Allergy Ebook

51 Ways to Reduce Allergies

51 Ways to Reduce Allergies

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The practical application of due diligence to food allergenicity

In some cases, the practicalities of factory layout, the range of products and raw materials handled and other factors may make the elimination of cross-contamination unachievable. In such cases clear labelling of the presence of traces which have the potential to provoke an allergic reaction can provide an alternative approach. With products containing nuts the stakes clearly are higher. In this case, consideration should be given to the manner in which the information is communicated. In some instances, the presence of nuts or nut-derived ingredients is essential to provide the authentic characteristics of the product. In this case, merely labelling their presence may not be enough and it may be necessary to emphasise their presence. This may be done by emboldening the nut ingredients in the list of ingredients. Even this may not provide complete peace of mind, as situations have arisen where a consumer allergic to, for example, almonds but not peanuts has innocently purchased a...

Allergenic Aspects of Egg Proteins

Eggs are one of the most common causes of food allergies in infants and young children. Although the majority of egg allergies are caused by egg-white protein, proteins in both the egg white and the yolk are associated with allergies. The egg white contains 50 ovalbumin, which is the major allergen. Other egg-white allergenic proteins are ovomu-coid, ovotransferrin, and lysozyme. Most egg allergies in young children are outgrown by the age of 5 years following an elimination diet. Owing to the allergenicity of egg proteins, it is advised not to feed egg yolks to infants younger than 6 months of age and to wait until children are 12 months old to feed them egg whites. When feeding egg yolks to children between the ages of 6 months and 12 months, the eggs should be prepared in such a way that the egg white can be completely removed, as in hardboiled eggs.

Foods commonly associated with allergy Table

Yunginger et al.3 and Sampson et al.4 showed the most common cause of severe food-related allergic reactions in adults and older children to be peanuts, crustaceans, shellfish, tree nuts and fish. In selected American children with atopic dermatitis (eczema), Burks et al.5 showed that skin prick testing with eight foods identified 99 of subjects who reacted to a food in DBPCFC, even if the food causing the reaction in the challenge had not been one of the foods used for skin testing. Or, put another way, subjects who reacted to an unusual food nearly always had a positive skin prick test (SPT) to one of the eight foods used for screening with or without associated symptoms on exposure to that food. Such studies need to be repeated in different populations of subjects. There are clearly geographical variations regarding these foods because the lists involved in reactions in Britain6 are like American lists but European studies give slightly different figures regarding allergic...

Diagnosis of drug allergy

Allergic reactions to drugs must be distinguished from similar clinical phenomena of different causes. Two forms of immunologic diagnosis then must be made identification of the specific cause of the reaction, and identification of the immunopathologic Table 1 Clinical classification of allergic reactions to drugs

Oral allergy syndrome

The constellation of immediate symptoms less than one hour after exposure and usually confined to the mouth has been called the oral allergy syndrome (OAS), first characterised in 1987 by Amlott etal.13 The initial group of 36 subjects was broadly divided into those whose symptoms did not progress (50 ) and those who responded to larger doses of allergen, with more severe reactions. For each individual subject the quantity of food required to cause OAS and other symptoms varied.13

Evolution of allergic reactions

Two of the most important features that distinguish allergic reactions associated with allergen-specific IgE are the rapid onset of symptoms, usually within 5-10 minutes of exposure to foods, and the gradual resolution in the course of one or two hours. Most mild to moderate reactions occur within this time frame. Mild to moderate reactions are generally defined as reactions confined to the skin or gastrointestinal tract, while severe reactions are those that threaten the airway or cause a fall of blood pressure. It can be very difficult in most subjects to predict when a reaction is becoming so severe that treatment must be initiated. Severe reactions can gradually evolve from relatively minor symptoms and can form a second phase of response once the initial symptoms have resolved, or they can gradually develop slowly and persist for considerable periods of time. This variation in the presentation of severe symptoms needs to be specifically sought in the history. Most reactions that...

Igemediated Food Allergies

In IgE-mediated food allergies, allergen-specific IgE antibodies are produced in the body in response to exposure to a food allergen, usually a protein. These IgE antibodies are highly specific and will recognize only a specific portion of the protein that they are directed against. Occasionally, IgE antibodies produced against one particular protein in a specific food will confer sensitivity to another food either because the food is closely related or because it shares a common segment with the allergenic protein. Some food proteins are more likely to elicit IgE antibody formation than others. Although exposure to the food is critical to the development of allergen-specific IgE, exposure will not invariably result in the development of IgE antibodies even among susceptible people. Many factors, including the susceptibility of the individual the immunogenic nature of the food and its constituent proteins the age of exposure and the dose, duration, and frequency of exposure, are...

Cellmediated Food Allergies

Cell-mediated food allergies are sometimes called delayed hypersensitivity reactions, because the symptoms of these reactions typically appear 6 to 24 hours after consumption of the offending food. Cell-mediated allergies involve the interaction of food allergens with sensitized lymphocytes, usually in the intestinal tract. These reactions occur without the involvement of IgE or other antibodies. The interaction between the allergen and the sensitized lymphocyte results in lymphokine production and release, lymphocyte proliferation, and the generation of cytotoxic T lymphocytes. Lymphokines are soluble proteins that exert profound effects on tissues and cells resulting in localized inflammation. Lymphocyte proliferation increases the number of reactive cells thus magnifying the inflammatory process. The generation of cytotoxic or killer T cells results in the destruction of other intestinal cells including the critical absorptive epithelial cells. The T lymphocytes responsible for...

Unreliability of Self Reported Food Allergy

Reports of food allergy from individuals or parents of children are notoriously unreliable. Such reports have to be treated with scepticism. It is common for parents to believe that foods are responsible for a variety of childhood symptoms. Double-blind provocation tests in children with histories of reactions to food only confirm the story in one-third of all cases. In the case of purely behavioral symptoms, the proportion that could be reproduced under blind conditions was zero. The same is true of adults' beliefs about their own symptoms. If unnecessary dietary restrictions are to be avoided, one has to be sceptical, and it may be necessary in some cases to seek objective confirmation of food intolerance. The gross overreporting of food allergy has to be borne in mind when examining data on prevalence that are based on unconfirmed subjective reports.

Documenting Possible Food Allergies

The diagnosis of food allergy is made from the history, supported by investigations and by responses to avoidance of specific food triggers. Since the value of investigations is limited, it is especially important to obtain a clear history. There are a number of practical points to be made Speed of onset. In general, the quicker the onset of the allergic reaction, the more reliable is the history. If a child develops a violent allergic reaction within a minute or two after ingesting a food, it is much easier to link the reaction to a specific food than if a reaction only occurs hours or days after eating a food. Failure to seek inconsistencies such as these is one factor that is responsible for the overdiagnosis of food allergy.

Drug Treatment in the Management of Food Allergy

At present, drug treatment has little part to play in the management of food allergies. There are two exceptions. First, there are a very small number of cases in which the reaction to a food is exclusively gastrointestinal, and in whom the reaction can be blocked by taking the drug sodium cromoglycate by mouth 20min before the trigger food is swallowed. Second, there are a small number of individuals who develop the life-threatening reaction, of anaphylactic shock when exposed to a trigger food. There are three ways in which anaphylactic shock may prove fatal. First, rapid swelling of the soft tissues in the pharynx may completely obstruct the airway the treatment is to bypass the obstruction, either by passing an endotracheal tube, or by performing a tracheostomy. Another mechanism is severe shock, with a profound drop in blood pressure the life- saving treatment is to restore the circulating volume with intravenous fluids and to give oxygen. The third mechanism is severe...

The need for hypoallergenic foods

Food proteins are essentially foreign proteins capable of eliciting immunological responses. Any food protein may be allergenic if it can be absorbed intact or as substantial fragments, through the gut mucosa, and then evoke an immune (allergic) response. Some foods, such as rice and vegetables, are less allergenic than others, such as milk, egg and nuts. The intrinsic properties of the protein, the overall composition of the food, and the processing (especially thermal processing) all have an effect on the allergic potential. In the management of food allergy it is possible to exclude the food responsible for symptoms and to replace it with less allergenic foods. In certain situations it is not possible simply to eliminate the food, e.g. milk during infancy. Up to 2.5 of infants are affected by cow's milk allergy (CMA) in the first two years of life, although most of these children will outgrow their reactivity within 2-3 years. However, during the interim period an alternative milk...

Prevention of allergy

There is general consensus that the prevalence of asthma and other atopic diseases, including food allergies, is increasing. A history of allergic disease in the immediate family (atopic heredity) is the most important risk factor. Recent studies indicate that exposure to allergens in utero and in the first few months of life is critical in the development of allergic disease in children with an atopic heredity. In children at high risk, reduction in exposure to allergen should lead to a decline in disease prevalence. Food proteins are important allergens in early childhood. A hypoallergenic diet has therefore been suggested as a means of preventing the development of allergy. Experimental evidence indicates that the child can be sensitised in utero. It is sometimes advised that an atopic mother should avoid highly allergenic foods during pregnancy. However, there is concern that this might adversely affect the growth of the foetus. Avoidance of allergens during early infancy has been...

Severe allergic reactions

This can be quite dramatic, with erythema and rash all over the body surface, and swelling of the face, lips and tongue. However, if confined to the skin and oral mucosa, it is usually not life-threatening. This reaction responds to oral or parentral antihistamine in addition to corticosteroids. Treatment may need to be continued for a few days until symptoms have completely subsided. Unless the cause of the reaction is known, the patient should be referred to an allergy clinic for evaluation.

Anaphylaxis And Acute Allergic Reactions

Anaphylaxis, a term used inconsistently in the literature, is a severe systemic hypersensitivity reaction characterized by either hypotension or airway compromise that is potentially life threatening in nature and that is caused by chemical and IgE mediators released from mast cells. Anaphylactoid was coined to describe responses clinically identical to anaphylaxis that were found to be non-IgE mediated and that did not require a sensitizing exposure. 1 Recent work has shown that the final pathway in classic anaphylactic and anaphylactoid reactions is identical, and anaphylaxis is now used to refer to both IgE and non-IgE reactions.2 Hypersensitivity is an exaggerated immune system response to presented antigens. Anaphylaxis lies at one end of a gradient of hypersensitivity reactions, and it is important to keep in mind that even apparently mild allergic reactions may progress to severe anaphylaxis.

Allergy to food additives20

An additive is a substance added to foods for preservation, coloration and some other purposes. Additives are numerous and include benzoates, metabisulphites and azodyes. The prevalence of adverse reaction to additives is 0.03-0.5 . Adverse reactions to additives occur in 20-25 of patients with aspirin intolerance and in 10-20 with chronic recurrent urticaria. IgE-mediated hypersensitivity, resulting in acute allergic reaction, has been described for azodyes, ethylene oxide and penicillin, and delayed-type hypersensitivity for nickel salt. A list should be provided of foods containing the additive that the patient does not tolerate. Clear labelling of packaged food helps to avoid accidental exposure.

Food allergyintolerance

Food allergy in the cat may be associated with concurrent flea bite, inhalant or flea-collar hypersensitivity (White 8c Sequoia, 1989). Food allergy as a disease is a well-recognised cause of feline dermatological problems (Carlotti et al, 1990 Rosser, 1993), the prevalence of which varies from rare to common according to different authors. The pathophysiology of this syndrome is not completely understood. Adverse reactions to food may be either toxic or nontoxic if they are non-toxic they may be either due to intolerance or to immunological (allergic) reactions. Food allergy may be defined as an immunologically mediated excessive reaction to food substances, to be distinguished from food intolerance where enzyme deficiencies, pharmacological factors and toxic reactions, among others, may be implicated. The diagnosis of food allergy is achieved with a diet trial using a source of protein and carbohydrate to which the cat has had no or minimal exposure. This may be home cooked or, more...

Foods that commonly cause allergy

Foods that can give rise to allergic reactions in susceptible individuals appear to be diverse in nature. However, although reactions to many different foods have been described in individual case reports, the list of common causal agents is relatively short. This has led researchers to postulate that there may be certain features characteristic of food allergens. Common causes of allergy are milk, egg, peanut, tree nuts, fish, shellfish, soy and citrus fruits for populations in the UK and the USA. The list can vary for different countries for example, Mediterranean countries such as Italy have a high incidence of sensitivity to olives, and in Japan even sensitivity to birds' nest soup has been described. To be capable of inducing an allergic reaction a food must contain substances that are immunogenic, and give rise to allergic sensitisation. This results in the production of IgE antibodies in preference to IgG and T cells of the Th2 phenotype rather than the Th1 phenotype. On...

Techniques for identifying allergens and quantifying allergenicity

A number of techniques have been used to identify allergenic proteins, most being based on the principle of Using ELISA or Western blotting, quantitative or semi-quantitative data on the binding of serum IgE to specific proteins can be calculated for individual patients. Generalisations on allergenicity of specific proteins in a food are made by assessing the proportion of affected individuals that have elevated IgE to that protein. These methods cannot predict the degree of symptoms that may be produced on exposure to each individual protein or the outcome of introducing novel foods into a community.

Fish and Shellfish Allergies

Seafood is a common source of food allergies. About 250,000 Americans experience allergic reactions to fish and shellfish each year. People with seafood allergies can have symptoms that range from mild to life-threatening. Even tiny amounts of fish substances can trigger a reaction in some people. What's more, these allergies are rarely outgrown. Examples of shellfish that are common causes of allergic reactions include shrimp, crab, lobster, oyster, clam, scallop, mussel, and squid. Fish that can trigger allergic reactions include cod, salmon, trout, herring, sardine, bass, tuna, and orange roughy. Symptoms of an allergic reaction include nasal congestion, hives, itching, swelling, wheezing or shortness of breath, nausea, upset stomach, cramps, heartburn, gas or diarrhea, light-headedness, or fainting. If you suspect that you have any food allergies, see an allergist for a careful evaluation. This generally includes a medical history, physical examination, and skin or blood testing....

Intolerances Allergies to Nuts

Intolerances to nuts, or more specifically, allergies to nut proteins, occur in a relatively small minority of people. However, there is evidence that such adverse reactions have become more common, and the severity of the reaction that occurs in these sensitive individuals means that they must be taken very seriously. Peanuts are the most commonly cited cause of these severe reactions, estimated to affect between 0.1 and 0.2 of the population, but allergic reactions to tree nuts, incuding Brazil nuts, almonds, hazelnuts, and cashews, and also to sesame seeds, have been reported.

Avoiding Foods to Prevent Allergy

Food allergy has been estimated to affect approximately 1 or 2 of infants and young children in Western Europe and is assumed to be increasing in line with other forms of atopic disease, although evidence to support this is limited. Some food allergies (e.g., peanut allergies) can persist into adulthood and in severe cases can be life threatening. Most confirmed food allergies are associated with a relatively limited range of foods, including cow milk, eggs, tree nuts, peanuts, soybeans, wheat, fish, and shellfish. The development of food allergy depends on several factors, including genetic factors and early exposure to allergenic proteins in the diet, food protein uptake and handling, and the development of tolerance. However, it remains uncertain whether sensitization occurs in utero and, if so, whether this occurrence is restricted to specific stages of gestation. There is little evidence to support any benefit of avoiding specific foods during pregnancy to reduce the risk of...

Mediators and nasal allergy

Mediator release after nasal airway challenge with allergen has now been extensively investigated. Nasal lavage for the recovery of secretions on the surface of the nasal mucosa has made it possible to identify a postallergen challenge increase in a vast number of putative mediators of inflammation in humans. As well as experimental provocation tests, the inflammatory response of the nasal mucosa to natural exposure to pollen can also be measured. Much can be learned about the immediate (early) phase and the late (delayed) phase reaction so that a hypothesis can be generated of the involvement of different trigger cells during the different parts of the allergic reaction (Figure 1). It would seem that mast cells arc the main source of histamine in the early phase, and basophils the main (but lesser source) in the late phase, during which there is no similar increase in prostaglandin D2. During the pollen season there is a large increase in the number of nasal mast cells, but perhaps...

Action Against Allergy

Action Against Allergy is an independent charity founded in 1978 by Amelia Nathan Hill. She was chronically ill with migraine, stomach upsets, painful limbs and joints and other severe symptoms and her doctor, who could find no cause, thought she was being poisoned. After many years of searching, she undertook an elimination diet devised by British allergy pioneer Dr Richard Mackarness and found subsequently that her health improved dramatically. Action Against Allergy, whose address is PO Box 278, Twickenham, Middlesex TW1 4QQ, adopts a wide definition of allergy, being convinced that its effects range from moderate symptoms to a severely debilitating chronic condition. AAA believes these can be triggered by a wide range of causes, including food, food additives, pollutants and chemicals. AAA does not confine its help to those who become subscribers. The organisation offers information packs, advisory leaflets covering diet and allergy management, and quick reference sources of...

Research into allergy and intolerance

Much progress has been made in recent years in understanding the mechanisms of allergy, but our knowledge is far from complete. Despite good work done in the UK and the United States and elsewhere, it is still uncertain how and why some people become allergic to certain foods and substances. As far as the allergy sufferer is concerned, all he or she can really do is try to avoid the offending food, scrupulously carry around prescribed medication, devise an action plan for when things go wrong - and wait and hope for better treatments to be developed. Further research is the customer's best hope. The fact that our knowledge is incomplete poses obvious difficulties for support groups, which rely on information provided by the medical community. This information may have to be modified from time to time and it may even change altogether. Key messages conveyed by support groups one year may be overturned the next, so that advice offered in good faith may later prove to have been unwise or...

Interpreting data on the natural history of food allergy

Cohort studies have been very successful in delineating the natural history of allergies to foods such as cows' milk and egg because they are almost completely outgrown within a few years. For longer lived allergies, such as fish, shellfish, peanut and tree nuts, the natural history is less clear because of the difficulties in interpreting the available data. This is illustrated by results from an interview survey investigating the prevalence of peanut allergy (Emmett et al. 1999). The data (Figure 10.3) suggest that more males are affected in childhood whereas in adulthood peanut allergy is more prevalent in females. There are a number of possible explanations for these results. Firstly, peanut allergy may be outgrown at an earlier age in males. Secondly, peanut allergy may be acquired later in females. Thirdly, there may be a combination of both of the above. Fourthly, the data may be explained by a cohort effect the adult generation surveyed may have a lower inherent risk of...

Common food allergies

Table 10.10 compares clinical reactions to foods, and Table 10.11 compares skinprick specific IgE reactions to foods, between allergy clinic populations from different countries. As such they deal with a selected population and some studies involve small numbers. They show that cows' milk and egg are among the 2-3 commonest foods causing allergy in most countries. Peanut, fish, soy, wheat and shellfish are among the next most common groups of foods causing allergy, although significant variations occur between countries. Thus, for example, shellfish allergy appears to be more common in countries such as the Philippines, Thailand and Singapore where it is a part of the staple diet from early infancy, than in many other countries where it is consumed later and less commonly. In contrast, clinical peanut allergy which is a big problem in Western countries appears to be less common in most Asian countries, and also in Spain (Crespo et al. 1995). Thus in Japan it is very rare (Hill et al....

Human Health Risks Allergenicity

Many children in the U.S. and Europe have developed life-threatening allergies to peanuts and other foods. There is a possibility that introducing a gene into a plant may create a new allergen or cause an allergic reaction in susceptible individuals. A proposal to incorporate a gene from Brazil nuts into soybeans was abandoned because of the fear of causing unexpected allergic reactions. Testing of GM foods may be required to avoid the possibility of harm to consumers with food allergies.

Hypoallergenic milk formulae7

According to the definition of the European Scientific Committee for Food, hypoallergenic or hypoantigenic formulae are those which contain hydrolysed protein. The peptides of HF should be as short as possible. In extensively hydrolysed formulae (eHF) 95 of peptides have a molecular weight below 1500 dalton and less than 0.5 of the remaining peptides are above 6000 dalton. Partially hydrolysed formulae (pHF) have 2-18 of peptides above 6000 dalton. These larger peptides may elicit allergic reactions. pHF have a higher capacity to induce positive skin tests and provocation tests and to bind to the human serum IgE antibodies of children allergic to cow's milk. Amino acid-based formula does not have peptides so there is no likelihood of allergic reactions. ELISA inhibition assay, with polyclonal antibodies specific for casein components of cow's milk, is a sensitive method for estimating residual antigenicity in hypoallergenic infant formulae, suggesting their potential application for...

Clinical categorisation of allergic reactions

In a series of 62 adults and children with peanut allergy, Ewan18 divided patients into those whose separate symptoms were Out of the 62 patients, 20 had skin changes only, 33 had evidence of airway involvement with laryngeal oedema or wheezing, and nine had evidence of a significant fall in blood pressure.18 The categorisation of laryngeal oedema is discussed below. Contact symptoms are common in food-related allergic diseases, especially in children and those with irritated or inflamed skin diseases such as eczema. These symptoms are very rare in people with food intolerance, and most adults (99 ) with the syndrome of chronic urticaria (bouts of intermittent episodes of itchy hives and swelling that last longer than 6 weeks) do not have food allergy.19 Sicherer et al.20 showed that in 102 individuals with peanut allergy, the first reaction is characterised by isolated skin reaction in 49 , by respiratory reaction only in 2 , by both skin and respiratory in 17 , by both skin and...

The Food and Chemical Allergy Association

The Food and Chemical Allergy Association, based at 27 Ferringham Lane, Ferring, West Sussex BN12 5NB, came into being as a result of a letter sent to a daily newspaper in 1976 by its founder, Ellen Rothera. She had been ill for eight years and came to believe that food allergies due to a malfunctioning immune system were the root cause. She managed to stabilise her condition and make a recovery. Ellen's letter to the Daily Express was not only published, but given a leading position. As a result she was inundated with letters and telephone calls from people desperately seeking answers to their own medical conditions. A small group gathered for a meeting and formed an association, which set out to find doctors with knowledge of allergy, learn from them and continue in a self-help role. A committee was formed and a secretary appointed to answer all enquirers. The FCAA continued in this manner for some years but eventually its role was changed to that of an advisory service. Today the...

Treating the immediate symptoms 551 Acute allergic reactions to foods

Development of symptoms within two hours of ingestion of the suspected food may be reasonably classified as an acute reaction. These reactions are commonly due to milk, egg, fish and nuts (Table 5.6). The person may or may not know the food responsible. In children, allergic reaction may occur to the first known exposure to a food such as cow's milk, egg or peanut. It may also develop in an adult to a food previously well tolerated although this is uncommon. Acute allergic reactions are usually IgE mediated. Allergic reactions occur as a result of interaction of allergen with IgE antibodies bound to receptors on the surface of mast cells. This interaction results in the release of mediators such as histamine, heparin, bradykinin, prostaglandin and leukotrienes. The allergen may come from a variety of sources such as foods (e.g. peanut), drugs (e.g. penicillin), insects (e.g. bee venom), etc. The reaction may involve one or more systems and may be mild, moderate or severe. The severity...

Determining the safety and efficacy of hypoallergenic infant formulas

Hypoallergenic protein hydrolysates to be used as an ingredient in infant formulas of high nutritional and therapeutic value should be rich in low molecular weight peptides, especially di- and tripeptides, with the least quantity possible of free amino acids. Sometimes it is difficult to know the composition of hydrolysates because of a large number of possible constituents, due mainly to potential degrees of polymerisation of the peptides, and several analyses may be done to assess their suitability. In addition to degree of hydrolysis, in vitro characterisation of peptide size and determination of allergenicity are valuable for quality control of the products and assurance of batch to batch consistency as well as for labelling. However, on the basis of the current knowledge, such data do not predict the immunogenic or the allergenic effects in the recipient infant, and the safety and efficacy of HA infant formulas can only be determined by clinical trials using scientifically...

OAS and pollen allergy

The frequency with which OAS occurs in subjects with pollen allergy is notable. Up to 40 of subjects with birch and ragweed allergy suffer OAS.15 Ragweed allergy is particularly associated with reactions to bananas and melons, and birch allergy with celeriac, apple and hazelnut allergens. The basis of the latter is thought to be homology between the relevant allergens, particularly Bet V 2 from birch, Mal d 1 from apple, and Bet v1 and Apig 2 from celeriac.16 Treatment of pollen allergy with immunotherapy has abrogated associated OAS reactions.17

Food Intolerance and Allergy

According to some surveys, 20 to 25 of people in the U.S. are allergic to certain foods. Self-reported information based on changes in dietary habits to accommodate a food problem is likely to be mostly erroneous. Often, patients who say they have a food allergy avoid a food and never seek medical advice. Diagnosis of food allergies is overworked, poorly defined, and misused. There are many misconceptions about food allergies, such as understanding of the causes of food allergies and their symptoms. A minority of practitioners who have overemphasized the magnitude of the role of food allergies in human illness have greatly contributed to this misconception. The American Academy of Allergy and Immunology has sharply criticized their concepts and questioned their practices. Double-blind placebo-controlled studies indicate that food allergies occur in 2 to 2.5 of the population. It has been estimated that 1 to 3 of children under the age of 6 years have allergies to foods. The frequency...

The British Allergy Foundation

The British Allergy Foundation has a broad sphere of interest, encompassing all types of allergy. BAF was formed as a registered charity in 1991 by a group of leading medical specialists who were all determined to improve the awareness, prevention and treatment of allergy. The charity is managed by a board of trustees which deals with all the business aspects of the organisation. All decisions on medical and scientific matters in which the foundation is involved are made by a team of medical advisers. These are among the leading allergists in the country and most are members of the British Society for Allergy and Clinical Immunology. The British Allergy Foundation is based at Deepdene House, 30 Bellegrove Road, Welling, Kent DA16 3PY and provides those affected by allergies with information and advice, including details of National Health Service allergy clinics. Leaflets, fact sheets and regular newsletters contain practical and informative articles. BAF also has a helpline (020 8303...

Novel and uncommon food allergies

There are a number of foods that are eaten in geographically or culturally quite specific populations and adverse food reactions are limited to these groups. However, with diversification of cultures and diets across the globe, particularly in developed countries, adverse reactions to these foods may be seen in many other countries. A good example is sesame seed, to which allergy in Western countries was rarely reported (Rance et al. 1999). However, there are reports of an increasing number of cases of sesame seed allergy in France coincident with the increase in Middle Eastern food and fast food bread (Kolopp-Sarda et al. 1997). Sesame seed often causes severe clinical allergy hence its importance. In France sesame seed was responsible for 0.6 of IgE-mediated food allergies seen in recent years in an allergy clinic population (Rance et al. 1999). Table 10.12 makes the point that uncommon food allergens are important causes of food allergy in specific countries. In an Israel allergy...

Mechanisms of food intolerance and food allergy

With regard to underlying mechanisms and trigger factors for food allergy and food intolerance, it is fair to say that our level of knowledge is very much in its infancy. We know, for example, that some individuals are more susceptible than others. Atopy (predisposition to allergic disease) is heritable, so could this What role do food allergens themselves play We know generally that the most common foods implicated in food allergy and food intolerance are egg, milk, peanuts, nuts, fish and soya.5-7 On average, an individual's gastrointestinal tract will process about 100 tonnes of food during a lifetime. Everything we eat is foreign to our body and potentially immunogenic. What is so special about some food allergens Why do only a proportion of people have the ability to sensitise and cause an allergic reaction What is the natural history of food allergy and food intolerance We do not know why with some foods, such as milk, sensitivity is lost with time, while with others, such as...

Commonly reported food allergies 1031 Cows milk

Cows' milk is an important weaning food in many countries. In recent years it has become practically ubiquitous, being found in an increasing range of commercially produced foods (Sampson 1998). There is extensive cross-reactivity between milks of different species (Businco et al. 1995, Carroccio et al. 1999). Cows' milk is one of the first foods to enter an infant's diet and therefore is often the first to cause problems. Adverse reactions to cows' milk can be divided into two main groups, immunological (IgE or non-IgE mediated) or non-immunolo-gical (Host et al. 1997, Host and Halken 1998). This latter group is mainly due to lactase deficiency and may be difficult to differentiate clinically from non-IgE mediated cows' milk allergy (Host et al. 1997, Bruinjzeel-Koomen et al. 1995). Cows' milk allergy gives rise to a spectrum of disease from immediate symptoms ranging from urticaria to anaphylaxis (Goldman et al. 1963, Sampson et al. 1992) and late symptoms which may not develop for...

Gesundheit and gnight The multiple responses to allergies

Some cells in the immune system cause the release of histamines, chemicals that cause the sneezing, runny nose, hives, itching, fatigue, and other symptoms of allergies. Histamines can also cause constriction of the bronchials (tubes that feed air into the lungs) that lead to the wheezing in asthma. In severe reactions, this tightening of the breathing tubes can be life-threatening. In addition to the redness, warmth, and swelling in the area, the cytokines and pressure on the nerve endings in the tissue cause pain. Check out the sidebar, Gesundheit and g'night The multiple responses to allergies, for more symptoms of allergies. If allergies and the body's response to them sounds just like the immune system and endometriosis, you're right In both cases the immune system is responding to seemingly harmless foreign matter (endometrial cells or irritants such as pollen) in a way that wreaks havoc on the body. The association is strong Many women with endometriosis also have multiple...

Food Allergy

Hypersensitivity reactions to ingested foods are generally due to IgE-mediated reactions to food components or additives. IgE-coated mast cells lining the gastrointestinal tract react to presented allergens in ingested foods and produce clinical findings associated with the release of biologic mediators, as previously described. Non-IgE-mediated food allergy reactions have also been described. Dairy products, eggs, and nuts are some of the most commonly implicated foods. A detailed history will provide the best clues to food allergy, with particular attention to other allergic history and prior reactions. Diagnosis is often difficult, since the offending food or foods may only occasionally produce symptoms, depending on the amount ingested and other foods present. Symptoms of food allergy include swelling and itching of the lips, mouth, and pharynx nausea abdominal cramps vomiting and diarrhea. Cutaneous manifestations, such as angioedema and urticaria, as well as anaphylaxis, can...

Insect Sting Allergy

Treatment is symptomatic and supportive. Mild local reactions can be managed with application of ice and oral antihistamines. More generalized reactions or local reactions of the head and neck may benefit from a short steroid course. Severe reactions are managed as outlined under Treatment above. Patients with severe reactions should be advised to carry self-administered epinephrine and antihistamines. A referral to an allergy specialist is indicated. I3,,7., 3

Drug Allergy

Although adverse reactions to drugs are a common clinical problem, true immunologically mediated hypersensitivity reactions probably account for less than 10 percent of these problems. Since most drugs are small organic molecules, they are generally unable to stimulate the immune system alone. However, when a drug or metabolite becomes protein bound, either in serum or on cell surfaces, the drug-protein complex can become an allergen and stimulate immune system responses. Thus, the ability of a drug or its metabolites to sensitize the immune system depends on the ability to be bound to tissue proteins. Approximately 100 to 500 patients die yearly of anaphylactic drug reactions. Penicillin is the drug most commonly implicated in eliciting true allergic reactions and accounts for approximately 90 percent of all allergic drug reactions. Of those patients who had fatal anaphylactic drug reactions, over 95 percent reacted to penicillin. Only about 25 percent of patients who die of...


Food allergy is discussed elsewhere (see 00122 and 00123). It is a frequent diagnosis in childhood. Diarrhea, rashes, and wheezing are common symptoms caused by infection probably more commonly than by food allergy. Parental desire to explain a child's frequent illness may lead to food being wrongly blamed for recurrent symptoms. Vague associations between food and the development of symptoms can result in many foods being unnecessarily excluded and children reduced to diets of very limited variety. For example, whilst 14 of children may be described as allergic to some food, as few as 5 may have had this diagnosis confirmed by their medical practitioners.

Drugs Allergy To

Comes, in individuals already sufficiently ill to warrant pharmacologic intervention. About 1-5 of hospitalized patients experience an allergic reaction to a medication. Approximately 10 of adults have experienced an allergic reaction to a drug. Identification of the offending agent, reversal of the immun-opathologic processes, and introduction of effective alternative therapy can be very difficult challenges. The human and financial costs of these reactions are considerable. In fact, the morbidity and mortality induced by allergic reactions to drugs unambiguously make this one of the most important categories of immunologically mediated disease. Inherent in drug therapy of humans is the administration of potential immunogens in standard doses and intervals in the context of somewhat similar clinical disorders. As relevant drug epitopes are defined in biochemical terms, primary and secondary immune responses can be studied in the context of current understanding of immunogenetics,...

Latex Allergy

Latex allergy is a concern in children and adults with meningomyelocele. It occurs in 24 to 67 percent of children with meningomyelocele. Increasingly severe allergic-type reactions are being reported related to latex and latex-containing products. Reactions vary from mild local reactions to anaphylaxis. Children may present with local or generalized swelling, hives or edema, itching, or a rash. Runny nose or eyes, coughing, sneezing, wheezing, stridor, and difficulty swallowing or breathing also may be presenting complaints. 1314 and 15 A history of latex allergy or sensitivity should be obtained in all children with meningomyelocele prior to any examination or procedure in which latex gloves or other latex-containing supplies may be used. Many routine medical supplies contain latex, including frequently used with meningomyelocele and latex allergy. If a severe allergic reaction is observed, the child should be discharged with an Epi-Pen, and formal testing for latex sensitivity...

History of Allergy

A history of asthma or severe allergy (e.g., anaphylaxis) to one or more allergens is associated with an increased risk of a contrast reaction. Patients with a history of asthma may have a fivefold greater risk of an adverse reaction than in the general population, and a history of allergy may double the risk. 1 A history of reaction during a previous contrast administration is associated with a three- to eightfold greater risk of a subsequent adverse reaction than in the general population. 1

Editorial Advisory Board

Brostoff, Centre for Allergy Research, Department of Immunology, University College London Medical School, Windeyer Building, 46 Cleveland Street, London W1P 6DB, UK T. J. Kindt, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Building 10, 9000 Rockville Pike, Bethesda, MD 20892, USA

How is the harm of a treatment documented

Occasionally, drugs may have serious adverse effects such as allergic reactions, hepatitis, cardiac arrhythmias and gastric ulcer. Despite this, attributing an adverse event to a specific treatment can sometimes be difficult, particularly when the event is rare, unexpected, or appears a long time after the start of treatment. It can also be difficult to recognize an adverse effect when it may occur as part of the natural history of the underlying condition. These challenges are discussed in Chapter 4.

Nomenclature and general properties

Atopic individuals become sensitized to allergens through exposure by inhalation (e.g. pollen grains, mite feces, animal danders, cockroach secretions, and fungal spores), by ingestion (e.g. milk, egg, peanut, fish), and by injection (e.g. insect venoms and parenterally administered drugs, such as penicillin). In general use, the term allergen can refer to these sources, to aqueous extracts prepared from the source materials, or to highly purified or cloned allergen proteins. The systematic nomenclature for purified allergens developed by the World Health Organization and International Union of Immunological Societies was revised in 1994. The nomenclature uses the taxonomic name of the source material and an Arabic numeral to describe the allergen, in the chronologic order of identification and purification. In the abbreviated form, the first three letters are used for the genus, followed by a single letter for the species. For example, ragweed antigen E (the first pollen to be...

Expression and biologic activity of recombinant allergens

Traditional methods of allergy diagnosis and treatment have relied on the use of heterogeneous allergen extracts. The problems with these extracts are that the absolute potency is difficult to define and some patients give adverse reactions when the extracts are injected (during immunotherapy), which can be life threatening. While there has been significant progress in the standardization of allergen extracts the use of purified recombinant allergens expressed in bacteria, yeast or insect cells offers the prospect of using defined proteins for both diagnosis and treatment. An increasing number of recombinant allergens have been produced and it is possible to investigate whether cocktails of 3-4 allergens would be suitable for clinical purposes. Typical vectors in which allergens have been expressed include pGEX and pET (in Escherichia coii) pSAY-1 and Pichia pastoris (yeast), and the baculovirus system, giving yields of 1-10 mg 1 1. The allergens can be obtained with a high degree of...

Association of Anaesthetists of Great Britain and Ireland 1995

Irrespective of the mode of triggering, all the clinical manifestations of an allergic reaction occur as a result of the liberation of vasoactive substances. The typical clinical features of anaphylaxis are hypotension, bronchospasm, oedema and the development of a rash (Figure I.4). Cardiovascular collapse is one of the most common early signs (Figure I.5). This is usually the result of vasodilatation and may be compounded by arrhythmias (usually supraventricular tachycardia), hypovolaemia and a reduction in venous return, which will be exacerbated if high inflation pressures are necessary to facilitate ventilation of the lungs. Bronchospasm is variable in its severity from a transient degree of difficulty with ventilation to the situation where gas exchange is impossible despite the use of high airway pressures and slow inspiratory and expiratory times. The presence of wheals and erythema near the point of venous access is usually a sign of localised histamine release which usually...

Immunological mechanisms

Once IgE antibodies are produced, they will bind to mast cells. This process, known as sensitisation, precedes symptoms of allergy. How early in life an individual can be sensitised has been a topic of much interest lately. Some would argue that sensitisation can take place in utero. The second stage following sensitisation can take place weeks or sometimes years later. This stage occurs when the individual encounters the same food allergen for the second time. The allergen will encounter the mast cells, which already possess allergen-specific antibodies on their surface. IgE antibodies will bind the allergen and this will lead to mast-cell degranulations and release of mediators such as histamine, and the characteristic features of allergic disease follow.8 These include urticaria (this is the specific term used for hives, which are red, itchy skin welts brought on by an allergic reaction) These reactions are also referred to as Type III hypersensitivity reactions. When we eat, food...

Mechanisms of oral tolerance

Oral tolerance is very much the norm. The reason why we are not all allergic and intolerant when we eat food is due to basic mechanisms that function in the development of our tolerance. Food intolerance and food allergy is in fact a failure of oral tolerance. The existence of oral tolerance has been known for a long time, but its mechanisms are still not fully understood. A number of experimental models have been used to demonstrate this phenomenon. One such example is the oral tolerance to ovalbumin in mice. This was induced by a single administration of ovalbumin and a demonstration of suppression of cellmediated immunity.23

The advantages of wellbuilt clinical questions

What criteria might be used best to specify a question at the dermatology consultation The answer to this question might vary according to patient attributes such as age, sex, past therapy and allergies. A question can be as only as good as the initial evaluation of the patient, which includes a detailed history and examination in order to obtain an accurate diagnosis. An exploration of which factors are important to the patient in terms of expectation of treatment outcome, willingness to put up with inconvenience of frequent medication, and tolerance of potential side-effects is also crucial at such an initial consultation. Specifying an outcome that means something to the dermatologist and patient is also important. For example, consider a 28-year-old man with psoriasis who is desperate for a remission of the visible plaques on his body because he is planning a once-in-a-lifetime holiday to the coast, where he wants to expose

Management of Thalassemia Major

Patients affected by thalassemia major are treated with regular blood transfusions and iron chelation therapy with desferrioxamine B (DFO). Life expectancy with this treatment extends to the third decade. The alternative oral iron chelator deferiprone (L1) is indicated only in patients with proven allergy or toxicity from DFO. Alternative chelation strategies and drugs, including the combination of deferiprone and DFO or ICL670 alone, are under investigation.

Antigen uptake by mucosal surfaces

The structure of mucosal surfaces (epithelium with tight junctions and a mucous layer) itself is an important determinant of antigen exclusion. Macro-molecules are shown to transgress this barrier by endocytosis. Granulocytes, macrophages and plasma cells in the lamina propria interact with these absorbed antigens, thus forming a secondary barrier of defense against penetration of antigens into the circulation. Certain diseases or altered states (e.g. malnutrition, vitamin A deficiency, decreased gastric acidity, allergy) may allow for increased amounts of macromolecular transport. It is thought, for example, that tight junctional complexes present between the mucosal epithelial cells are broken down during malnutrition and vitamin A deficiency. In

Toxicological data and regulatory approval

Perhaps the most important aspect of any compound proposed for use as a food preservative would be the toxicological characteristics. Because they occur in nature, it is often thought that naturally occurring antimicrobials are less toxic than synthetic compounds. Obviously, this is not always true. A naturally occurring antimicrobial must be shown to be non-toxic either by animal testing or by its continuous consumption as a food over a long period. The latter may be problematic even for some common potential natural antimicrobials such as spice extracts. This is because, while spices have been consumed for centuries, they are not normally consumed in the concentrations necessary to achieve antimicrobial activity. In addition to lack of toxicity, naturally occurring compounds must be able to be metabolized and excreted so as not to lead to residue build-up (Branen, 1993). In addition, they should be non-allergenic (Harlander, 1993). Food antimicrobials should not bind nor destroy...

Introduction the law and food intolerance

Throughout history laws have existed to protect the consumer against the adulteration of food, whether deliberate or accidental. Watering down of milk and the contamination of food with heavy metals have long been the subject of investigation and prosecution. How does this translate into modern life and the problems of food intolerance The first point to be clear about is that with a few minor exceptions, the law does not specifically recognise or refer to the problem of food intolerance and allergic reactions. It is therefore necessary to examine the legal provisions that do exist in order to see where they can be of help to the sufferer and provide protection against inadvertent consumption of a food which may give rise to a reaction.

Clinical Features

The patient with evolving cardiogenic shock often will exhibit a rapid progression of findings indicating poor perfusion. Clinical evaluation, diagnostic testing, and treatment are initiated simultaneously. History from the patient is often blunted by the severity of the patient's condition, so family, EMS personnel, and medical records should supplement the patient's history. Key information includes current medications, allergies, and past history of MI, CHF, diabetes mellitus, and renal failure. Although the patient may experience chest pain, ischemic equivalents include profound weakness, shortness of breath, or a feeling of impending doom.

Case presentation 1 continued

Outpatient setting.26,27 Brown et al. randomized 194 patients with moderate-to-severe cellulitis to 2 g intravenous cefazolin daily or 2 g intravenous ceftriaxone daily, while both groups received probenecid 1 g orally.26 Outcomes were similar, 91-8 versus 92-7 clinical cure, with cost savings associated with the cefazolin group. However, the majority of patients were intravenous drug users with injection site infections, follow up was not complete and patients were given a prescription for penicillin and cloxacillin upon enrolment.26 Grayson et al. randomized 116 patients who presented with moderate to severe cellulitis to 2 g intravenous cefazolin and 1 g probenecid orally or 1 g intravenous ceftriaxone and placebo.27 Clinical cure rates were similar 86 in the cefazolin arm versus 96 in the ceftriaxone arm (P 0-11) and remained equivalent up to 1 month follow up, 96 versus 91 (P 0-55).27 Both studies excluded patients with penicillin allergies, septic patients requiring...

TABLE 329 Toxicity of Local Anesthetics

True allergic reactions to local anesthetics are rare. They are usually due to the metabolite para-aminobenzoic acid (PABA) in the case of ester anesthetics and the preservative methylparaben (MPB), structurally similar to PABA, in the case of amide anesthetics. Esters are more commonly associated with allergic reactions than amides. If a true allergy is suspected based on history or documentation, the optimal approach is to use a preservative-free agent from the other class. local anesthesia is extremely specific and limited to those patients who have true allergies to ester or amide anesthetics, which are quite rare.

The legal background labelling

The practical protection which individuals with food allergy and intolerance can expect from the law is information rather than elimination. To this end, comprehensive food labelling requirements have developed. Throughout the European Union these requirements are largely harmonised and stem from EC Directive 79 112 on the labelling and presentation of foodstuffs. The provisions are enacted within the UK as the 1996 Food Labelling Regulations. Although it originated two decades ago, the Directive and its enactments in EU Member States have been progressively updated over the years. The legislation requires that all foods are labelled with either a legally provided name or a customary name which is well understood by purchasers in the place of purchase, or a true name which accurately describes the food. A list of ingredients is required for most foods which details what they contain, including any additives. Notice the emphasis on the word 'most' as with many requirements, there are...

General Anesthetic Agents and Neuromuscular Blocking Agents

Patients with previous reactions to an agent used during general anesthesia should have intradermal testing done for both putative agents and an alternative neuromuscular block. Low-risk agents such as pancur-onium should be given preference over high-risk agents such as succinylcholine, if both yield negative skin tests. However, a negative skin test result does not eliminate the possibility of developing a reaction to one of these agents. Pretreatment for neuromuscular blocking agent allergy has been found to be ineffective.

Type I hypersensitivity

The central mechanism of atopic allergy is type I hypersensitivity (Figure 1). Mucosal contact with allergen results in uptake by an antigen-presenting cell (APC) and presentation in the form of an allergenic peptide held in the groove of the major histocompatibility complex (MHC) class II molecule to a helper T lymphocyte. This then provides help for a previously committed B cell, which is capable of recognizing the antigen, to make IgE antibody.

Case presentation 2 continued

Associated with polymicrobial infection, the most commonly recommended initial antibiotic is a p-lactam p-lactamase inhibitor plus clindamycin.3'4'29'32-35'37,48 Acceptable alternative regimens include single agents such as carbapenems, second-generation cephalosporins or fluoroquinolones with anaerobic activity and combinations with ampicillin and metronidazole or clindamycin, with either a third-generation cephalosporin, an aminoglycoside, fluoroquinolone, or aztreonam.3'4'29'32-35'48 With animal models of group A streptococcus necrotizing fasciitis, clindamycin has been shown to have more effective killing power than penicillin, because bacteria reach the stationary growth phase rapidly while penicillin loses effectiveness in this phase.3 Clinical data seem to support this with improved survival in patients treated with clindamycin.30,48 Also owing to its effect on protein synthesis inhibition and toxin production, clindamycin may improve survival in patients with group A...

Special Considerations

In a child, identifying a fracture with plain radiographs may be difficult owing to an open epiphysis. It is often necessary to obtain radiographs of the uninvolved hand for comparison. If a surgical procedure is indicated and the child is unable to tolerate the procedure after a digital nerve block alone, conscious sedation may be required. Medications commonly used for conscious sedation include the sedatives anxiolytics, such as benzodiazepines and barbiturates pain relief is achieved using opioids such as fentanyl and morphine. In children, a commonly used agent is ketamine, a nonopiate phencyclidine derivative that produces both analgesia and sedation. Before performing conscious sedation, specific attention should be paid to allergies (including those to latex), current medications, and last oral intake of solids and liquids.

Controversies in Disease Evolution Studies

Evolutionary medicine has proposed explanations for an array of modern ailments ranging from obesity to lower back pain, asthma, otitis media, depression, and addictions. Allergies, for example, are thought to be related to originally adaptive responses to parasitic infections (Nesse & Williams, 1994). Even more problematic are evolutionary explanations for current behavioral aberrations, such as homicidal assault, sexual abuse and incest, depression, and infanticide. Intellectually it may be satisfying to link contemporary ills to past conditions, but the extent of genetic determinism is problematic.

And if the treatment still does not work

After agreeing on a treatment, a patient may return saying that the treatment does not work. Having explored obvious issues such as whether the ointment ever reached the skin, and whether the allergic reaction from topical benzoyl peroxide was in fact a predictable irritant reaction which could be circumvented by less frequent or vigorous application, other treatment options are often explored. If several treatments fail in a particular patient, the patient may belong to a subset with refractory disease, making it even more difficult to generalise from clinical trials of people with more responsive forms of the disease. Dermatologists frequently face the problem of trying several drugs in succession. External trial evidence could be improved by better descriptions of study participants in terms of previous treatments and by means of sequential RCTs that try different treatment approaches following failure of a treatment.

The diagnostic pathway

Diagnostic tests for food allergy, as with all medical tests, cannot be discussed in isolation. They are only one part of the whole diagnostic pathway. When an individual presents a particular problem to a health professional, a diagnostic pathway is embarked upon. This pathway starts with the professional taking the individual's medical history, the story of their particular problem. This is often complemented by an examination. The pathway may or may not conclude with particular tests. All diagnostic tests should be seen within the context of this pathway. Tests only serve to add further pieces of information to that already gleaned from the history and examination. They very rarely alone give a definitive answer. This chapter will start with an explanation of how to judge any test's 'worth'. It will then describe particular aspects of the history and examination relevant to the diagnosis of food allergies and intolerance. There will then follow an introduction to the wide range of...

Preoperative Examination

Medical history, such as past history (previous abdominal surgery, trauma, accident) the presence or absence of previous anesthesia and its related complications previous drug allergies the presence or absence of contraindications to anticholinergic agents, such as ischemic heart disease, glaucoma, prostatic hypertrophy review of oral medications use of anticoagulants or nonsteroidal antiinflammatory drugs (NSAIDs) blood coagulation tests thoracic and abdominal radiography and electrocardiography.

Other dairy products to improve infant health

Infant formulas or so called breast milk substitutes aim to provide an efficient and safe alternative diet for infants of those women who are not able to continue breastfeeding until six months of life. infant formula can be fed directly after birth when breastfeeding is not possible follow-on formulas are designed for children after the sixth month of life. Breast milk substitutes aim to mimic the composition of human breast milk concerning protein, fat and carbohydrate composition. The only carbohydrate of infant formulas is lactose, whereas follow-on formulas contain other carbohydrates, too. Protein sources are mainly bovine whey or casein (in the standard cow's milk based formulas) or soy protein (for infants with lactose intolerance or cow milk protein allergy). The quality parameter for the evaluation of infant diets is the ability to allow normal physical growth as well as optimal neurological and mental development. Hypoallergenic formulas are commonly classified by the...

The accuracy of diagnostic tests

Every disease has a rate of prevalence and incidence within both the general population and specific populations. The term 'prevalence' is a statistic based upon a particular point in time. It refers to the number of cases of a particular disease divided by the total number of people within the population and is usually represented as a percentage. 'Lifetime prevalence' is the number of people within a population who may have a particular disease at some time in their life, expressed as a percentage of the total population. The term 'incidence' refers to the number of new cases of a disease occurring over a specified period of time. The two terms are useful for different kinds of disease. The prevalence of a disease is often useful for more chronic diseases - those diseases which people rarely recover from, but also rarely cause death. A useful example is an estimate of the lifetime prevalence of peanut allergy within a given population. Diseases with high recovery rates or with high...

The Paediatric Patient

Pre-operative assessment in children should be as rigorous as in adults and questions should be addressed to the child even though the parents may answer for them. Most children are healthy but chronic conditions such as asthma, multiple allergies, congenital heart disease and systemic conditions (such as muscular dystrophy) may also be encountered. The presence of one congenital abnormality should stimulate the search for others. Chromosomal abnormalities may be linked particularly with congenital heart disease. Except for true emergency surgery, children with colds or upper respiratory tract infections should have their surgery cancelled and rescheduled to a later date. The inflamed airway is exquisitely sensitive to any kind of manipulation, resulting in laryngeal spasm. Laryngeal spasm in children is particularly dangerous because of the rapid onset of severe desaturation, made more marked by their higher metabolic rate.

IgE Antibodies against nonhuman antigens

In patients who are allergic to an allergen, an allergic reaction occurs if the donor plasma contains the allergen. This may particularly occur if it concerns food allergens, which may be present in the donor plasma after consumption of the food involved. The patient develops urticaria. The reactions can be prevented, in the case of red cell concentrates, by washing the cells three times. Very rarely a similar reaction is induced by donor IgE antibodies against an allergen which at the time of the transfusion is present in the patient.

Health Risks and Benefits of GM Food

Critics of GM food present three kinds of arguments to suggest that it may not be good to eat (Thompson, p. 76). First, GM foods may produce allergic reactions because known or unknown allergens could be introduced into products people believe are safe. The food industry should and does take this problem seriously the liability issues alone are sobering. For example, because many people are allergic

Past medical and drug history

The possibility of a psychiatric history should be considered. Some clusters of symptoms at presentation are more likely to be linked with psychiatric diagnoses. People presenting with multiple symptoms, and concerns over many foods and other environmental problems, have been shown to be more at risk of symptoms of depression or anxiety.10 Parents may make claims of multiple food allergies in their children. Such claims have been known to be sufficiently extreme to be diagnosed as Munchausen's by Proxy.11

Potential Adverse Effects

Cereals do not have any intrinsic non-specific toxins. However, acrylamide, a carcinogen and potential neuro-toxin, has recently been found at levels up to 120 mg 100 g_1 in baked and fried foods, including breads and processed cereals. Research is ongoing, but the early indications are that acrylamide from these sources is unlikely to increase cancer risk. Detrimental effects may be caused by antinutrients in cereals and, in susceptible individuals, by adverse immune responses (celiac disease, food allergies). Cereals may also be a source of toxins of fungal origin (mycotoxins) or of toxic environmental, agricultural, or industrial contaminants.

Assessments of specific IgE via skin prick tests or in vitro methods

The use of skin prick tests and in vitro identification of specific IgE is discussed later in this chapter. Such tests are usually insufficiently sensitive or specific to be used in isolation for the diagnosis of food allergies. It is suggested that the only reason for not proceeding to DBPCFC is if there is strong suspicion that a likely food substance caused an anaphylactic reaction, and positive evidence of specific IgE. Open challenge and if necessary DBPCFC should follow negative skin prick tests. Positive tests in the presence of non-life-threatening symptoms should be followed with a DBPCFC.

Elicit a Medical History

The patient reports no past medical history. He has not seen a doctor since he was a child and has had no hospitalizations and no history of past surgeries. He reports smoking a half of a pack of cigarettes per day, moderate alcohol use, and occasional drug use, including marijuana and cocaine. He takes no medications except for an over-the-counter multivitamin daily and ibuprofen for the occasional headache and muscle pain. He has no known drug allergies. At the same time that you have been learning the medical history, a nurse has been putting in two large bore IVs and starting intravenous fluids for resuscitation. What next

Triggers for Loss of Tolerance

The mechanism of response to gluten in celiac disease is quite different from that of IgE-mediated food allergies. IFN-7, a potent inflammatory cytokine, is characteristically produced in celiac disease as well as TNF-a. IL10 and TGF- 3, which are both counter-inflammatory regulatory cytokines for the intestine, are also expressed in celiac disease, although they are apparently inadequate to prevent the substantial inflammation that occurs.

Chapter References

International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema. Lancet 351 1225, 1998. 10. Roche WR Fibroblasts and asthma. Clin Exp Allergy 21 545, 1991. 11. Busse WW, Gern JE Viruses in asthma. J Allergy Clin Immunol 100 147, 1997. 13. Schatz M, Zeiger RS Asthma and allergy in pregnancy. Clin Perinatol 24 407, 1997. 14. McFadden ER Jr. Clinical physiologic correlates in asthma. J Allergy Clin Immunol 77(1 Pt. 1) 1-5, 1986.

Interpretation of skin tests

Those without symptoms but with positive skin prick tests may lie in one of two groups. They may indeed be false positives, and the positive reaction may be due to irritants or other mast cell secretagogues and not an indication of specific IgE. The other group includes the asymptomatic but skin prick test positive people who are at greater risk of developing allergic symptoms, but not necessarily food allergies, later in life. This is termed 'latent allergy'.27

Acellular Human Dermis and Mammalianderived Implant Materials

In contrast to the synthetic materials previously described, several bioimplantable materials are derived from mammalian tissues, especially from human cadavers. Injectable collagen is derived from bovine tissue and is comprised mainly of type I collagen. While it has been used extensively in lip, malar, and chin augmentation, it typically resorbs in 3-9 months. Minimal tissue reaction is seen in most forms. A concern when using collagen for implantation is its relatively high propensity for allergic reaction. As such, skin testing is recommended prior to the implantation of large amounts of collagen.

General Systems Concepts

In earlier works (Tan, 2001), the principles of GST concerning the behaviors of organizational systems and subsystems were used to think about the design of different classes of clinical and administrative health management information systems required to run hospitals and health provider organizations. To apply GST to the e-health care system and environment, the first step is to identify the various associated subsystems in terms of their inputs, processes, outputs and feedback loops. One subsystem that comes to mind is e-health records (EHRs), which will be discussed in detail in Chapter Four. In this system, the input consists of patient records stored in a data warehouse or a database. The processes are comprised in the management of those records, including automatic data gathering, cleaning and verifying, adding or deleting information, and retrieving or combining data to answer queries. The output of the system is the information or knowledge from the records that is displayed...


13-14 years in the International Study of Asthma and Allergies in Childhood (ISAAC) suggest that atopic eczema is not just a problem confined to Western Europe, high prevalence being found in many developing cities undergoing rapid demographic change.8 There is reasonable evidence to suggest that the prevalence of atopic eczema has increased two to threefold over the last 30 years, although the reasons for this are unclear.9 No reliable estimates of incidence are available for atopic eczema.

Ring Tourniquet Syndrome

A tight ring encircling the proximal phalanx may become entrapped because of distal swelling. Such swelling may be the result of trauma, infections, skin disorders, allergic reactions, or the tight ring alone. As the digit expands, venous outflow is restricted by the tight ring, producing more swelling. This vicious cycle may lead to nerve damage, ischemia, and digital gangrene.

Aminopenicillins Ampicillin Amoxicillin

Antibiotics of the penicillin group, aminopenicillins have low toxicity and generate few side effects other than a risk of allergy. Forty to 50 of enterobacteria are resistant to these antibiotics (Goldstein 2000). Adding clavulanic acid-inhibiting beta-lactamases has increased the efficacy, but 30 - 40 of bacteria are currently resistant to it (Goldstein 2000). The aminopeni-cillins are very effective on streptococci. This group of antibiotics can be used without risk in pregnant women but after having verified the sensitivity of the bacterium on the antibiogram.

Other nonIgE antibodies

The body also is capable of producing other types of antibodies such as IgM, IgG and IgA against foods. Some studies have claimed a role for IgA-secreting cells, which have been shown to rise after ingestion of a particular foodstuff, or IgG4 that is said to correlate with clinical hypersensitivity. No studies have been able to demonstrate the role of these antibodies in the pathophysiology of food allergy. Food-specific non-IgE antibodies seem to be much more likely to reflect the particular diet of the individual, a normal phenomenon rather than diagnostic of disease.

Common Variable Immunodeficiency

Thomas A Selvaggi, Laboratory of Clinical Investigation, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Bethesda, Maryland, USA Michael C Sneller, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA

Unproven and inappropriately applied tests

There are both unconventional theories and unproved methods being used within the field of allergy. Critics distinguish between diagnostic methods that remain unproven, those that are experimental and those that are accepted by the peer review process and are regarded as standard practice. Some diagnostic procedures are particularly associated with certain conditions and certain methods of practising. One such group of clinicians are those who work within the field of clinical ecology, involved in the diagnosis of idiopathic environmental intolerances. There are also alternative or complementary practitioners who diagnose food allergy or intolerance in a variety of ways. A thorough review of the most prominent of these practices has been published by The Royal College of Physicians.26

Electrodermal testingelectroacupuncture

This is a test used by alternative or complementary health workers. The device used for this in vivo test is made up of a galvanometer that measures the activity of the skin at designated acupuncture points. The patient holds the negative electrode in one hand, while the positive electrode is pressed upon the points. Vials of food extracts in contact with an aluminium plate are also within the circuit. A drop in electrical current is diagnostic of an allergy to that particular food. There is no clearly described theory behind the procedure, and furthermore no clinical or scientific evidence that electro-dermal testing can diagnose food allergy.

Inappropriately applied laboratorybased tests

There are laboratory-based tests, some in common usage, which have not been shown to identify food allergies or intolerances with any accuracy. Lymphocyte subset counts and lymphocyte function assays are useful for diagnosing congenital or acquired lymphocyte cellular immunodeficiency states, but not allergic disease. Cytokines and their receptors are involved at many levels of the immune response. The correlation of assays with disease, and in particular their diagnostic value, is yet to be established.

Molecular Characterization Of Pathogen And Molecular Testing

E. histolytica and E. dispar genome shotgun sequencings are underway as a joint effort from TIGR 11 and the Sanger Centre, 12 funded by the National Institute for Allergy and Infectious Diseases and the Wellcome Trust, respectively. The genome is around 18-20 Mb in size in 14 chromosomes. 11-13 However, partial genomic data from these organisms are available since the end of the 1980s. 14,15 These data allowed designing molecular assays that are sensitive to detection and, more interestingly, that can differentiate between both. 16,17 Following these pioneering works, other early molecular techniques were designed as well. 18-21 To be readily used in the clinic, molecular detection and differentiation techniques have to be usable on feces, and as any infectious disease diagnostics technique, to be both sensitive and specific (or in fact, have good positive and negative predictive values). As these values depend on prevalence, it is quite clear that a ''good'' technique in a Western...

Clinical reactions to drugs

Immune responses to drugs are necessary but not sufficient for clinical allergic reactions to drugs. If the fluid phase has an excess of univalent haptenated carriers over multivalent carriers, many immunopathologic reactions will not occur. Cross-linking of IgF and activation of mast cells will not occur. Immune complexes cannot form in univalent hapten excess. Direct cytotoxic reactions are inhibited by fluid phase determinants. The affinity and isorype arrays of the immunoglobulins expressed also influence the nature of a reaction. Stratification of clinical allergic reactions to drugs according to the immunopathologic scheme of Gell and Coombs can be considered. Type I IgH-mediated immediate hypersensitivity reactions do occur in the forms of anaphylaxis, urticaria and angioedema, but some drugs can induce these reactions via complement activation or direct pharmacologic effects. Type II cytotoxic reactions occur, for example immune cytopenias, but most cell-destructive or...

History And Physical Examination

Obstetric and gynecologic history, including menstrual status and contraceptive use, should be obtained on every woman of reproductive age. Cessation of menses, as well as such symptoms as nausea, vomiting, fatigue, and urinary frequency, may be suggestive of pregnancy. The date of the last normal menstrual period aids in determination of gestational age (although it may be misleading if, for example, contraceptive use was recently discontinued). Quickening, the first maternal perception of fetal movement, could also help establish gestational age. Primigravida women note fetal movement between 18 and 20 weeks' gestation. With subsequent pregnancies, quickening typically occurs about 2 weeks earlier (i.e., between 16 and 18 weeks' gestation). The patient's history of prenatal care and the course of current and past pregnancies, as well as the essential components of any medical history (past medical history, medications, allergies, social history, family history, and review of...

Allergic contact dermatitis

Allergic contact dermatitis is one of the best studied forms of delayed-type hypersensitivity and it is the result of sensitization to these small molecular compounds, also described as haptens. Molecules with a molecular weight under 500 Da are assumed to be bound by intraepidermal Langerhans cells, the major cutaneous representative of the family of dendritic antigen-presenting cells (APCs). These haptens are transported by Langerhans cells to the skin draining lymph nodes, where, in the paracortical T cell areas, induction of immunity to a given hapten may occur. It is thought that expansion of hapten-specific T cells in the lymph nodes is followed by dissemination of these T cells in peripheral blood and subsequently, perhaps through skin-specific homing, into the skin. Rechallenge of the skin then leads to elicitation of an eczema-type response, with presentation of haptens to specific T cells in the skin compartment. Well-known examples of contact allergens An essential question...

Prostaglandin H Synthase Function

Prostaglandins, thromboxane, and prostacyclin modulate many important physiological processes, including the mediation of inflammation, allergy, and fever. Compounds that control their production are potentially important pharmaceutical agents (Marnett et al., 1999 Smith et al., 2000). In the first step of the biosynthesis of these lipids, arachidonic acid undergoes an oxygen-dependent transformation into prostaglandin G2 (PGG2), a hydroperoxide, and then its peroxidation to the corresponding alcohol prostaglandin H2 (PGH2).

Cytokines and vascular endothelium

IL-4 and IL-13 IL-4 and IL-13 selectively induce VCAM-1 and inhibit E-selectin and ICAM-1. These cytokines also amplify production of chemokines by endothelial cells. It is likely that these actions of IL-4 are important in the pathogenesis of the late-phase reaction which is associated with allergy.

Source function and chemical nature of eosinophil chemotactic factors

During initial studies, mast cells and basophils were intensely investigated for the release of eosino-philotactic agents because these cells are considered the main effector cells of allergic reactions. The factors isolated were mostly of low molecular weight and probably represented the eosinophilotactic activities of platelet-activating factor (PAF) and the eicosanoids. The low molecular weight eosinophilotactic activity generated de novo from neutrophils was later shown to represent primarily leukotriene B4 (LTB4) and related eicosanoids (Table 1). All these factors are also able to attract a number of cell types other than eosinophils.