Allergy Ebook

How To Win Your War Against Allergies

How To Win Your War Against Allergies

Not Able To Lead A Happy Life Because Of Excessive Allergies? Want To Badly Get Rid Of Your Allergy Problems, But Are Super Confused And Not Sure Where To Even Start? Don't Worry, Help Is Just Around The Corner Revealed The All-In-One Power Packed Manual Containing Ample Strategies And Little-Known Tips To Get Rid Of Any Allergy Problems That Are Ruining Your Life Learn How You Can Eliminate Allergies Completely Reclaim Your Life Once Again

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Allergy Relief

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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...

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...

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...

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

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

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...

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 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...

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...

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...

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...

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.

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.

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.

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...

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...

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...

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....

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...

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.

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

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....

NOC Health Promoting Behavior

Assess for knowledge of factors related to attacks, past history of respiratory infections, and measures taken to maintain health of child. Assess health history of allergies in family members, what does or does not precipitate attack, and what behaviors result from the attack. Teach parents and child handwashing technique allow for demonstration.

Magnification Endoscopy

Chromoendoscopy is the term describing the use of special dyes during endoscopy to highlight histological changes within the gastrointestinal mucosa. A specific dye is applied to the mucosa, typically with the use of a spray catheter passed through the accessory channel of an endoscope. After the application of the dye, careful endoscopic inspection is performed looking for areas that either fails to stain or stain differently than their surroundings. The dye used is chosen based on the particular pathology sought and the choice reflects the different cell types and cell components stained by each dye. In the case of squamous cell dysplasia, iodine is used as the stain based on a chemical reaction between iodine and glyco-gen (52). The glycogen rich prickle-cell layer of the stratified squamous esophageal epithelium stains greenish brown after the application of a potassium iodide solution or Lugol's iodine. Dysplastic epithelium lacks the glycogen-rich granules in the prickle-cell...

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.

Discharge And Home Healthcare Guidelines

Allergic purpura is an allergic reaction that leads to acute or chronic inflammation of the vessels of the skin, joints, gastrointestinal (GI) tract, and genitourinary (GU) tract. It occurs as an acquired, abnormal immune response to a variety of agents that normally do not cause allergy, and it is manifested by bleeding into the tissues, organs, and joints, which leads to organ dysfunction, discomfort, and immobility. An acute attack of allergic purpura can last for several weeks, but usually episodes of the disease subside without treatment within 1 to 6 weeks. Patients with chronic allergic purpura can have a persistent and debilitating disease. The most severe complications are acute glomerulonephritis and renal failure. Hypertension often complicates the course, and if bleeding is excessive, the patient can develop a fluid volume deficit. On rare occasions, patients may be at risk for airway compromise from laryngeal edema. Allergic purpura occurs in response to agents such as...

Primary Nursing Diagnosis

The treatment prescribed is based on the acuity and severity of the symptoms. Some patients are treated pharmacologically with corticosteroids to relieve edema and analgesics to manage joint and GI discomfort. Allergy testing to identify the provocative allergen is usually performed. If the allergen is a food or medication, the patient needs to avoid ingesting the allergen for the rest of his or her life. Patients who are placed on corticosteroids or immunosuppressive therapy need an environment that protects them as much as possible from secondary infection. If the patient is on corticosteroids, monitor her or him for signs of Cushing's syndrome and the complications of corticosteroids, such as labile emotions, fluid retention, hyperglycemia, and osteoporosis.

Deep Vein Thrombosis and Pulmonary Embolism 321

Longed ischemic deficits, anticoagulatory therapy, unexpected or allergic reactions to anticoagulants, immobilization before surgery, influenza-like diseases, and other conditions that initiate an acute phase reaction. Additionally, the medical history of relatives is important in order to detect a thrombophilic disposition venous thromboembolism, arterial occlusion, cerebral ischemia, transitional neurologic deficits, and relatives with continuous anticoagulatory medication.

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...

Genetic Considerations

While susceptibility to anaphylaxis is increased among those who have inherited sensitivity to antigens, the genetic component has not been well defined. Over 20 genes have been associated with the development of allergy and mutations and of these, many passed on in families. Family studies indicate that if both parents suffer from allergies, the allergy risk in their offspring is 80 . Implicated genes include the IL-4, IL-4 receptor, cytokine, INF7, p-adrenergic receptor, 5 lipoxygenase, PHF1, TARC, and leukotriene C4 synthetase genes.

Gender Ethnicracial And Life Span Considerations

Anaphylactic shock can occur at any age and in both men and women, but women seem a little more susceptible than men. Individuals with food allergies (particularly shellfish, peanuts, and tree nuts) and asthma may be at increased risk for having a life-threatening anaphylactic reaction. People at the ends of the lifespan are most at risk. To prevent infants and children from experiencing severe allergic reactions, pediatricians carefully plan vaccines and diet to limit the risk of allergic reaction until a child's immune system is more mature. Severe food allergy is more common in children than in adults, but diagnostic contrast, insect stings, and anesthetics are more common in adults than in children. Teenagers with food allergies and asthma may be at high risk for an allergic reaction because they are more likely to eat outside the home and less likely to carry their medications. Older people also have a great risk of anaphylaxis, and their risk of death is high owing to the...

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...

Nonimmunological mechanisms

The best example is scombroid poisoning, due to an excessive amount of histamine in some species of fish such as tuna and mackerel.22 Because histamine is a mediator released from mast cells in food allergy, sometimes pharmacological food intolerance due to histamine is confused with allergic-type reactions. In scombroid poisoning, when fish is inadequately refrigerated, marine bacteria convert the amino acid histidine to histamine. This will generate a histamine concentration greater than the body's normal capacity to metabolise and hence the individual will suffer from the full spectrum of histamine effects, including flushes, vomiting and diarrhoea.

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

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.

Diagnostic Tests and Risk Factors

Muscle relaxants and natural rubber latex are very significant and potent allergens in the perioperative period. In patients with a suspicious history, a search for specific IgE antibodies can be done prior to the operation to minimize the risk of a potential anaphylactic reaction (see Sects. 4.8 and 4.9). If a latex allergy is suspected, a skin prick test is recommended (see Sect. 4.9). All patients with an anaphylactic reaction should undergo an consultation with an allergy and immunology specialist, and the results documented in an allergy Generally, all patients with a history of asthma or atopy (including hay fever and food allergies) have an increased risk of anaphylactic anaphylactoid reactions in the perioperative interval. Risk factors have been clearly demonstrated for two major allergens commonly found in hospital 1. Although reactions to iodinated radiographic CM are not true allergic ones, patients with a history of a previous reaction to contrast material have a three-to...

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

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.

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...

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.

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...

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...

Adverse Reactions and Warnings

The most serious adverse event reported subsequent to Activase administration is bleeding. If serious intracranial, gastrointestinal, retroperitoneal, or pericardial bleeding occurs, treatment must be immediately discontinued. Allergic reactions, including anaphylactoid reactions, laryngeal edema, and urticaria have also been reported. The product should be used with extreme caution in pregnant women, for whom there are no well-controlled studies. Activase has an embryocidal effect in rabbits when administered in doses of twice the level used to treat AMI in humans. Caution should also be exercised with nursing mothers as it is not known if Activase is excreted into human milk. Negative results were recorded when the product was subjected to a mutagenicity test (the Ames test), chromosomal aberration assays in human lymphocytes, and short-term tumorigenicity studies. Long-term studies in animals to evaluate carcinogenic potential or effect on fertility have not been undertaken.

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

Occupation and smoking

These diseases are not all Type I, IgE-mediated reactions. Some cases of occupational asthma and some of contact dermatitis occur as a result of irritation.12 Hypersensitivity pneumonitis occurs as a result of a Type III or possibly a Type IV hypersensitivity reaction.13 As with non-industrial food allergy or intolerance, the pathophysiological mechanism affects the choice of diagnostic tests.

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.

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

Cells Regulates Inhalation Tolerance

Recent studies provide evidence that distinct properties of two phenotypic and functional distinct pulmonary DC subsets, i.e., myeloid DC (mDC) (CD11c+, CD11b+, Gr1-) and plasmacytoid DC (pDC) (CD11c+, CD 11b-, Gr1+) are crucial to the development of adaptive immune responses in the lung116. In a murine model of experimental allergic asthma, adoptive transfer of mDCs confers immunogenicity117, whereas adoptive transfer of pDCs results in inhalation tolerance118. In agreement with these data, we recently found that only mDCs but not pDCs stimulate sensitized CD4+ lymphocytes to produce high amounts of IL-5, IL-13, and IL-10 ex vivo. In addition, our data demonstrate that pulmonary pDCs have the ability to actively suppress the mDC-induced activation of sensitized CD4+ lymphocytes ex vivo115. In support of the view that pDCs play a critical role in inhalation tolerance, Oriss et al. reported increased accumulation of pDCs in lymph nodes of tolerized mice, whereas under conditions that...

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.

Cockroaches And Human Health

Cockroaches are also important because people can become allergic to them, especially under conditions of constant exposure. These reactions usually involve the skin and or respiratory system. Studies have shown that people who exhibit skin or bronchial responses to cockroaches have elevated levels of cockroach-specific antibodies. These responses can be severe and may require treatment. The species most commonly involved in producing allergic reactions are the German and American cockroaches.

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...

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.

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...

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...

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.

Human Sensitization and Irritation Tests

The fact that sodium hypochlorite is not a sensitizer is a significant advantage that sodium hypochlorite solutions have over some other topical antiseptics. To clarify sensitization potential, Hazelton Laboratories examined 1.1 sodium hypochlorite solution using a standard test for predicting sensitization or allergic reactions, the Guinea Pig Maximization Test 46 . This test consisted of dermal and intradermal application of various concentrations of test solutions of sodium hypochlorite as an induction dose, followed 2 weeks later by a challenge dose of sodium hypochlorite solution. No reaction to the challenge dose was observed with sodium hypochlorite. The author concluded

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).

Characteristics of patients with food intolerance

Subjects reported reactions to the common allergenic foods - legumes, tree nuts, crustaceans and fish. Twenty-one out of the 22 subjects in this group had positive skin prick tests to the offending food. The second group reported reactions to food such as sugar, wheat, egg, cured meat and yeasts. Only four out of the 23 subjects in group 2 had a positive skin prick test in this group (evidence of IgE) that supported their reported reactions (chi-squared 24.68, p value < 0.0001). The second group's symptoms started at an older age - 28.9 years versus 17.1 years (p 0.0015) - and were related to a much broader range of foods - 25.6 versus an average of 5.5 (p 0.0002). In this key study Parker et al. showed that the group of adults with allergic-type symptoms were significantly more likely to suffer swelling and respiratory symptoms than the group with non-allergic complaints and negative skin prick tests. The group with non-allergy-mediated complaints reported significantly more...

Epidemiology in Food and Nutritional Toxicology

Some examples of human epidemiological studies used in food and nutritional toxicology include linking aflatoxin B1 with liver cancer, food colors with allergic reactions, and prevention of lung cancer by carotenoids. Although links or correlations can be obtained by using epidemiological tools, the major disadvantage of epidemiological studies is the variety of things humans are exposed to, making it difficult to isolated effects of a specific substance on a population. Also, variability in population will affect the outcomes of epidemiological studies. Although epide-miological studies have limitations, they often can be used to corroborate the results of animal-based experiments.

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.

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

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...

Chloro13Dinitrobenzene 6Chloro13Dinitrobenzene

This substance is one of the strongest primary skin irritant known, and a universal contact allergen. Occupational dermatitis has been reported, but current use is decreasing or performed with completely closed systems. DNCB is sometimes used for topical treatment of alopecia areata, severe warts, and cutaneous metastasis of malignant melanoma.

Dipentamethylenethiuram Disulfide

Conde-Salazar L, Del-Rio E, Guimaraens D, Gonzalez Domingo A (1993) Type IV allergy to rubber additives a 10-year study of 686 cases. J Am Acad Dermatol 29 176-180 Conde-Salazar L, Guimaraens D, Villegas C, Romero A, Gonzalez MA (1995) Occupational allergic contact dermatitis in construction workers. Contact Dermatitis 35 226-230 Kiec-Swierczynska M (1995) Occupational sensitivity to rubber. Contact Dermatitis 32 171-172 Von Hintzenstern J, Heese A, Koch HU, Peters KP, Hornstein OP (1991) Frequency, spectrum and occupational relevance of type IV allergies to rubber chemicals. Contact Dermatitis 24 244-252

Clinical Characteristics

Although optimal therapy of listeriosis has not been verified by randomized clinical studies, penicillin or ampicillin alone, or in combination with gentamicin, are considered the drugs of choice. However, L. monocytogenes strains exhibit tolerance to penicillin and ampicillin (39). Although on an average the minimal inhibitory concentration (MIC) of penicillin is usually less than 1 ig mL, the minimal bactericidal concentration commonly exceeds 10 or more times that amount (39,40). The combination of penicillin with gentamicin shows synergistic activity in vitro and for these reasons has been considered the first-choice therapy of listeriosis in humans (39). However, in vivo synergism has not been uniformly observed and retrospective clinical studies have not consistently shown better results for the combined therapy of listeriosis than simple penicillin monotherapy (17,34,39,41,42). For patients with P-lactam allergy, trimethoprim-sulfamethoxazole or erythromycin may be considered....

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...

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.

Websites and addresses

American Academy of Allergy, Asthma and Immunology www.aaaai.org British Allergy Foundation Deepdene House, 30 Bellegrove Road, Welling, Kent DA16 3PY Tel. 020 8303 8525 Fax. 020 8303 8792 www.allergyfoundation.com Food Allergy Network www.foodallergy.org 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.

Avoidance and elimination diets

An assessment should be made of the severity of the reaction, which gives an indication of the strictness of the recommended avoidance regimen. If the symptoms are severe and life threatening, complete elimination of the food is mandatory. Less severe symptoms may allow some degree of flexibility. A detailed explanation is essential for successful avoidance. Egg, milk, soy and nuts may be hidden in other foods and reading the ingredient list is essential. Alternative food should be suggested and it is essential to make sure that the avoidance diet is nutritionally adequate. A complete dietary history is of utmost importance and may uncover important sources of allergenic foods such as milk. It would also allow the caring physician dietitian to suggest alternative foods with equivalent nutritional value. For example, soya milk or hypoallergenic formulae can be given for cow's milk intolerance during infancy. The services of a qualified dietitian are extremely useful.

Avoidance therapy 521 General principles

The diagnosis of food-related symptoms should not be taken lightly, as food avoidance can be difficult, expensive, disruptive and even harmful to the health of the patient, especially in infants and young children1 (Table 5.1). The increasing complexity of our food intake and a higher proportion of packaged cooked foods in our diet make the avoidance of a particular food difficult (Table 5.2). The food industry has become increasingly important in the lives of patients with food allergy and intolerance.2 Those involved in the processing and packaging of foods should be aware of the basic principals of food intolerance and how changes in the food processing packaging might affect the lives of millions of people with food intolerance3 (Table 5.3). Table 5.2 Foods that commonly cause allergy or intolerance should be clearly labelled when these are used in a packaged food by the food industry (Report of the FAO Technical Consultation on Food Allergies. Rome, Italy, 13-14 November 1995,...

Approach to food avoidance

Once the diagnosis of food allergy or intolerance has been made, avoidance of the offending food (or foods) is the most important treatment.5 The diagnosis of food intolerance is not always easy, as patients often tend to blame foods for If the history is highly suggestive of food allergy or intolerance, for example where an acute reaction has occurred immediately after ingesting a food, further confirmation may not be required. The suspected food should be excluded from the diet. If the subject is highly allergic, small amounts can produce severe, and even fatal, allergic reactions.3 A dietitian is best placed to give explanation and suggest alternatives. Prophylactic pharmacotherapy, if needed, should also be prescribed. Highly atopic children and occasionally adults may be allergic to several foods such as cow's milk, egg and nuts. It is important that the diagnosis is made accurately and careful consideration is given to providing information about alternative foods with adequate...

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.

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...

Animal Toxins and Plant Toxicants

Overall, healthy individuals can tolerate naturally occurring toxicants. However, there are several conditions under which natural toxicants can create problems. Inborn errors of metabolism or certain drug interactions can make individuals prone to problems caused by natural toxicants. Whereas nutrients can be beneficial to most, they can be deleterious to some, e.g., consumption of lactose by lactose-intolerant people. Other examples include individuals with celiac sprue, sucrase deficiency, fructose intolerance, galactosemia, and phenylketonuria. Individuals taking drugs that inhibit monoamine oxidase enzymes can be affected when eating cheeses or drinking wines, which are high in tyramine. Individuals with sensitivities due to allergies can be affected by foods. Hypersensitivity to a particular substance produces anaphylactic shock. Examples of foods that cause allergies include milk, wheat, nuts, citrus, strawberries, fish (shellfish), and egg. Some individuals have bizarre food...

Other symptomatic treatment

Ketotifen with antihistaminic and anti-inflammatory properties has been used in food allergic reactions such as urticaria and bronchospasm. It may be useful as an additional therapy in some patients. Beta-2 agonists such as salbutamol or terbutalin may be used when bronchospasm is a prominent feature in an allergic reaction. These drugs can be delivered by inhalation through a metered dose inhaler, in an aerosol form through a nebuliser, or by intravenous route. Food-related eczema and rhinitis should be treated along the standard line with topical steroids and antihistamine in addition to allergen avoidance.

Specific immunotherapy

The exact mechanism is unknown but presumably depends on the development of specific IgG antibodies which bind to the IgE receptor on mast cells and basophils, thus making it unavailable for IgE. This mode of treatment has been used successfully for the treatment of pollen and insect allergy but its usefulness in other allergic diseases has been controversial. Several studies evaluating the effectiveness of specific immunotherapy in food allergic diseases such as peanut and fish allergy produced conflicting results. The majority of the studies did not find evidence of protection in peanut allergic patients, and severe reactions during the treatment were common. However, some studies have supported the use of immunotherapy in the treatment of fish and egg allergy. The overall consensus is that specific immunotherapy has no place in the treatment of food allergy.

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.

Conditions That May Simulate Atopic Dermatitis

Delayed contact dermatitis enters into the differential diagnosis of atopic dermatitis, and the two may coexist. An airborne contact allergy can simulate photosensitive atopic dermatitis. Shoe material allergy can simulate atopic dermatitis localized to that site. Both allergic and irritant contact reactions can simulate adult atopic hand dermatitis. Differentiation requires a high index of suspicion, careful history taking, and delayed patch testing when appropriate.

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...

Implantation Technique Perioperative Care

Once the perianal tunnel has been made, preparation of the ABS device can begin on a sterile table intended for this purpose. Tissue, blood, and any potentially aggressive surgical material are excluded from this area in order to avoid possible alteration of the device. All three components of the system are carefully bled of any air bubbles, which might prevent cycling of the pressurization fluid. This rather delicate preparation should be entrusted to a nurse trained in the technique. The pressurization fluid is an isotonic solution, as the artificial sphincter walls are semipermeable membranes and radiopaque (except in the case of iodine allergy), to allow postoperative control of fluid movements in the system. The fluid is prepared extemporaneously and composed of Telebrix 12 sodium (53 ) and sterile water (47 ) in our practice. Other possible solutions are described by AMS.

In Vivo Assays of Langerhans Cell Migration

With respect to the regulation of LC migration in humans, there is only limited information available to suggest that similar stimuli are responsible. Preliminary results suggest that sensitization, via the skin, to diphenylcyclopropenone (a chemical contact allergen) is associated with a reduction in epidermal CDia+ LC frequency measured i7 h following exposure (Fig. 1 45). In addition, a significant increase in the flow and cellular content of lymph following exposure of human volunteers to sodium lauryl sulfate has been demonstrated (46). Direct evidence 2. At various periods following treatment, ears and or draining auricular lymph nodes are removed for analysis. Changes induced in epidermal LC frequency and lymph node DC number following topical exposure of mice to the contact allergen oxazolone are shown in Fig. 2 (see Note 7).

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).

Heterologous Enzyme Production

Regular enzyme application in the dough system is carried out by exogenous addition of commercial preparations. Although substantial amounts of these compounds are obtained from recombinant organisms, mainly fungi and bacteria, all of them contain a cocktail of minor enzymatic activities that may negatively affect bread quality. Moreover, these products may act as allergens, producing a high prevalence of occupational hypersensitivity, in terms of dermal and bronchial (asthma) allergies (164-166). Alternatively, recombinant baker's yeast strains producing a technological enzyme can be employed to obtain the same benefits, avoiding airborne allergen pollution at the workplace (167).

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...

Glyceryl Trinitrate Glycerol Trinitrate

Nitroglycerin is an explosive agent contained in dynamite, and an antianginal and vasodilator treatment available in systemic and topical forms. It is a well known irritant agent in dynamite manufacture. It can also cause allergic reactions in employees of explosives manufacturers, and in the pharmaceutical industry. Transdermal systems are the main source of iatrogenic sensitization. Nitroglycerin can cross-react with isosorbide dinitrate. Aquilina S, Felice H, Boffa MJ (2002) Allergic reactions to glyceryl trinitrate and isosorbide dinitrate demonstrating cross-sensitivity. Clin Exp Dermatol 27 700-702 Kanerva L, Laine R, Jolanki R, Tarvainen K, Estlander T, Helander I (1991) Occupational allergic contact dermatitis caused by nitroglycerin. Contact Dermatitis 24 356-362 Machet L, Martin L, Toledano C, Jan V, Lorette G,Vaillant L (1999) Allergic contact dermatitis from nitroglycerin contained in 2 transdermal systems. Dermatology 198 106-107

Venous thromboembolism

The maternal complications of anticoagulant therapy include haemorrhage, osteoporosis, thrombocytopaenia and allergy. With UFH, the rate of major bleeding in pregnant patients is 2 which is similar to heparin and warfarin when used for the treatment of DVT in the nonpregnant. One of the potential advantages of LMWH over UFH is an enhanced anti-Xa (antithrombotic) anti-IIa (anticoagulant) ratio, resulting in a theoretically reduced bleeding risk. UFH causes a dose-dependent loss of cancellous bone and, if administered for more than one month, symptomatic vertebral fractures occur in 2-3 , with significant density reduction evident in > 30 with long-term therapy. LMWHs carry a much lower risk of symptomatic osteoporosis than UFH 56 . Around 3 of non-pregnant patients receiving UFH develop an idiosyncratic immune, IgG-mediated heparin-induced thrombocytopaenia (HIT), which is frequently complicated by extension of pre-existing VTE or new arterial thrombosis. The HIT risk is...

Classes of Carbohydrates

As in the case of other macronutrients, food safety problems are not generally associated with excessive intakes of natural sources of protein, the exceptions being those occurring because of allergic reactions or hypersensitivity. The wide availability of protein in the U.S. has led to higher consumption, well in excess of daily recommendations. Fad diets and misinformation about benefits of high-protein diets have further led to increased protein consumption. Regardless of the overt symptoms of protein toxicity, nutrition experts express caution. Animal studies have shown that excessive ingestion of protein can lead to liver and kidney hypertrophy. Studies on humans have shown that the ingestion of high-protein diets increases calcium excretion.

Future labelling trends

Importance, in order to allow them to make informed decisions, and is becoming increasingly recognised as essential where a public health risk is concerned. It has not, therefore, been surprising that the labelling of potentially allergenic compounds in foods has become a key issue, particularly as product liability laws will also need to be considered in the event of a consumer having a reaction from an unlabelled product. Although a number of countries have their own provisions in place or at the proposal stage, there is considerable interest in the Codex and EC proposals in this respect. Owing to the reference role of Codex standards in World Trade Organisation agreements and possible trade disputes, many countries will undoubtedly focus on Codex provisions once agreed. Adoption of an amending Directive at EC level will have direct implications for each of the EU Member States and for those wishing to become part of the expanded Union in the future. Two issues are apparent and of...

Choosing the method of abortion

The anti-progestogen mifepristone is used in combination with prostaglandin doses to achieve medical abortion. There are few contraindications to medical termination and they include suspected ectopic pregnancy, chronic adrenal failure, long-term steroid use, haemorrhagic disorders, treatment with anticoagulants, known allergy to mifepristone or misoprostol, smokers over 35 with ECG abnormalities and breastfeeding women. Medical abortions require to be performed in hospitals or premises registered for abortion. The patient attends briefly to take the mifepristone dose and attends subsequently for day-patient admission, usually 36 to 48 h later. It is customary for legal reasons to supervise the swallowing of the mifepristone tablets, but side effects are trivial and the women can leave after 10 min. Women may bleed slightly in the 48 h following the mifepristone dose and, particularly at early gestations, a very small number may miscarry. The route of prostaglandin administration and...

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.

Treatment of Hemophilia B

Medicinal treatments for hemophilia B began in 1954 with the isolation of antihemophilic factors of bovine and porcine origin, although severe allergic reactions were common with these treatments 37 . The subsequent development of cold-insoluble cryoprecipitate and PCC in 1965 dramatically changed the treatment of hemophiliacs. The most significant advance came in the 1970s with the development of lyophilized concentrates of FVIII (for hemophilia A) and FIX (for hemophilia B), which have transformed the life of many hemophiliacs 4,6 .

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...