab could also be extended as an adjunct to latex immunotherapy.

SUMMARY

Despite of the progress made in the secondary prevention of latex allergy, the disease still continues to be a global health problem.

Latex Anaphylaxis Caused by Occupational Exposure to Balloons

Latex allergies often develop by sensitization to latex allergens by repeated exposure. Because in recent years latex has been ubiquitous in medical equipment, health workers have a higher prevalence of latex allergies than the general population, and care must be taken to ensure workers' safety. We report a case of a female health care worker in her 20s who experienced a severe, biphasic anaphylactic reaction within minutes after being exposed to rubber balloons at a latex-free children’s hospital. After being stabilized with epinephrine, dexamethasone, and fluid resuscitation, over a six-hour period, she was discharged home. En route home, her symptoms recurred, and she was admitted to the ICU for observation for impending respiratory failure. She was hospitalized for about 48 hours before being discharged home. She presented to the occupational medicine clinic a few days later for further management. No acute care was required and she was discharged.

This case is consistent with occupational latex-induced anaphylaxis. Health personnel should be educated about the importance of compliance with latex allergy mitigation procedures, as well as the severe nature of hypersensitivity reactions that may occur in sensitized persons. It may be beneficial to address the social pressures that can contribute to noncompliance, as balloons are a common gift for children and may be viewed as an acceptable way to cheer up a sick child, tempting some staff to turn a blind eye to policy. The reasons for the policy, and for strict adherence, should be communicated clearly.

Acute Urticaria and Anaphylaxis: Differences and Similarities in Clinical Management

Acute urticaria is a common condition that presents with wheals and/or angioedema. However, these symptoms are also frequent in anaphylaxis, a life-threatening reaction that should be immediately diagnosed and treated. In both, mast cells play a central role in the physiopathology. Causes and triggers of acute urticaria and anaphylaxis are similar in general, but some peculiarities can be observed. The diagnostic approach may differ, accordingly to the condition, suspicious causes, age groups and regions. Adrenaline is the first-line treatment for anaphylaxis, but not for acute urticaria, where H1-antihistamines are the first choice. In this paper, we review the main aspects, similarities and differences regarding definitions, mechanisms, causes, diagnosis and treatment of acute urticaria and anaphylaxis.

Adverse Event Leads to Quality Improvement Plan: Learning From a Classroom Latex Exposure

A growing number of students with health conditions, many of which carry with them the potential for an emergency, increases the likelihood of adverse events occurring in the school setting. An adverse event can be either preventable or nonpreventable. This article reviews a preventable adverse event which took place in a second-grade classroom of a student with spina bifida. Children with spina bifida are at increased risk for the development of latex allergy and subsequent anaphylaxis. The seriousness of accumulated exposure to latex necessitated initiation of a quality improvement plan with the goal of decreasing the risk of future exposures and increasing the quality of collaboration among school staff in meeting student health needs. The article describes the adverse event and discusses the five factors that were addressed in the quality improvement plan: communication deficit, knowledge deficit, hierarchical culture, product labeling, and data collection.

Allergic Reactions Captured by Voluntary Reporting

BACKGROUND

The epidemiology of hospital adverse reactions (ARs), particularly allergic reactions, or hypersensitivity reactions (HSRs), is poorly defined. To determine priorities for allergy safety in healthcare, we identified and described safety reports of allergic reactions.

METHODS

We searched the safety report database of a large academic medical center from April 2006 to March 2016 using 101 complete, truncated, and/or misspelled key words related to allergic symptoms, treatments, and culprits (e.g., medications, foods). Patient and event data were summarized for ARs and two types of ARs, HSRs and side effects/toxicities.

RESULTS

Among 9111 key word search-identified events, 876 (10%) were ARs, of which 436 (5%) were HSRs and the remaining 440 (5%) were side effect reactions or toxicities. Whereas the most common HSRs were simple cutaneous reactions (83%), the following severe immediate HSRs were also identified: shortness of breath (16%), anaphylaxis (14%), and angioedema (12%). Most HSRs were caused by drugs (81%), with antibiotics (26%), particularly β-lactams (11%), and vancomycin (8%), commonly implicated. Other causes of drug HSRs included contrast agents (24%), chemotherapeutics (7%), and opioids (6%). Nondrug HSRs were from blood products (8%), latex (3%), and devices (3%). Food reactions were rarely identified (1%).

CONCLUSIONS

We identified ARs, HSRs, and side effects/toxicities, contained in a decade of safety reports at an academic medical center. Allergy safety in the healthcare setting should target approaches to common and severe reactions, with a focus on the safe administration of β-lactams, vancomycin, contrast agents, chemotherapeutics, and opioids. Priority nondrug HSR culprits include blood products, latex, and devices.

Epidemiology of perioperative anaphylaxis in the United States: new insights but more to learn and do

Gonzalez-Estrada and colleagues report an estimated risk of severe or fatal perioperative anaphylaxis of one in 6,825 procedures during the period 2005-2014. This is slightly higher than that reported previously in France and England. Several predictors of near-fatal and fatal reactions are identified, such as increased age, cancer, and congestive cardiac failure.

Hancornia speciosa serum latex fraction: a non-allergenic biomaterial

Plant-derived products can assist in the healing process of dermal wounds. It has been demonstrated that Hancornia speciosa latex present angiogenic, osteogenic, anti-inflammatory, and antioxidant activities. Then, it could contribute to the wound healing process. However, natural products in contact with skin may cause dermatitis. The objective of this work was to evaluate the allergic and irritant potential of H. speciosa serum fraction latex using in vitro assays. The obtained results showed that the H. speciosa serum fraction latex has a slightly irritant potential and is not cytotoxic neither allergenic for human cells. Moreover, we identified a remarkable low amount of proteins in this material in comparison to Hevea brasiliensis latex. This result could explain the non-allergenic potential of H. speciosa serum fraction latex because proteins present in latex are the main responsible for allergy. This biomaterial could be used as a non-allergenic source for development of new medicines.

Latex allergy guidelines for people with spina bifida

An estimated 85% of individuals with spina bifida (SB) survive into adulthood, warranting SB-specific transition to adult healthcare guidelines to address the diverse and complex medical, adaptive, and social needs particular to this condition. Latex allergy constitutes one important health concern for this population that requires ongoing and life-long evidence-based management. This article discusses management of latex allergy according to the SB Latex Allergy Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida, reviews current care models in which such latex allergy guidelines can be implemented, and explores further relevant research topics in SB care relative to latex allergy.

Update on latex allergy: New insights into an old problem

Despite the efforts made to mitigate the consequences of this disease, natural rubber latex allergy (NRLA) continues to be a global health problem and is still considered one of the main worries in the working environment in many countries throughout the world. Due to thousands of products containing latex, it is not surprising that the current statistics suggest that prevalence remains high among healthcare workers and susceptible patients. In developed countries, reduction in the prevalence of IgE-mediated allergy to latex proteins from gloves may lead to lax attention by health care personnel. On the other hand, this situation is different in developing countries where there is a lack of epidemiological data associated with a deficit in education and awareness of this issue. The aim of this review is to provide an update of the current knowledge and practical recommendations regarding NRLA by allergologists from different parts of the world with experience in this field.

Current state of occupational latex allergy

PURPOSE OF REVIEW

During the 1980s, natural rubber latex (NRL) emerged as a major cause of occupational allergy and asthma, especially in healthcare workers using powdered NRL gloves. Increased recognition of NRL allergies and transfer of research findings into prevention strategies resulted into an almost elimination of this health problem. Here, the current knowledge on allergens, their use in diagnostics, prevalence data of occupational NRL allergy and the status of prevention strategy are summarized.

RECENT FINDINGS

While the current studies conducted in high-income countries show that prevention measures have reduced NRL allergy, this does not yet apply worldwide. For latex allergy diagnosis, it is important that recombinant allergens as reliable tools are available, because in several European countries and the United States, NRL skin prick test extracts and powdered latex gloves for bronchial challenge test are no longer commercially available, leading to a deficit in diagnostic tools. Due to the fact that latex is suitable with good properties as a raw material for gloves, alternatives with significantly lower protein content and without cross-reactive structures to latex proteins are sought.

SUMMARY

Awareness of the sensitization risk associated with the use of latex gloves should still be present in all occupational settings.

Comparison of surgical gloves: perforation, satisfaction and manual dexterity

The purpose of this study was to assess the effectiveness of two different surgical gloves (powdered latex and powder and latex free) for glove perforation frequency, problems and satisfaction with glove usage and manual dexterity levels during surgical operations that include scrub nurses. Scrub nurses wore antiallergenic gloves (powder and latex free) gloves during three operations, double latex and powdered gloves during three operations and single latex and powdered gloves during three operations. The gloves were checked for punctures after each surgery with a water-inflation test. In our study, 19% of single gloves and 18.1 % of double gloves and 4.8% of powder and latex free worn by scrub nurses were punctured during surgery. None of the inner gloves in double gloves were punctured. Although wearing double gloves restricts manual dexterity, results in discomfort problems such as perspiration and fetor and results in a low satisfaction rate among scrub nurses, double gloves are protective against injuries and punctures.

Occupational food allergy

PURPOSE OF REVIEW

Occupation is an important contributing factor in the presentation of allergic disease in adults. This review article focuses on the contribution of occupation to the development and presentation of food allergies.

RECENT FINDINGS

A variety of occupations involve repeated transdermal and respiratory exposures to food-related allergens, which can result in sensitization. A sensitized individual can then manifest symptoms of food allergy after ingestion of the relevant food, even in a nonoccupational setting. Cooks and other food-processing workers bear increased risk for being sensitized to foods. Although any type of food can become a causal agent for this phenomenon, published cases of occupational food allergy concentrate on fish and seafood allergies among cooks and food-processing workers who come into direct contact with these foods. Latex-fruit syndrome is also a relatively common form of occupational food allergy among healthcare workers. Hand eczema has also been shown to be an important risk factor for occupational sensitization to food allergens.

SUMMARY

The association of occupation with food allergy in adults has been documented. Considering the under-recognized nature of this phenomenon, we should be aware in our clinical practice that a patient's occupation might be relevant to his or her food allergy.

Hancornia speciosa serum fraction latex stimulates the angiogenesis and extracellular matrix remodeling processes

The Hancornia speciosa latex reveals angiogenic, osteogenic, and anti-inflammatory properties, which present its potential for developing of wound healing drugs; however, the latex compounds responsible for angiogenesis remain unknown. One strategy to screen these active compounds is evaluation of latex fractions. This study aimed to obtain different fractions of latex and evaluate its angiogenic activity separately using the chick chorioallantoic membrane (CAM) assay. The serum (SE) fraction was responsible for angiogenesis, which was subject to biochemical characterization and computational simulations in order to understand the contribution of H. speciosa latex in wound healing process. Our results revealed weak antioxidant potential and absence of antimicrobial activity in the SE fraction. Phytochemical analysis identified chlorogenic acids (CGA) as the main compound of SE fraction. CGA bioactivity predictions identify different molecules associated with extracellular matrix (ECM) remodeling, such as metalloproteinases, which also are overexpressed in our CAM assay experiment. Docking simulations revealed the interactions between CGA and matrix metalloproteinase 2. In conclusion, SE latex fraction stimulates angiogenesis and may influence ECM remodeling. These properties may contribute to the wound healing process, and also confirm the widespread use of this plant.

Consensus statement of the Italian society of pediatric allergy and immunology for the pragmatic management of children and adolescents with allergic or immunological diseases during the COVID-19 pandemic

The COVID-19 pandemic has surprised the entire population. The world has had to face an unprecedented pandemic. Only, Spanish flu had similar disastrous consequences. As a result, drastic measures (lockdown) have been adopted worldwide. Healthcare service has been overwhelmed by the extraordinary influx of patients, often requiring high intensity of care. Mortality has been associated with severe comorbidities, including chronic diseases. Patients with frailty were, therefore, the victim of the SARS-COV-2 infection. Allergy and asthma are the most prevalent chronic disorders in children and adolescents, so they need careful attention and, if necessary, an adaptation of their regular treatment plans. Fortunately, at present, young people are less suffering from COVID-19, both as incidence and severity. However, any age, including infancy, could be affected by the pandemic.Based on this background, the Italian Society of Pediatric Allergy and Immunology has felt it necessary to provide a Consensus Statement. This expert panel consensus document offers a rationale to help guide decision-making in the management of children and adolescents with allergic or immunologic diseases.

Hevea latex-associated allergies: piecing together the puzzle of the latex IgE reactivity profile

Introduction: IgE-mediated Hevea latex allergy and associated food-allergies constitute a significant health issue with serious consequences of diagnostic error. Hence, there is a need for more reliable confirmatory diagnostics.Areas covered: Here, we summarize the major limitations of conventional tests using native extracts and describe how piecing together the IgE reactivity profile can benefit correct diagnosis in difficult cases in whom conventional tests yield equivocal or negative results. A diagnostic algorithm integrating traditional sIgE and component-resolved diagnosis (CRD) is presented.Expert opinion: Moreover, it is clear that the discoveries in the field of the Hevea latex proteome will contribute to our understandings and accurate approach of sometimes complex cross-reactivity phenomena that extend beyond the 'latex-fruit syndrome.'

Protecting Patients with Latex Allergies

: The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafety.pa.gov. For the original article discussed in this column or for other articles on patient safety, click on "Advisories and Events" and then "Pennsylvania Patient Safety Advisory" in the top navigation menu.

Growing up with spina bifida: bridging the gaps in the transition of care from childhood to adulthood

Spina bifida is the most common nonchromosomal birth defect, resulting in permanent disability of multiple organ systems, yet compatible with long-term survival. Important advances across various disciplines have now improved survival among the spina bifida population. Although the majority of individuals living with spina bifida are now adults, there are few publications in the neurosurgical literature regarding the care of adults with spina bifida, associated medical conditions, surgical interventions, and long-term complications. The major goals for transitioning adult patients with spina bifida are preservation of function and promotion of independence as well as general overall health. Nevertheless, many gaps exist in our knowledge and understanding of the complex needs of this aging patient population. The goal of this paper was to provide a comprehensive updated review of the literature regarding the challenges and considerations involved in the transitional care to adulthood for patients with spina bifida. Unique to this review, the authors provide a first-hand personal communication and interview with an adult patient with spina bifida that discusses many of these challenges with transition.

Severe anaphylaxis after pelvic examination: a case report of dual latex and chlorhexidine allergies

Background

Natural rubber latex and chlorhexidine have previously been identified as causative substances in perioperative anaphylaxis. A pelvic examinations is generally considered noninvasive, however, this procedure is rarely associated with severe allergic reactions. We reported a rare case of dual latex and chlorhexidine allergies which caused anaphylaxis after pelvic examination in a woman with a history of latex-related fruits allergy.

Case presentation

A 54-year-old woman had severe anaphylaxis after a pelvic examination due to dual latex and chlorhexidine (CHX) allergies. The gynecologist used CHX for the vaginal preparation and wore latex-containing gloves with lubricating gel during the examination. In vivo and in vitro tests revealed CHX sensitization by a positive skin prick test to chlorhexidine at a very low concentration (0.002 mg/mL), and a positive basophil activation test to CHX. Latex allergy was confirmed by a positive specific IgE to latex and a positive glove-use test at 20 min. An analysis of specific IgE to latex component revealed positive results for Hev b 1, 5, 6.02, and 11. As she also had a past history of fruit allergy, prick-to-prick testing with latex-related fruits was performed. The results were positive for avocado, banana, jackfruit, kiwi, and longan.

Conclusions

Concomitant mucosal exposure of both natural rubber latex and CHX in highly sensitized patients during pelvic examinations can lead to severe anaphylaxis. Pre-procedural screening for an allergy to latex or CHX, or to any other allergen, should be performed in patients where there is suspicion of a specific allergy due to a previous allergic reaction. Increased awareness of these two allergens in all healthcare settings may improve patient safety.

Latex Allergy Risks Live On

Reduction in the prevalence of IgE-mediated allergy to latex proteins from gloves in patients may lead to lax attention by health care personnel to avoid use of latex products in latex-allergic subjects. Recent evidence from the Pennsylvania Patient Safety Reporting System shows an alarming continuation of adverse events mostly from latex urinary catheters. We are strongly advocating that health care personnel must continue to pay close attention to avoidance of latex in patients with a history of latex allergy.

Profile Shift in Latex Sensitization over the Last 20 Years

BACKGROUND

Natural rubber latex (NRL) allergy is commonly diagnosed according to medical history, skin allergy tests, and serological analyses. However, skin tests are increasingly being abandoned because of (i) their time-consuming nature, (ii) latex preparations for skin tests being not commercially available, and (iii) the use of in-house prepared test solutions is becoming ever more difficult due to increasing regulatory hurdles. In this light, we have evaluated differences in the profiles of current and former patients with suspected latex allergy.

METHODS

Sera of skin test-positive patients from a historic cohort (1995-2001, n = 149 patients) and currently (2014-2015, n = 48 patients) were simultaneously analyzed for specific IgE to latex by ImmunoCAP. If the serological screening was positive (≥0.35 kU/L), component-resolved diagnostics including profilins and cross-reactive carbohydrate determinants (CCDs) were performed.

RESULTS

In contrast to 88% (131/149) of the skin test-positive patients from the 1990s, only 51.1% (24/47) of the current cohort were found positive for specific IgE to latex. While 48.3% (72/149) of the patients had a convincing positive history in the 1990s, current skin test-positive patients rarely reported a relevant medical history (8.5%, 4/47). Specific IgE levels to latex were significantly higher in former patients with suspected latex allergy (p < 0.001) than in former sensitized individuals without allergy. However, this significant difference was lost in current allergic and sensitized patients with positive skin tests.

CONCLUSION

Sensitization profiles in patients with latex allergy have changed significantly over the last 2 decades. Discrimination between NRL sensitization and clinical allergy remains a diagnostic challenge. Our data highlight the need for a combination of all 3 criteria, i.e., patient history, skin test, and analysis of specific IgE, for a correct diagnosis of latex allergy.

Focus on the agents most frequently responsible for perioperative anaphylaxis

Adverse reactions (ARs) to drugs administered during general anesthesia may be very severe and life-threatening, with a mortality rate ranging from 3 to 9%. The adverse reactions to drugs may be IgE and non-IgE-mediated. Neuromuscular blocking agents (NMBA) represent the first cause of perioperative reactions during general anesthesia followed by latex, antibiotics, hypnotic agents, opioids, colloids, dyes and antiseptics (chlorhexidine). All these substances (i.e. NMBA, anesthetics, antibiotics, latex devices) may cause severe systemic non-IgE-mediated reactions or fatal anaphylactic events even in the absence of any evident risk factor in the patient's anamnesis. For this reason, in order to minimize perioperative anaphylactic reactions, it is important to have rapid, specific, sensitive in vitro diagnostic tests able to confirm the clinical diagnosis of acute anaphylaxis.

Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers

Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.

Addressing Molecular Diagnosis of Occupational Allergies

PURPOSE OF REVIEW

Numerous clinically relevant allergenic molecules enhance the performance of specific (s) IgE tests and improve the specificity of allergy diagnosis. This review aimed to summarize our current knowledge of the high-molecular-weight allergens involved in the development of occupational asthma and rhinitis and to critically analyze the contribution of component-resolved diagnosis in the management of these conditions.

RECENT FINDINGS

There is a lack of standardization and validation for most available extracts of occupational agents, and assessment of sIgE reactivity to occupational allergen components has been poorly investigated, with the notable exception of natural rubber latex (NRL) and wheat flour. In the case of NRL, the application of recombinant single allergens and amplification of natural extracts with stable recombinant allergens improved the test sensitivity. IgE-sensitization profile in patients with baker's asthma showed great interindividual variation, and extract-based diagnostic is still recommended. For other occupational allergens, it remains necessary to evaluate the relevance of single allergen molecules for the sensitization induced by occupational exposure. Progress has been made to characterize occupational allergens especially NRL and wheat, although there is still an unmet need to increase the knowledge of occupational allergens, to include standardized tools into routine diagnostic, and to evaluate their usefulness in clinical practice.

The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review

An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.