Allergy Ebook

Allergy Relief

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Dictionary of Contact Allergens Chemical Structures Sources and References

Abietic acid is probably the major allergen of colophony, along with dehydroabietic acid, by way of oxidation products. Its detection in a material indicates that allergenic components of colophony are present. Bergh M, Menne T, Karlberg AT (1994) Colophony in paper-based surgical clothing. Contact Dermatitis 31 332-333 Karlberg AT, Bergstedt E, Boman A, Bohlinder K, Liden C, Nilsson JLG, Wahlberg JE (1985) Is abietic acid the allergenic component of colophony Contact Dermatitis 13 209-215 Karlberg AT, Bohlinder K, Boman A, Hacksell U, Hermansson J, Jacobsson S, Nilsson JLG (1988) Identification of 15-hydroperoxyabietic acid as a contact allergen in Portuguese colophony. J Pharm Pharmacol 40 42-47 Acetaldehyde, as its metabolite, is responsible for many of the effects of ethanol, such as hepatic or neurological toxicity. A case of contact allergy was reported in the textile industry, where dimeth-oxane was used as a biocide agent in textiles and its degradation led to acetaldehyde. in...

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...

Food Intolerance and Allergy

Mast Cell Diagram

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...

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....

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...

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...

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...

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.

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

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.

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...

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...

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.

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...

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...

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...

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...

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...

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...

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...

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...

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....

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...

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

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...

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...

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.

The Role of Skin and Provocation Tests

A drug provocation test is carried out for diagnostic therapeutic purposes and consists of the controlled administration of the drug to a patient with a history that suggests drug allergies. The European Network of Drug Allergy from the European Academy of Allergology and Clinical Immunology recommends the use of a provocation test when skin tests and biological tests are not available or not validated. This approach has elicited some controversial discussion, because with the exception of aspirin and 3-lactams, results of tests are only available for very small patient groups. One of the most important reports on drug provocation tests, con

Discharge And Home Healthcare Guidelines

Although asthma can result from infections (especially viral) and inhaled irritants, it often is the result of an allergic response. An allergen (antigen) is introduced to the body, and sensitizing antibodies such as immunoglobulin E (IgE) are formed. IgE antibodies bind to tissue mast cells and basophils in the mucosa of the bronchioles, lung tissue, and nasopharynx. An antigen-antibody reaction releases primary mediator substances such as histamine and slow-reacting substance of anaphylaxis (SRS-A) and others. These mediators cause contraction of the smooth muscle and tissue edema. In addition, goblet cells secrete a thick mucus into the airways that causes obstruction. Intrinsic asthma results from all other causes except allergies, such as infections (especially viral), inhaled irritants, and other causes or etiologies. The parasympathetic nervous system becomes stimulated, which increases bronchomotor tone, resulting in bron-choconstriction. The classification for asthma is...

Primary Nursing Diagnosis

Pharmacologic measures are often used to manage symptoms. Physical therapy includes various passive modalities of treatment, such as heat, ice, massage, ultrasound, and electrogalvanic stimulation, often directed by a physical therapist, and exercises to stretch and strengthen the spine and supporting musculature. Spinal adjustments performed by osteopathic or chiropractic physicians can also relieve symptoms. Chemonucleolysis may be used by injecting the enzyme chymopapain into the nucleus pulposus. Ask if the patient is allergic to meat tenderizers, since such an allergy contraindicates the use of chymopapain in the procedure.

Construction Materials

Testing with the material as is under occlusion is absolutely contra-indicated because of high irritancy. A semi-open test might be indicated in cases with a high suspicion of contact allergy, particularly when resins are involved and testing with the standard and supple mentary series remains negative. The main allergen in cement is potassium dichromate, which is present in the standard series. Fast-curing cements contain epoxy resins, which are increasingly recognized as major allergens in the construction industry but also in other industrial areas (painting, metal, electronics, and plastic). The epoxy resin of the standard series is insufficient to detect all cases of relevant epoxy resin allergies, as has been shown by a large German multicenter study 8 . Sometimes acrylic resins may also be present.

Imaging Criteria for Radiographic Assessment in Adults

Decisions about radiographic imaging in cases of suspected renal trauma are based on the clinical findings and the mechanism of injury. Since the majority of renal injuries are not significant and resolve without any intervention, many attempts have been made to identify patients who could be spared the discomfort, radiation exposure, possible allergic reaction, and expense of a radiographic evaluation (Miller and McAninch 1995).

Tixocortol 21Pivalate Tixocortol 21Trimethylacetate CAS Registry Number [55560968

Tixocortol 21-pivalate is a 21-ester of tixocortol, widely used in topical treatments. It can induce severe allergic contact dermatitis. This corticosteroid is a marker of the allergenic A group that includes molecules without major substitution on the D cycle (no C16 methylation, no C17 side chain). A short-chain C21 ester is possible. Molecules are cloprednol, cortisone, fludrocortisone, fluoro-metholone, hydrocortisone, methylprednisolone, methylpred-nisone, prednisolone, prednisone, tixocortol, and their C21 esters (acetate, caproate or hexanoate, phosphate, pivalate or trimethyl-acetate, succinate or hemisuccinate, m-sulfobenzoate). tixocortol. Ann Dermatol Venereol 129 348-349 Lepoittevin JP, Drieghe J, Dooms-Goossens A (1995) Studies in patients with corticosteroid contact allergy. Understanding cross-reactivity among different steroids. Arch Dermatol 131 31-37

Evaluation of Eyelid Lesions

Lesions Definition

Current and past illnesses should be reviewed. Of importance in patients presenting with rash-like symptoms is the recognition of atopy (as manifest by hay fever or asthma) as this history is suggestive of atopic dermatitis. Inquiry regarding past allergic reactions to food or medications is essential. Any systemic condition that may suppress the immune system and thus predispose the patient to cutaneous infections or neoplasia (such as HIV and diabetes) should be questioned.

Economic Importance Injurious Families

Injurious Domestic Animals

The adults have mouthparts that have very effective piercing stylets, enabling these flies to bite and suck blood. Some major families with this characteristic include members of Simuliidae (Fig. 28), Culicidae (Fig. 29), Psychodidae (Fig. 30), Ceratopogonidae, Tabanidae (Fig. 31), and the blood-sucking Muscidae (Figs. 32 and 33). The bites from these groups can often cause severe allergic reactions, resulting in intense itching, rashes, and local swelling or, in some instances, hospitalization as a consequence of toxemia or anaphylactic shock.

Products of the maillard reaction

Premelanoidins have been shown to inhibit growth, cause liver damage, and interrupt reproduction in laboratory animals. Maillard products of fructose-glycine and fructose-arginine increase the mutagenicity of 3-amino-1,4-dimethyl 5H-pyridol-(4,3-b)indole. Antimutagenic effects seem to correlate well with antioxidant effects. However, mutagenicity of benzo(a)pyrene is moderately inhibited by such products. Some products of the Maillard reaction have been shown to induce allergic reactions.


Dimethylaminopropylamine is an aliphatic amine present in amphoteric surfactants such as liquid soaps and shampoos. It is present as a residual impurity thought to be responsible for allergy from cocamidopropylbetaine. It is structurally similar to diethyl-aminopropylamine. It is also used as a curing agent for epoxy resins and an organic intermediate in chemical synthesises (ion exchangers, additives for flocculants, cosmetics and fuel additives, dyes and pesticides). Patch test has to be carefully interpreted, since the 1 aqueous solution has pH> ii (personal observation). Angelini G, Foti C, Rigano L, Vena GA (1995) 3-Dimethylaminopropyl-amine a key substance in contact allergy to cocamidopropylbetaine Contact Dermatitis 32 96-99 Kanerva L, Estlander T, Jolanki R (1996) Occupational allergic contact dermatitis from 3-dimethylaminopropylamine in shampoos. Contact Dermatitis 35 122-123 Speight EL, Beck MH, Lawrence CM (1993) Occupational allergic contact dermatitis due to...

Antithyroid Drug Therapy

Thyrotoxicosis can be controlled more quickly than with thionamides using solutions of saturated potassium iodine (SSKI or Lugol's solution 1-3 drops t.i.d.) which blocks the release of stored hormones. Side effects of iodine are uncommon and include acneiform eruptions, fever, coryza, and salivation 99 . Severe and fatal allergic reactions to iodine have also been observed 99 .

Pharmacologic Highlights

Parenteral therapy Iron dextran (Imferon) is the preferred medication for intramuscular injections. Pregnant and elderly patients with severe iron deficiency anemia may be given total-dose intravenous infusions of iron dextran in a sodium chloride solution, after a small test dose is given to gauge any allergic reaction.

The Epithelial Barrier Function

The postnatal balance between epithelial barrier function and oral tolerance thus appears to be critical for the induction of immunological homeostasis. Notably, although the incidence of food allergy (apparently non-IgE-mediated) is increased in children with IgA deficiency, it is not strikingly elevated 78 - perhaps because the induction of Teg cells is enhanced in addition to compensatory SIgM, which in such individuals partially replaces the lacking SIgA in the gut 31, 79 . Also, bacterial overgrowth occurs in the jejunum of vagotomized patients only when IgA deficiency is combined with suboptimal function of innate defenses such as gastric acid and peristalsis 45, 80 . In this context, it is notable that the frequency of selective IgA deficiency among patients with Crohn's disease in Sweden is significantly increased, that is, one in 100 compared to one in 600 for the healthy population (Lennart Hammarstrom, personal communication).

Angioedema and Urticaria

Urticaria And Angioneurotic Edema

TREATMENT The key to treatment is to determine the underlying cause since urticaria is always present secondary to an underling immunologic process. Elimination of the inciting factor is curative. Allergy testing may be useful for recurrent cases. In acute urticaria, an etiology is found 20 to 30 of the time and most commonly includes drugs, food or food additives, intravenous radio-opaque contrast medium, hymenoptera stings, infections, or systemic inflammatory diseases. Marked emotional tension may precipitate or exacerbate the condition. Cold, pressure, and sunlight may trigger urticaria in rare familial or sporadic cases. Often, however, the cause cannot be determined. Cold compresses often give relief. Use of subcutaneous epinephrine injection may be necessary for hypotension or airway involvement. In chronic cases the etiology is found in less than 5 of cases.

Peanuts and tree nuts

Over the last few decades, peanuts have become a ubiquitous part of the Western diet as they are a versatile form of easily digested protein (Lucas 1979). In a study looking at the use of dietary manipulation to prevent the development of food allergy, all infants in the control group were exposed to whole peanuts by their second birthday (Zeiger et al. 1989) occult exposure probably occurs even earlier. Adverse reactions to peanuts and tree nuts are generally IgE mediated, occurring rapidly with subjects presenting with dermatological, respiratory and gastrointestinal manifestations (Hourihane et al. 1997). Peanuts and tree nuts are responsible for a third of all admissions with anaphylaxis (Bock 1992). Peanuts are part of the legume family, they are more closely related to peas, beans, soy and lentils than the tree nuts. It has been suggested that there is extensive cross-reactivity between peanut and tree nuts in terms of sensitisation but not clinical reactivity (Sampson and...

Helping the Public Get Accurate Science Based Information

C Finished dosage form that contains the drug substance r Biologic Product O Any virus, serum, toxin, vaccine, blood, blood component or derivative, allergenic product, or analogous product applicable in prevention, treatment, or cure of disease or injuries. They are a subset of drug products, distinguished by the biological manufacturing process.

Cocamide DEA Coconut Oil Fatty Acids Diethanolamide NNbis2Hydroxyethyl Coco Fatty Acid Diethanolamide Cocoyl

Fowler JF Jr (1998) Allergy to cocamide DEA.Am J Contact Dermat 9 40-41 Kanerva L, Jolanki R, Estlander T (1993) Dentist's occupational allergic contact dermatitis caused by coconut diethanolamide, N-ethyl-4-toluene sulfonamide and 4-tolydietahnolamine. Acta Derm Venereol (Stockh) 73 126-129 Pinola A, Estlander T, Jolanki R, Tarvainen K, Kanerva L (1993) Occupational allergic contact dermatitis due to coconut diethanolamide (Cocamide DEA). Contact Dermatitis 29 262-265

Bernard E Bulwer MD MSc and Scott D Solomon MD

At the time of presentation, his medications included captopril, lasix, digoxin, potassium chloride, aspirin, multivitamins, and unspecified dietary supplements. He had no known drug allergies. His family history was significant for coronary heart disease. He smoked more than two packs of cigarettes daily for more than 20 yr, and averaged almost a quart of alcoholic beverages of various descriptions. He admitted no intravenous drug use, but occasionally used cocaine.

Renal Salt and Water Retention [7

This occurs acutely, circulatory shock may result. This can occur when an acute increase in capillary permeability is produced by an allergic reaction or extensive burn. More commonly, edema develops relatively gradually and intravascular volume is maintained by avid renal salt and water retention. Consequently, in addition to the local hemodynamic derangements which produce peripheral edema, renal salt and water retention also contributes importantly to most states of generalized edema formation.

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...

Managing Diabetes Supplies

You should also carry a travel letter from your doctor explaining that you have type 1 or 2 diabetes and the medications you are using to treat it. This note should also include the medicines you are taking for other conditions as well as any food and drug allergies you have. Also obtain a spare prescription for all your medications in case you lose your supplies or your stay is prolonged. Wear your MedicAlert bracelet at all times, and carry a card or letter explaining that you have diabetes written in the languages of the places you are visiting. Keep a list of emergency phone numbers your doctor's office, your pharmacy, your insulin pump company, and (if you're traveling abroad) the American embassy or consulate and a list of English-speaking doctors in the country you are visiting. The International Diabetes Federation website (see Resources) has contact information for diabetes organizations in many countries.

Open patch test and the diagnosis of contact urticaria

Some food substances can induce an immediate urticarial-type reaction at the point of contact. No standardised test exists for investigating such contact urticaria, but one can demonstrate such a reaction by an open test. The substance is placed on the skin of the flexor surface of the forearm for 30-45 minutes in an attempt to replicate the urticaria. It may be necessary to use non-intact, eczematous skin. This contact urticaria may be secondary to an allergic or non-allergic reaction. In the non-allergic type no previous sensitisation has taken

How Decisive Are Commensal Bacteria

Indigenous gut bacteria play a central role in the extended hygiene hypothesis. Thus, the intestinal microbiota of young children in Sweden was found to contain a relatively large number of Clostridium spp., whereas high levels of Lactobacillus spp. and Eubacterium spp. were detected in 234 an age-matched population from Estonia this difference might contribute to the lower incidence of allergy in the Baltic countries compared with Scandinavia 235 . A Finnish study likewise reported that allergic infants had more Clostridia and tended to have fewer bifidobacteria in their stools than non-allergic controls 236 . Absence of early postnatal gut colonization with a normal commensal microbiota dominated by lactic acid-producing bacteria might likewise contribute to the increased risk for food allergy generally noted in children delivered by cesarian section, particularly when genetically predisposed 116, 117 . Nevertheless, in clinical studies it has been difficult to reveal a convincing...

Effects on Particular Organs or Organ Systems

The skin suffers toxic effects itself, including cancer, primary irritation, allergic reactions, hair loss, pigment disturbances, ulceration, and chloracne. Dermatitis is an inflammation of the dermis. Irritant contact dermatitis and allergic dermatitis can both be caused by exposure to chemicals and produce similar symptoms, including hives, rashes, blistering, eczema, or skin thickening. The difference between them is that a true allergy takes time to develop, typically at least two weeks whereas irritation does not require a previous exposure. For example, no one reacts to poison ivy when first exposed. Only after a second or subsequent exposure does the itchy rash develop. Occupational exposure to a variety of substances is known to be capable of causing asthma. This is an allergic reaction in which exposure causes histamine to be released. Histamine stimulates the bronchi to contract, greatly increasing breathing resistance. This is known to affect bakers exposed to flour and...

Immediate and Nonimmediate Reactions to Contrast Media

Anaphylactoid reactions simulate a true allergic reaction, but are not mediated by immunoglobulins. No antibodies to contrast material have ever been demonstrated. The diagnosis of contrast media-associated nonallergic anaphylaxis is based on clinical history alone. Additionally, the role of a histamine release test and other in vitro basophil activation tests in the diagnosis of allergic reactions to CM has not yet been defined. Skin reactions of the maculopapular exanthematous and urticarial angioedematous types account for the majority of nonimmediate hypersensitivity reactions to CM. There is increasing evidence that a significant proportion of the reactions are T cell-mediated (Christiansen et al. 2000). Skin tests have been widely used to confirm such delayed hypersensitivity. CM have consistently tested positively as an allergen in patch tests and or delayed intradermal tests (IDT) in reactors but not in controls (Brockow et al. 2005a). These tests may be useful in allergy...

The Dutch Food Intolerance Databank ALBA

ALBA is perhaps the most influential of the food intolerance databanks worldwide. It was established in 1982 by the Agricultural University of Wageningen and became operational in 1984. Since 1988, the databank has been hosted by a division of the government research organisation Netherlands Organisation for Applied Scientific Research (TNO), located in Zeist. ALBA currently holds data on around 500 brands and 11 000 products from 150 manufacturers and retail organisations, representing approximately 25-40 of the total Dutch manufactured food market. The 'free-from' booklets represent just one of the services offered by LIVO - the National Information Centre for Food Hypersensitivity, based in The Hague. As well as distributing over 12 000 'free-from' lists to consumers every year, LIVO provides a telephone enquiry service and produces general consumer information on food allergy and intolerance. ALBA distributes a further 2000-3000 special combination 'free-from' lists to consumers...

Crossreactions between foods

Cross-reactivity is due to a reaction to identical or similar protein allergens that occur in more than one food, or in a food and an inhalant pollen. This is different from associated reactivity where two or more food allergens may be seen to be associated epidemiologically. A good example of the latter is the high rate of association between egg and peanut allergy although the allergens are not related. Establishing a cross-reaction requires the demonstration of at least a positive correlation between the magnitude of specific IgE to both foods, and RAST inhibition studies are needed for confirmation. Cross-reactivity is seen at an immunological level when a subject is sensitised to both foods on the basis of positive skinprick or specific IgE testing to both foods. However, often only a smaller proportion will demonstrate clinical cross-reactivity, that is a reaction to both foods on clinical exposure. cross-reactivity between legumes in 49 out of 69 patients (71 ) with atopic...

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...

How common is anaphylaxis

A French study28 supports Bock's findings from Colorado. This multi-centre study investigated the presentation rate of food-induced anaphylactic shock to 46 emergency departments, 29 dermatology units and 19 internal medicine departments. In 794 reported cases of anaphylaxis, food was implicated in 81 cases (10 ). Unusually, only 19 patients (23.4 ) had known food allergy. The presence of the causative allergen in 'hidden form' contributed to 25 cases (31 ) of food-related anaphylaxis. An enhancing factor, such as alcohol consumption or exercise,29 was present in 221 cases (27.8 ). the full calendar year of 1993 and over a three-month period in 1994. They found nine cases of collapse (severe anaphylaxis) and 15 cases of generalised allergic reaction (without hypotension) in 55 000 attendances in 1993. The rate of generalised allergic or severe anaphylaxis (combined total 24 cases) was, therefore, one case in every 2300 casualty attendances, or 6.8 per 100 000 of the local population...

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.

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

Potential Adverse Effects

Because transgenes code for proteins, human health risks associated with these proteins and products produced by these proteins are possible. These potential risks include creation of novel toxicants, possible shifts in the nutritional content of food, and the possible creation of novel allergens. Most of the scientific attention has focused on allergens, because they are difficult to assess and there has been an increase in the incidence of food allergies. Novel proteins and their products can be altered after synthesis by alterations in amino acid sequence and by reactions with other chemicals, such as glycosylation. Assessing each of these possibilities will be challenging.

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...

The Anaphylaxis Campaign

The Anaphylaxis Campaign, of which I am director, was set up early in 1994 following five well-publicised deaths caused by allergic reactions to peanuts or tree nuts. Those who died included my teenage daughter Sarah, whose death was particularly shocking because her previous allergic reactions to nuts had been mild. As a journalist, I had some expertise in gathering information and there were indications early on that, far from being rare, nut allergy was really quite common. Supported by my MP, Cranley Onslow, I set in motion the beginnings of an awareness campaign. However, I was not alone. Following the intense national publicity, several parents of children with nut allergy came forward and we formed the core group of the Anaphylaxis Campaign. As knowledge of the group spread, we found we were overwhelmed with letters from families similarly affected 60-70 per day in the first few weeks. By early 2000, membership stood at around 5500. Members pay 5 a year. The Anaphylaxis...

Additional communication initiatives

The ingredients list on the label of a product is the most accurate way of assessing the suitability of a product for a sufferer of allergies. However, reading labels is a laborious and time-consuming process and makes shopping a lengthy ordeal. Most companies and retailers now produce lists of products free from key allergens which make food selection much quicker and easier. The lists are available from the companies directly and are often on the Internet. Once again peanut and nut allergies are often handled as a special case, as they are the most common food causes of anaphylaxis. 'Free-from' lists are updated every six months to reflect any changes that may have occurred. Users of lists are also advised to check ingredients' lists, particularly where a 'new recipe' or 'new improved' flash indicates a recipe change. In the case of anaphylactic reactions information must always be accurate and up to date. Peanut and nut-free lists are often controlled closely and carry a 'Use by'...

Collaboration with the food industry retail and manufacturing

Were concerned about food-induced anaphylaxis and the risks of allergy sufferers inadvertently coming into contact with lethal ingredients. Soames seemed to be implying that it would be several years before all prepacked food would be adequately labelled and therefore safe. A major point for discussion was the 25 rule governing compound ingredients. Under this European regulation, any ingredient which itself consists of more than one ingredient (e.g. the salami used on a pizza topping or a sponge finger on a trifle) does not have to have its component ingredients listed if it constitutes less than 25 of the finished food. Consequently, small amounts of an ingredient may be undeclared, quite legally. But it soon became clear that major retailers and manufacturers were responding voluntarily to allergy issues, irrespective of the regulations. Weeks after the meeting with Soames, Britain's leading supermarket chains announced that their own-brand products would show nuts on the...

Websites and addresses

American Academy of Allergy, Asthma and Immunology British Allergy Foundation Deepdene House, 30 Bellegrove Road, Welling, Kent DA16 3PY Tel. 020 8303 8525 Fax. 020 8303 8792 Food Allergy Network Ortolani C, Bruinzeel-koomen C, Bengtsson C et al. 'Controversial aspects of adverse reactions to food', Allergy, 1999 54 27-45. Sampson H A, 'Food allergy. Part 2 Diagnosis and management', J Allergy Clin Immunol, 1999 103 981-9.

Sources of further information and advice 691 Consumers

There are a number of self-help groups that offer information and advice to sufferers. In the UK, the British Allergy Foundation and the Anaphylaxis Campaign are among the most important. The British Allergy Foundation provides information, advice and support to allergy sufferers, including a helpline, a regular newsletter and leaflets. The Anaphylaxis Campaign works to raise general awareness of severe food allergies and provides general advice and a video on anaphylaxis, as well as producing a quarterly newsletter. In the United States, the Food Allergy Network provides a wide range of assistance for food allergy sufferers, including general advice, product alert information, plus a video and a bi-monthly newsletter.

Food Labelling Agenda

FLAG (Food Labelling Agenda) is a national consumer pressure organisation launched in June 1997 by a group of concerned food and health writers. The organisation campaigns for 'clear, comprehensive and meaningful labelling on all food and food products' and its first task in March 1998 was to deliver a petition calling for improved food labelling to Downing Street. It won support from a huge number of individuals and organisations, including those with interests in allergy, genetic engineering, infant feeding, heart disease, cancer, vegetarianism, eating disorders and green issues. The accurate labelling of potential allergens is one of FLAG's major concerns. The organisation is steered by Michelle Berriedale-Johnson and Sarah Stacey and their postal address is PO Box 25303, London NW5 1WN. A newsletter is produced for supporters.

Gastrointestinal reactions

Gastrointestinal reactions to foods are very common and not all are associated with positive results on standard tests. A severe feature of food allergy in childhood is called eosinophilic enterocolitis, where the lining of the bowel is filled with cells called eosinophils, which are major factors in local allergic inflammation and reactivity. Patients, usually less than two years old, have severe abdominal pain and bloody diarrhoea, usually made worse by several foods. The treatment of this is the same as for food-related anaphylaxis, i.e. allergen exclusion. In many cases multiple allergens may need to be excluded, and enterocolitis can be a very difficult problem to treat.33 Diarrhoeal reactions to foods are common. Isolated gastrointestinal symptoms are a rare manifestation of allergy20,21 but are a common feature of intolerance reactions. Wheat is a common cause of diarrhoeal reactions and benign wheat intolerance must be distinguished from coeliac disease. In coeliac disease a...

Summary trends in treatment

Despite recent advances in our knowledge of immune processes involved in food allergy and intolerance, there have been few major developments in the treatment of this common condition. Avoidance of the offending food remains the mainstay of treatment. Pharmacological therapy is useful in acute reaction The importance of a detailed history cannot be overstated. The diagnosis can often be made on the history alone. A dietary history helps to identify the consumption of the offending food and aids in suggesting replacement. Patients with a history of acute allergic reaction to foods such as milk, egg, fish or nuts have to be extremely careful in consuming packaged food or when eating out. Packaged foods should be labelled clearly with the highly allergenic foods to reduce avoidable morbidity and mortality. In children with cow's milk intolerance, the development of relatively safer extensively hydrolysed formulae has been a welcome relief. However, the increasingly complicated processing...

Heat treatment and cooking

As a general rule heat decreases the allergenicity of proteins, and heat in the presence of moisture even more so, but this biological activity is rarely removed. Allergenicity of whole wheat flour or purified gluten is only reduced and not eliminated by heating up to 120oC for up to one hour (Varjonen et al. 1996, Sutton et al. 1982). Heating rice glutelin and globulin fractions also reduces IgE binding ability by 40-70 (Shibasaki et al. 1979), but the food remains allergenic. Peanut and nut allergens are resistant to heating and even roasting.

Person Responsible Mixer operator

Background to the HACCP studies and the actions that must be taken. Briefing about allergies should be included in all induction sessions and regular updates will ensure that staff continue to be well informed. It is particularly important that information is given to all those who work in an area that handles nuts and peanuts, and all staff understand the importance of the quality controls.

Key aspects of legislation from a manufacturing view

Food legislation plays an important role in the development of a policy for the handling of allergens in food manufacturing. Manufacturers have a responsibility to provide safe food for consumers, and this includes safety from an allergy sufferer's view. The obvious legislation is that which directly relates to food, such as Food Labelling Regulations. However, in addition other areas of the law need to be considered and these include relevant consumer protection legislation and requirements arising from the European Product Liability and Product Safety Directives. Manufacturers need to consider the extent to which their position and that of their products will be influenced by a number of potential circumstances. A significant number of people have unfortunately died or have been seriously ill as a direct result of an allergic reaction following the ingestion of foods which, unknown to them, contained small amounts of allergens to which they had an anaphylactic reaction. These cases...

Identification of allergens

The main challenge to the food industry is to provide accurate and up-to-date information at all times so that sufferers of allergies can select foods with confidence. Nut oils are an area worthy of comment. Research suggests that refined, bleached, deodorised nut oils do not initiate allergic reactions,2 even in those who are anaphylactic to nuts. Unrefined, cold pressed or virgin nut oils are chosen specifically for their distinctive flavour. These oils are not refined and contain small amounts of protein from the original nut. The same research study showed that unrefined oils were able to cause reactions in individuals who have suffered previous anaphylaxis, but that generally the reactions were not as severe as those experienced when nuts were eaten. The small amount of protein that is present in unrefined oils is removed through the process of refining, bleaching and deodorising, rendering the oils suitable for allergy sufferers.

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

Nontoxic food reactions

These reactions are either immune-mediated or non-immune-mediated. When the reaction is immune-mediated the term 'food allergy' is applied, and when non-immune-mediated the term 'food intolerance' is recommended. Both types of reactions are reproducible and depend on an individual's susceptibility. Food allergy Food allergy itself can be subdivided into two categories, IgE-mediated food allergy and non-IgE-mediated food allergy (Fig. 1.1). Immunoglobulin (Ig) E, or IgE, is the main antibody involved in induction of immediate allergic reactions. Most of the research evidence available on food allergy has been focused on IgE-mediated food allergy. Indeed, most common food allergies are mediated by IgE antibodies. The mechanism underlying IgE-mediated food allergy is fairly well established. Symptoms of this form of food allergy appear rapidly, are varied and range from anaphylaxis to skin reactions.2 Non-IgE-mediated food allergy is less well understood. Such allergies include reactions...

Information for industry

In 1999, the Food and Drink Federation in the UK published Food Allergens Advice Notes. These summarise the current legal position with regard to labelling of allergens and liability issues and provide advice regarding handling allergenic ingredients in the factory and use of defensive labelling. In 1993, the Food and Consumer Products Manufacturers of Canada (FCPMC) in association with Health Canada and the Allergy and Asthma Information Association produced an industry training programme called 'Allergy Beware'. The purpose of the programme, which includes a teaching guide, a video and a factory audit checklist, is to raise awareness about anaphylaxis in the food industry. The Food Allergy Research and Resource Program (FARRP) at the University of Nebraska provides analytical services, information and training to the US food industry on issues related to food allergy. Many of the organisations listed above under 'Publications, CD-ROMs and training materials' have websites on the...

Control of allergens throughout the supply chain 841 Crosscontamination

All aspects of the supply chain must be evaluated for presence or risk of contamination with key allergens. This includes purchasing of raw or semifinished materials, transport of these materials, storage within the production unit, production, packing and distribution. At each stage full HACCP evaluations of all equipment used, processes and risks need to be undertaken and documented to provide information on the suitability of the product for sufferers of different allergies. A full evaluation of a production line may involve many HACCP studies.

Diagnosing adverse food reactions

Different studies vary considerably in their working diagnostic criteria for food allergy. This has an important influence on the resultant measurement of prevalence and incidence in a population. In looking at IgE-mediated allergic problems, there are three levels of diagnostic criteria (1) questionnaire-based histories, (2) specific IgE and or skinprick testing and (3) food challenges (see Chapter 3). If, for example, we compare two population studies defining the prevalence of cows' milk allergy, one using skin testing and the other questionnaire-derived data, a higher prevalence will emerge in the latter study design. Double-blinded, placebo-controlled food challenges represent the gold standard but can not be practically used in large population-based studies where a combination of skinprick testing and questionnaire-based histories is more applicable.

Handling food allergens in retail and manufacturing

Food allergies can be uncomfortable, severe or potentially fatal to those who suffer them, depending on the nature of the reaction. The most common advice to sufferers is to avoid consumption of the trigger food in the diet. On the surface this seems a relatively simple and straightforward means of avoiding reactions. However, the fact that some individuals can react to minute amounts of the trigger food combined with the fact that the most common triggers of food allergies (milk, egg, wheat and nuts) can be widespread throughout a host of different foods means that avoiding allergens can be a time-consuming process. All food manufacturers have an overriding legal responsibility to ensure that their products are safe and fit for the purpose intended. They must also comply with the relevant labelling legislation. The first step is to identify the key allergens. These are the allergens that are the most common causes of food allergies. Following this, a comprehensive evaluation of...

Frequency of individual symptoms

Vomiting and abdominal pain (not shown in the table) were rarely isolated features of a reaction. Abdominal pain correlated more strongly with severe symptoms than did vomiting. Abdominal pain also correlated more strongly with severe symptoms than did more minor symptoms such as rash or itch. Abdominal pain may be an under-appreciated symptom of at least moderately severe allergic reactions to peanut.

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

Likely future developments

Discussions are currently underway regarding the future development of the databank. The difficulties in identifying allergenic ingredients from product labels have not been resolved and there is still likely to be an important future role for the databank, even if the labelling of allergens becomes mandatory in the EC (see Section 6.7.2).

Molecular characteristics of common allergens

The majority of allergens described are protein in nature with or without carbohydrate moieties (glycosylated), with a molecular weight ranging between 10-100 kDa. Most proteins in foods can be immunogenic and provoke production of specific antibody, mainly IgG, in individuals with or without an atopic tendency. Only a limited range of proteins is commonly associated with the production of IgE in the atopic individual, and is considered allergenic. Protein molecules that initiate immune responses are commonly over 7000 daltons in size (Roitt et al. 1998). No common molecular motif for allergens has been described, but they do have some properties in common. Allergens, particularly those that lead to persistent allergies, are thought to be resistant to digestion (Astwood et al. 1996, Becker 1997), the rationale being that this results in persistence in the body and stimulation of the immune system. There are certain fruit allergens, which may be unstable, even being degraded by enzymes...

The catering industry

So far I have concentrated on food sold in supermarkets, but it has to be accepted that the greater risks for people with severe allergies lie in catering establishments, where the owners are under no legal obligation to label allergenic ingredients. Most of the known deaths from food-related allergies have occurred when the food was eaten away from home. Although information on near-fatalities is largely anecdotal, it is almost certain that most of these incidents happen when food is eaten in hotels or restaurants or bought from a takeaway. No example is typical, but the following account of a near-fatal reaction has particular force because two allergy sufferers were affected. A family went into a restaurant and made their choice from the menu. Because the two daughters were allergic to nuts, the waiter was questioned directly about the ingredients of the food they had selected. The waiter looked busy, harassed and a little annoyed, but he disappeared into the kitchen briefly and...

Food safety legislation

A failure to comply with these requirements because of the unnotified, inadvertent presence of an allergen in a product through manufacture or cross-contamination, could give rise to a criminal offence being committed, even though no intention existed. There is, however, a due diligence defence available to manufacturers in the event of proceedings under both the FSA and the GPSR which would require the manufacturer to prove that he had taken all reasonable precautions and exercised all due diligence to prevent inclusion of an allergenic material. Manufacturers can reduce the risk of prosecution and contribute substantially to the establishment of a due diligence defence by implementing Good Manufacturing Practice and documenting all procedures taken as evidence of GMP processes, training and results, as detailed earlier.

Immunological markers

The role of cord blood total IgE as a marker for the development of food allergy is not clear. Studies do not consistently show a positive association (Dean 1997, Kjellmann et al. 1988, Kulig et al. 1999). Furthermore, in the recent German multicentre allergy study where an association between cord blood total IgE and sensitisation to foods at one year of age was found, the authors comment on the poor predictive performance of cord blood IgE (Kulig et al. 1999). This study puzzlingly also showed that an elevated cord blood total IgE was a significant protective factor for early-onset atopic eczema (Edenharter et al. 1998). Thus, cord blood total IgE is an unhelpful marker in predicting the development of food allergy and in planning appropriate prevention strategies. Prenatal sensitisation with antigen-specific IgE has been reported but seems to be uncommon, and limited to cows' milk (Businco et al. 1983, Host et al. 1992). It is therefore unlikely to play a role in the vast majority...

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.

Confirmation of presence of allergens

Once all the above steps have taken place, food manufacturers are able to make a judgement based on all the evidence obtained as to whether a product contains or is free from a particular allergen. Information should be provided to allergy sufferers to enable them to select suitable foods for their diet. The provision of information to consumers on packaged food and food sold loose is discussed later in the chapter. In addition, a number of tests are available that can be used to analyse products for the presence of a given allergen. Generally a radio-immunoassay technique is used which checks samples of a product for specific proteins that have been previously identified as allergens. These tests can be useful, but in some instances results do need to be interpreted with care. Any analysis is only as accurate as the samples that are taken. The sampling of liquid or fluid foods gives a relatively reliable sample, as the food can be further blended to give an even distribution of all...

Comparison of allergen contents of different foods or food sources

ELISA with a standard curve provides information on quantities of specific allergens. Sometimes it is necessary to compare one extract with another to determine if the allergens present are the same (homologous) or different (heterologous). This is useful for determining if a particular treatment reduces or increases the allergenicity of a particular food source, for example whether hydrolysis has removed cow's milk allergens from infant formula. It is particularly useful for determining if a food causing an allergic reaction was contaminated or contains cross-reacting proteins with another known allergen, e.g. a food containing hazelnuts that caused a reaction in an individual with peanut allergy. Figure 7.3 shows a schematic representation of an ELISA inhibition to determine the similarity of two allergenic food sources. This assay may also be adapted to provide quantitative data where the percentage inhibition obtained with dilutions of a homologous antigen to the one bound to the...

Canteen and restaurant facilities

Welcome to our factory.This site uses peanuts and hazelnuts in some products. Peanut or hazelnut dust is present in the air within certain areas of the factory. If you suffer allergic reactions to either peanuts or hazelnuts we recommend that you do not enter these areas of the factory at all. Please speak to your contact at this site for information regarding areas where peanuts and hazelnuts are used. If you are in any doubt at all regarding your susceptibility to peanuts or hazelnuts we advise you to avoid these areas. restaurant facilities as well as snack and coffee bars in factories and retail environments. All the controls outlined here for food manufacture apply equally well to food provision in a catering environment. Allergens should only be present in products where a sufferer would expect to find them, and information should be available for allergy sufferers to consult to assess whether a certain dish is suitable for their specific diet. If in doubt the allergy sufferer...

Sources of further information and advice

The Ministry of Agriculture, Fisheries and Food has produced information packs for the catering industries on how to anticipate the problems that might arise from allergic individuals in their restaurants. The Anaphylaxis Campaign, the British Allergy Foundation and their American counterpart, the Food Allergy Network, are excellent sources of rationally prepared and non-hysterical advice for individuals affected by food allergy and intolerance. The American Academy of Allergy, Asthma and Immunology has a website that has free patient information available, links to other sites and access to American physicians who may treat individuals. The Anaphylaxis Campaign has recently gone online. The British Allergy Foundation website is rather rudimentary at present.

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.

Significance Of Fleas

Flea allergy dermatitis (FAD) is a severe condition found primarily in dogs, but also occasionally seen in cats. In a flea-allergic animal, flea salivary antigens initiate a cascade of symptoms, resulting in intense pruritus accompanied by scratching, biting, and self-inflicted trauma. An affected animal typically displays obsessive grooming behavior, with accompanying depilation, leaving the skin with weeping sores, often resulting in secondary infection. FAD is treated with corticosteroids, which possess undesirable side effects, especially when continuous use is required as in chronic FAD cases. Until development of FAD immunotherapy, successful treatment involves flea elimination from the animal's environment and flea bite prevention.

Types of foods available

Allergic reactions require large protein molecules (antigens) to stimulate the production of antibodies. To reduce allergenicity, the source protein can be broken down into small peptide molecules and amino acids by enzyme hydrolysis. This process has been used successfully in the production of hydrolysed formulae (HF). These infant formulae are based on animal or vegetable protein (casein, whey, soy and bovine collagen) and are used extensively in children with cow's milk allergy or intolerance. In gluten-induced enteropathy a specific protein (gluten) is responsible for stimulating the immune reaction. Foods have been prepared without gluten, that are suitable for these individuals. When a protein is denatured by heat, most of the original tertiary structure is lost, so that many of the sites recognised by antibodies on the native molecule are destroyed. There are many examples of allergenicity being reduced, but not eliminated, by heating. Thermal processing can be part of a...

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

Treatment of mild or localised reactions

A mild form of urticarial rash and itching may be the only manifestation if the sensitivity to food is low or only a small amount has been ingested. Oral symptoms, of swelling and numbness of the lips and localised itching, are common symptoms of allergy to fresh or raw fruits in some patients who are highly sensitive to pollen (oral allergy syndrome). Treatment with oral antihistamine may be sufficient for these episodes. Patients should keep a supply of non-sedating antihistamine such as cetirizine (10 mg) or loratidine (10 mg) tablets. For children, antihistamine syrup (cetirizine or chlorpheniramine) should be prescribed. If the episode does not respond to oral antihistamine or if there are signs of progression, medical help should be sought.

Idiopathic Scrotal Edema

Acute idiopathic scrotal edema (AISE) is a fairly common, yet underreported cause of the acute scrotum in children, accounting for as many as 30 of patients who undergo assessment (Najmaldin and Burge 1987). It is characterized by the rapid onset of nontender, frequently unilateral scrotal and penile erythema and edema. The patient is usually afebrile and is otherwise asymptomatic, apart from the distressing appearance of the genitalia. It is usually found in prepubertal children from 5 to 11 years of age. As the name implies, the cause of AISE is unknown however, some children present with a history of asthma or allergic conditions such as eczema or dermatitis (Klin et al. 2002). Laboratory investigations are usually normal, with occasional

Learning from the Mistakes of the Past in the Development of Natural Products

Indeed as a direct result of this additional research, Taxol was recommended as a candidate for preclinical development in 1977. Further work demonstrated strong activity against human tumor xenograft systems and stimulated hope of efficacious performance in the clinic. Taxol's mechanism of action was elucidated in 1979, formulation work completed, and toxicology studies started in 1980 32, 100 . With the completion of nonclinical studies, approval was given for entry into phase I clinical trials in 1983 28, 141 . The early clinical trials raised serious issues of toxicity. Indeed, further development of Taxol was almost discontinued. The problems, however, were determined to be related to the poor solubility of Taxol in aqueous systems and the necessity for a high dose, when compared to other antineoplastic agents of the time. The development of a suitable formulation required the use of Cremophor EL, a polyethoxylated castor oil derivative, which created a whole new...

Future Of Natural Products

The search for and the development of natural products will result in the creation of a variety of different types of alliances between industry, government, individuals, universities, and hopefully even foster a spirit of international cooperation 25, 26, 32, 86 . Over the last few years, those involved in the pharmaceutical industry have already seen the increasing numbers of partnerships, alliances, agreements, and other types of relationships forged between large pharmaceutical companies and smaller biotechnology companies, all for the purpose of seizing opportunities of new technology. The collaborations that currently exist in the field of chemotherapy can set an example for other therapeutic areas as well as drug treatment in general. Another pertinent example has been the formation of the International Cooperative Biodiversity Group (ICBG) Program 32 . The ICBG is a collection of academic, industrial, U.S. governmental organizations, and developing countries. This program is...

Prevention and Control of Influenza

The available vaccines include purified inactivated egg-grown whole virus or purified surface antigens. Only surface antigens (subvirion vaccines) are recommended for children under 12 years, because the whole-virus vaccine causes febrile responses in children. Persons with known allergies to eggs should not be given egg-grown vaccine. Cold-adapted attenuated live influenza vaccines have been shown to be safe and effective in experimental trials and are currently under review for licensing for general use.

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.

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