The subject of food poisoning

THE subject of food poisoning was once largely a series of disconnected observations and records of outbreaks ; but during the last three decades the facts have been associated and the discrepancies and fallacies removed. For example, the old expression ‘ptomaine poisoning' has been shown to be without meaning and entirely incorrect. Now it is possible to give a clear account of food poisoning, including the various causal agencies, the paths of infection and the reservoirs of the various bacteria responsible. In the first edition in 1943, the author of the book under notice gave a clearly written account of the subject, and the second edition has brought it up to date. The first edition dealt very inadequately with staphylococcus food poisoning ; but this has now been remedied by the addition of a new, separate chapter of 22 pages on this subject which gives all the essential facts. An additional section (appendix I) on laboratory investigation of food poisoning cases is of doubtful utility, as this very technical subject is mainly of interest to the laboratory worker, and for him the account is barely adequate and is available elsewhere.

AbstractFood poisoning is encountered throughout the world. Many of the toxins responsible for specific food poisoning syndromes are no longer limited to isolated geographic locations. With increased travel and the ease of transporting food products, it is likely that a patient may present to any emergency department with the clinical effects of food poisoning. Recognizing specific food poisoning syndromes allows emergency health care providers not only to initiate appropriate treatment rapidly but also to notify health departments early and thereby prevent further poisoning cases. This article reviews several potential food-borne poisons and describes each agent's mechanism of toxicity, expected clinical presentation, and currently accepted treatment.

Abstract

Although food allergy can have serious health consequences, little is currently known about people’s perceptions of food allergy. The present study examined the differences in awareness and perceptions of food allergy and anxiety between young people with and without a food allergy. Participants completed a questionnaire which asked about their perceptions and knowledge of allergies, perceived health competence and anxiety. Of the 162 participants 24 reported they were allergic to at least one food; these people perceived that their allergy had significantly less of an impact on their lives than others believed it would. Allergy status interacted with perceived health competence to affect anxiety. People with an allergy and with high health competence reported the greatest anxiety levels. Very few of the sample knew the meaning of the term ‘anaphylaxis’. Findings are discussed in terms of health education implications and possibilities.

Educators

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Journal of Asthma & Allergy

http://jaa.sagepub.com/content/3/4/172

The online version of this article can be found at:

DOI: 10.1177/2150129711431888

Journal of Asthma & Allergy Educators 2012 3: 172 originally published online 28 December 2011

Stephanie E. Hullmann, Elizabeth S. Molzon, Angelica R. Eddington and Larry L. Mullins

Dating Anxiety in Adolescents and Young Adults With Food Allergies: A Comparison to Healthy Peers

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OnlineFirst Version of Record - Dec 28, 2011

>> Version of Record - Jul 23, 2012

Downloaded from jaa.sagepub.com by guest on August 25, 2013172

Journal of asthma & allergy educators August 2012

Research Article

Abstract: The present study sought to examine dating

anxiety and problems in social relationships and healthrelated quality of life in adolescents and young adults

with food allergies compared with their healthy peers.

It was hypothesized that individuals with food allergies

would experience greater dating anxiety and poorer social

functioning and physical and mental health–related

quality of life than their healthy peers. Participants with

food allergies were age, gender, and ethnicity matched to

young adults without a history of allergies or any other

chronic illness for analyses. The majority of adolescents and

young adults with food allergies reported that their allergies

interfere with physical intimacy with their current partner.

Results further revealed that adolescents and young adults

with food allergies reported greater dating anxiety and fear

of negative evaluation than healthy peers. No differences

were observed between the groups on physical or mental

health–related quality of life or social functioning. For both

groups, dating anxiety was a significant predictor of mental

quality of life and social functioning.

Keywords: food allergy; dating anxiety; quality of life

A

pproximately 150 individuals (adults and children) die

annually due to adverse reactions to food.1

These adverse

food reactions are often caused by food allergies, which affect

6% to 8% of children and 2% of adults in the United States.1

Adverse food reactions are characterized by an immunological

IgE reaction to the proteins on the food, with the 8 most

common food allergies being fish, peanut, egg, soy, wheat,

shellfish, tree nut, and cow’s milk.1

Individuals with food

allergies are faced with considerable uncertainty. The severity

of an allergic reaction to food can be unpredictable and

depends on several factors, including an individual’s sensitivity,

the type of food, and amount of food eaten.1

Exposure to

food proteins can occur without an individual’s knowledge

and without consuming the food. For example, individuals

with peanut allergies may not be aware when peanut oil has

been used in cooking, or they may have an allergic reaction

to the peanut oils from peanut shells and skins that have been

thrown on a restaurant floor. There is also evidence to suggest

that engaging in physically intimate behaviors with a partner

who has recently consumed the allergen can cause an allergic

reaction.2

Peanut allergens can remain in salvia for over an

hour, even after an individual has brushed his/her teeth or used

mouthwash.3

Notably, research suggests that kissing can allow

for the transfer of allergens through the skin, oral mucosa, or

saliva.2,3 As such, adults with food allergies must be diligent to

avoid exposure, inquire about ingredients and food preparation

when they have not prepared the food themselves, and

communicate about their allergies with their partner.

Whereas allergies have traditionally been thought of simply

as a nuisance disease with little impact on an individual’s

psychosocial functioning,4

recent research has demonstrated

the mental health implications associated with having allergies.

Specifically, adolescents and young adults with allergies

experience higher rates of depressive and anxious symptoms

and poorer mental and physical health–related quality of life

(HRQOL) than their healthy peers.5

Women with allergies have

also demonstrated increased levels of state and trait anxiety

when compared with healthy controls.6

Additionally, researchers

have examined the difference between healthy controls and

individuals with allergies to understand the impact the disease

has on HRQOL. Researchers have found that individuals with

allergies have significantly lower HRQOL when compared with

healthy controls.7,8 In an interesting allergen exposure task,

DOI: 10.1177/2150129711431888. From the Department of Psychology, Oklahoma State University, Stillwater, Oklahoma. The author(s) declared no potential conflicts

of interest with respect to the research, authorship, and/or publication of this article. Address correspondence to: Stephanie E. Hullmann, MS, 116 North Murray Hall,

Oklahoma State University, Stillwater, OK 74078; e-mail: [email protected].

For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermission.nav.

© 2011 The Author(s)

Dating Anxiety in Adolescents and Young Adults

With Food Allergies

A Comparison to Healthy Peers

stephanie e. hullmann, ms, elizabeth s. molzon, Ba, angelica r. eddington, ms, and larry l. mullins, Phd

Downloaded from jaa.sagepub.com by guest on August 25, 2013

IMP

Food Allergy Seminar.Lecture.ClassPresentation Transcript

1. Food Allergy Update: Overview for SCAFP Suzanne S. Teuber, M.D.

[email_address] Professor of Medicine Training Program Director, Allergy

and Immunology

2. Sometimes tough to avoid…

3. Definitions

4. Adverse Food Reactions Bacterial food poisoning Heavy metal

poisoning Scombroid fish poisoning Caffeine Alcohol Histamine Toxic /

Pharmacologic Non-Toxic / Intolerance Non-immunologic Lactase

deficiency Galactosemia Pancreatic insufficiency Gallbladder / liver

disease Hiatal hernia Gustatory rhinitis Anorexia nervosa Idiosyncratic

Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol

2006;117:S470-475.

5. Adverse Food Reactions Systemic (Anaphylaxis) Oral Allergy Syndrome

Immediate gastrointestinal allergy Asthma/rhinitis Urticaria Morbilliform

rashes and flushing Contact urticaria Eosinophilic esophagitis Eosinophilic

gastritis Eosinophilic gastroenteritis Atopic dermatitis IgE-Mediated (most

common) Non-IgE Mediated Cell-Mediated Immunologic Protein-Induced

Enterocolitis Protein-Induced Enteropathy Eosinophilic proctitis Dermatitis

herpetiformis Contact dermatitis Sampson H. J Allergy Clin Immunol

2004;113:805-9, Chapman J et al. Ann Allergy Asthma & Immunol

2006;96:S51-68.

6. Pathophysiology

7. Allergens Proteins or glycoproteins (not fat or carbohydrate as primary

immunogens) Generally heat resistant, acid stable Major allergenic foods

(>85% of allergy) Children: milk, egg, soy, wheat, peanut, tree nuts Adults:

peanut, tree nuts, shellfish, fish , fruits and vegetables commonly stated

that “ 90% of food allergies are caused by the “Big 8 ””, this was true for

children with atopic dermatitis, not the general population with anaphylaxis.

ER studies in US: FRUITS and VEGGIES same % as peanut, crustaceans

highest

8. Emergency Department Visits for Food Allergy (Clark et al. JACI

2004;113:347) Crustaceans: 19% Peanuts: 12% Fruits and Veggies: 12%

Are these counted in food allergy prevalence estimates? -NO

9. CASE: Crustacean Allergy: IgE Towards Protein in the Food, NOT

Iodine 79 year old man had anaphylaxis to shrimp at age 20, 25 Doctors

told him he was allergic to iodine in seafood Avoided seafood, iodized salt

for years Age 70: retirement dinner, hostess picked shrimp out of his

portion and gave it to him --- ER visit for anaphylaxis At age 79, specific

IgE measurement extremely high to shrimp: >100 kU/L On follow-up after

education on avoidance, happily consuming foods with iodized salt

because he didn’t have to screen salt source any more

10. Pan-allergens Proteins in food, pollen or plants that possess

homologous IgE binding epitopes across species Tropomyosins:

crustacea, dust mites, cockroach, mollusks Storage mites in flour:

anaphylaxis reported! Parvalbumins: fish Bovine IgG: beef, lamb, venison,

cow’s milk Lipid transfer protein: fruits (peach, apple), vegetables, peanut,

tree nuts Profilin: fruits, vegetables Class 1 chitinases: fruits, wheat, latex

11. Immune Mechanisms IgE-Mediated IgE-receptor Histamine Protein

digestion Antigen processing Some Ag enters blood Mast cell APC B cell T

cell TNF- IL-5 Non-IgE Mediated

12. Risk Factors

13. Risk Factors for Development of Food Allergy Chapman J et al. Ann

Allergy Asthma & Immunol 2006;96:S51-68. Local Factors (Rodent

Models) Pepsin digestion Gastrointestinal infections? Malabsorption Rate

of absorption Antigen processing Nature and dose of Ag Transdermal

exposure Host Factors Age (esp neonates) Genetic susceptibility FHx of

atopy FHx of food allergy Atopic dermatitis Transdermal food exposure

(peanut)

14. Food Allergy Disorders

15. Anaphylaxis Syndromes Food-induced anaphylaxis Food allergy = #1

cause of anaphylaxis in the ED Rapid-onset, up to 30% biphasic May be

localized (single organ) or generalized Potentially fatal Do DNA Allergy

Relief Treatments for these high risk foods: peanut, tree nut, seafood

(cow’s milk and egg in young children) Food-dependent, exercise-induced:

2 forms Specific foods (wheat, celery most common) Any food (post-

prandial)

16. Fatal Food Anaphylaxis Frequency: ~ 150 deaths / year Clinical

features: Biphasic reaction can contribute –initially better, then recurs

Cutaneous symptoms may not be present Respiratory symptoms

prominent Risk factors : Underlying asthma – Delayed epinephrine

Symptom denial – Previous severe reaction Adolescents, young adults

History: known food allergen Key foods: peanuts and tree nuts dominate

(~90% of fatalities) , fish,crustaceans, few milk, few misc. Most events

occurred away from home Bock SA, et al. J Allergy Clin Immunol

2001;107:191-3.

17. Cutaneous Reactions Acute urticaria/angioedema – common Contact

urticaria - common Food allergy rarely causes chronic

urticaria/angioedema 1/3 of kids with moderate to severe atopic dermatitis

may have food allergy (especially cow’s milk, egg, soy, wheat). Morbilliform

rashes may be seen in these children upon food challenge. Contact

dermatitis (food handlers)

18. Respiratory Responses Upper and lower respiratory tract symptoms

may be seen (rhinoconjunctivitis, laryngeal edema, asthma) Rarely

isolated, usually accompany skin and GI symptoms Inhalational exposure

may cause respiratory symptoms that can be severe Occupational

Restaurants Kitchen/Home Example: crabs to be boiled

19. Pollen-Food Syndrome or Oral Allergy Syndrome Clinical features:

rapid onset oral pruritus, rarely progressive Epidemiology: prior

sensitization to pollens Key foods: raw fruits and vegetables Allergens:

Profilins and pathogenesis–related proteins Heat labile (cooked food

usually OK) Cause: cross reactive proteins pollen/food Birch Apple, carrot,

celery, cherry, pear, hazelnut Ragweed Banana, cucumber, melons Grass

Melon, tomato, orange Mugwort Melon, apple, peach, cherry

20. GI Syndromes of Children and Adults: Celiac Disease (Gluten-sensitive

enteropathy) In children: FTT, or weight loss Malabsorption, diarrhea,

abdominal pain May be subtle In adults, average 10 years of nonspecific

symptoms: Diarrhea, abdominal pain GERD Malabsorption May present

atypically with osteoporosis, infertility, neurologic sx Pathophysiology: an

immune-mediated enteropathy triggered by gluten peptides in genetically

predisposed patients (DQ2 or DQ8) Lymphocytic infiltration of small bowel

Villus atrophy

21. Celiac Disease (Gluten-sensitive enteropathy) Cont’d: Diagnosis

~1/133 people in US have celiac disease – many are currently

undiagnosed IgA anti-tissue transglutaminase (IgG if IgA-deficient), anti-

endomysial Ab, little role for anti-gliadin Ab currently due to poor specificity

Upper endoscopy with biopsy; Management Strict, lifelong, gluten

avoidance (wheat, barley, rye) Rare risk of GI lymphoma Oats almost

always OK Link with resources: dietician, local support groups, national

organizations (listed at www.celiac.nih.gov)

22. GI Syndromes of Children and Adults Gastrointestinal Anaphylaxis or

Immediate Gastrointestinal Allergy IgE-mediated Acute

emesis/diarrhea/abdominal pain Can present without other signs or

symptoms of an allergic reaction to food

23. GI Syndromes of Children and Adults Eosinophilic Gastrointestinal

Disorders: eosinophilic esophagitis/gastritis/gastroenteritis Prevalence

increasing, eosinophilic esophagitis is the most common syndrome, all rare

in adults Symptoms Post-prandial N/V/D/abdominal pain, weight loss FTT

in infants and young children, irritability, sleep disturbance GER, often

refractory, may be seen In teens/adults: dysphagia, food impaction

24. Eosinophilic Gastrointestinal Disorders: eosinophilic

esophagitis/gastritis/gastroenteritis cont’d: Diagnosis Biopsy: eos infiltration

(mucosa serosa): >15/HPF Presence of eos doesn’t necessarily invoke

food allergy May affect esophagus to rectum Response to specific food

elimination found in a subset of patients (especially eosinophilic

esophagitis): can screen for food allergy with prick/in vitro IgE, patch

testing with food is currently under investigation

25. Disorders Not Proven to be Related to Food Allergy Migraines

Behavioral / Developmental disorders Arthritis Seizures Inflammatory

bowel disease

26. Prevalence and Natural History

27. Prevalence of Food Allergy Perception by public: 20-25% Confirmed

allergy (oral challenge) Adults: 3-4% Infants/young children: 6-8% Specific

Allergens Dependent upon societal eating and cooking patterns

Prevalence higher in those with: Atopic dermatitis Certain pollen allergies

Latex allergy Prevalence seems to be increasing

28. Estimated Prevalence of Food Allergy Sampson H. J Allergy Clin

Immunol;113:805-19. Food Children (%) Adults (%) Cow’s milk 2.5 0.3 Egg

1.3 0.2 Soy 0.3-0.4 0.04 Peanut 0.8 0.6 Tree nut 0.2 0.5 Crustaceans Fish

0.1 0.1 2.0 0.4

29. Prevalence of Clinical Cross Reactivity Among Food “Families” Food

Allergy Prevalence of Allergy to > 1 Food in Family Fish 30% -100% Tree

Nut 15% - 40% Grain 25% Legume 5% Any 11% Sicherer SH. J Allergy

Clin Immunol. 2001 Dec;108(6):881-90.

30. Natural History Dependent on food & immunopathogenesis ~ 85% of

cases of cow milk, soy, egg and wheat allergy remit by age 3 yrs –

numbers may be worse now for milk and egg Declining/low levels of

specific-IgE favorable IgE binding to conformational epitopes favorable

Non-IgE-mediated GI allergy Infant forms resolve in 1-3 years Toddler /

adult forms more persistent

31. Natural History (cont’d) Allergies to peanuts, tree nuts, seafoods, and

seeds typically persist ~20% of cases of peanut allergy resolve by age 5

years. Prognostic factors include : PST <6mm ≥ 2 years avoidance History

of mild reaction Few other atopic diseases Low levels of peanut-specific

IgE Rarely re-develop allergy: role for regular ingestion?

32. Diagnosis and Management

33. Evaluation: History & Physical Exam History: most important

Symptoms, timing, reproducibility, treatment and outcome Concurrent

exercise, NSAIDs, EtOH Diet details / symptom diary Subject to recall “

Hidden” ingredient(s) may be overlooked Physical exam: assess for other

allergic and alternative disorders Identify general mechanism Allergy vs

intolerance IgE versus non-IgE mediated

34. Evaluation of Food Allergy Suspect IgE-mediated Panels/broad

screening should NOT be done without supporting history because of high

rate of false positives. Prick skin tests (prick-prick with fresh food if pollen-

food syndrome) In vitro tests for food-specific IgE Suspect non-IgE-

mediated Consider biopsy of gut, skin Suspect non-immune, consider:

Breath hydrogen Sweat test Endoscopy

35. Interpretation of Laboratory Tests Positive prick test or specific IgE

Indicates presence of IgE antibody NOT clinical reactivity ~90% sensitivity

~50% specificity ~ 50% false positives Larger skin tests/higher IgE

correlates with likelihood of reaction but not severity Negative prick test or

specific IgE Essentially excludes IgE antibody (>95% specific)

36. Unproven/Experimental Tests Intradermal skin test with food Risk of

systemic reactions and death Not predictive (high false positive rate)

Provocation/neutralization, cytotoxic tests, applied kinesiology (muscle

response testing), hair analysis, electrodermal testing, food-specific IgG or

IgG4 (IgG “RAST”) Note: industry/restaurants have no way of ascertaining

whether a consumer was “diagnosed” by these methods or has a true food

allergy. Science does not enter until a lawsuit is filed….

37. Diagnosis: Elimination Diets & Food Challenges Elimination diets (1 - 6

weeks) most useful for chronic disease ( eg. AD, GI syndromes) Eliminate

suspected food(s) or Prescribe limited “eat only” diet or Elemental diet Oral

challenge testing (MD supervised, emergency meds available) Open

Single-blind Double-blind, placebo-controlled (DBPCFC)

38. Diagnostic Approach: IgE-Mediated Allergy If test for specific-IgE

antibody is Negative: reintroduce food* Positive: start elimination diet If

elimination diet is associated with No resolution: reintroduce food*

Resolution Open / single-blind challenges to “screen” DBPCFC for

equivocal open challenges * Unless convincing history warrants supervised

challenge

39. Treatment of Food Allergy Complete avoidance of specific food trigger

Ensure nutritional needs are being met Education Anaphylaxis Emergency

Action Plan if applicable most accidental exposures occur away from home

This frozen dessert could have peanut, tree nut, cow’s milk, egg, wheat

40. Peanut allergen exposure through saliva: assessment and

interventions to reduce exposure. Maloney JM et al. JACI 2006:118:719-24

. In our UC Davis group of patients with severe tree nut or peanut allergy,

5.3% volunteered that they had a reaction from kissing, sometimes several

hours after partner had eaten food. 1/3 in dating situation . This study:

Waiting 60 min, then brushing still did not remove peanut allergen

completely Authors suggest waiting several hours and ingesting a peanut-

free meal to be more effective than tooth-brushing or gum-chewing.

41. Treatment: Dietary Elimination Education Hidden ingredients in

restaurants/homes (peanut in sauces,egg rolls) Labeling issues (“spices”,

changes, errors) Cross contact (shared equipment) Seeking assistance

Food allergy specialist Registered dietitian: (www.eatright.org) Food

Allergy & Anaphylaxis Network (www.foodallergy.org; 800-929-4040) and

local support groups


restaurants/homes (peanut in sauces,egg rolls) International products

Restaurants: outsourced dressings/desserts a problem Woman with near-

fatal reaction after patisserie cake Secret ingredients

43. FALCPA won’t help this: “No Nuts in It!” swore the chef -- Meal served.

Told specifically that there were no nuts in it 36 yr old woman with tree nut

allergy – peanuts OK Upscale bistro; chef in charge Told waitress of life-

threatening allergy – asked to check with chef to make sure dishes she

was ordering were safe. Was told, “No problem.” Highly Educated Expert

Chef

44. Ate a few bites and started to have tingling in the mouth Called the

waitress over and asked if there was any way there were nuts in the dish –

was told “No” Reaction progressed over minutes, trouble breathing and

speaking, used her Epi-Pen, 911 called Hospitalized Jambalaya

45. After discharge, she spoke to the chef, who repeatedly denied to her

that there were nuts in the dish Important to find out the cause, because if

it was a new allergy she would have to track it down to avoid it in future

along with tree nuts Threatened a lawsuit Chef only then disclosed ground

cashews were used as a secret ingredient

46. “ Didn’t know it could be so serious” The chef maintained that he had

been residing on planet earth despite an address in San Francisco

47. Hospitality literature Wait staff: majority thought it was OK to pick an

allergen off a dish and serve it to the customer 80% of managers said they

were familiar with food allergy but only about 50% could define it. Others

gave examples of things like spoiled food.







49. Contain cow’s milk: Artificial butter flavor, butter, butter fat, buttermilk,

casein, caseinates (sodium, calcium, etc.), cheese, cream, cottage cheese,

curds, custard, Half&Half ® , hydrolysates (casein, milk, whey),

lactalbumin, lactose, milk (derivatives, protein, solids, malted, condensed,

evaporated, dry, whole, low-fat, non-fat, skim), nougat, pudding, rennet

casein, sour cream, sour cream solids, sour milk solids, whey (delactosed,

demineralized, protein concentrate), yogurt. MAY contain milk : brown

sugar flavoring, natural flavoring, chocolate, caramel flavoring, high protein

flour, margarine, Simplesse ® . AS of January 1, 2006, all food containing

“Big Eight Allergens” (cow’s milk, peanut, tree nut, hen’s egg, soy, wheat,

fish, crustacean) in the U.S. MUST declare the ingredient on the label in

COMMON language. Does NOT apply to non-Big 8 allergens (e.g.,

sesame). Label reading used to be very challenging Example: Cow’s Milk

Food Allergen Labeling and Consumer Protection Act of 2004 (P.L. 108-

282) (FALCPA)

50. Geographic Unit United States (U.S. Public Law 2004) European Union

(European Commission 2003) Australia-New Zealand (Australia New

Zealand Food Authority 2001) Canada (pending law, Health Canada 2008)

Japan (Ministry of Health 2001) Cow’s milk √ √ √ √ √ Hen’s egg √ √ √ √ √

Wheat √ √ √ √ √ Soy √ √ √ √ Peanut √ √ √ √ √ Tree nuts √ √ √ √ Fish √ √ √ √

Crustacean √ √ √ √ Molluscs √ √ Sesame √ √ √ Mustard seed √ celery √

buckwheat √

51. Undeclared food (allergens) Current laws don’t help people with allergy

to less common food allergens that are present in small amounts.

Example: spices. UCD: personally have patients with oregano, cumin,

garlic allergy. Virtually any food can be an allergen Prefer not to

experiment with finding a threshold in an uncontrolled setting! FULL

disclosure of all ingredients would be helpful Gets back to fact that we

need more data on meaningful thresholds for a reaction E.g., soy lecithin

52. May Contain.. FDA mandated to publish results of follow-up studies on

utility and consumer preferences for “may contain” labeling. Should be

available soon. Consumers “hate it” As detection kits improve, can the use

of these terms decrease? Need thresholds







54. Cross-Contact We need to do a better job teaching patients And

restaurant staff Utensils Surfaces Pans/pots Deep fryers Scatter No need

to “eliminate” allergens when there is a “safe” area for all and

knowledgeable staff.







56. Emergency Treatment: Anaphylaxis Epinephrine: drug of choice Self-

administered epinephrine readily available at all times If administered, seek

medical care IMMEDIATELY Train patients, parents, contacts:

indications/technique Anti-histamines: secondary therapy only: WILL NOT

STOP ANAPHYLXAXIS Written Anaphylaxis Emergency Action Plan

Schools, spouses, caregivers, mature sibs / friends Emergency

identification bracelet

57. MYTH: Prior Episodes Predict Future Reactions No predictable pattern

Severity depends on: Sensitivity of the individual Dose of the allergen

Other factors (e.g., food matrix effects, exercise, concurrent medications,

airway hyperresponsiveness) Must always be prepared for an emergency .

58. Patients with severe food allergy may not receive education on

avoidance, self-injectable epinephrine or referral to an allergist at

emergency department visits. It is imperative for primary care doctors and

allergists to recognize the risks and help patients avoid a future accident.

Emergency Department Management of Food Allergy Clark S, et al. J

Allergy Clin Immunol 2004;113:347-352.

59. Future Immunomodulatory Therapies Recombinant anti-IgE antibody

Mutated B-cell epitopes Minimal T-cell epitopes Immune-modulating

adjuvants (ISS) Probiotics T lymphocyte manipulation to induce tolerance

Heat-killed E. coli encoding mutated allergens Chinese herbal remedies

(Food Allergy Herbal Formula) Oral tolerance induction

60. Induction of tolerance after establishment of peanut allergy by the food

allergy herbal formula-2 is associated with up-regulation of IFN- γ . Qu et

al. CEA 2007;37:846 . Murine model of peanut anaphylaxis Treatment by

gavage bid x 6 weeks started AFTER mice allergic completely blocks

reactions Still blocked reactions to peanut 4 weeks after treatment stopped

IL-4, IL-5, IL-13 significantly decreased in mesenteric lymph nodes of

treated mice IFN- γ significantly increased in mesenteric lymph nodes of

treated mice An apparently synergistic combination of phytochemicals is

present

61. Phamacological and immunological effects of individual herbs in the

Food Allergy Herbal Formula-2 (FAHF-2) on peanut allergy. Kattan JD et

al. Phytotherapy Res 2008;epub ahead of print 4/08 The nine separate

“herbs” were individually tested as in the previous studies in the murine

model No single herb offered full protection One offered statistically signif

(but only 4 mice) protection (only ¼ mice had a reaction to peanut): Huang

Bai: Phellodendron bark Huang Bai also reduced plasma histamine levels,

but no change in IgE or specific IgG2a levels, whereas FAHF-2 results in

decreased IgE and increased IgG2a Tried a simplified formula with only

Huang Bai and 2 other “herbs”, but 2/5 mice had anaphylactic reactions to

peanut Best results with full formula

62. Food Allergy Initiative and NIH-NIAID Food Allergy Consortium

Funding to Xiu-Min Li and Hugh Sampson at Mt. Sinai. Food Allergy Herbal

Formula 2 is a bitter-tasting decoction/tea. Now, a tablet form has been

developed (12 small tablets tid is the human dose). Phase I trial scheduled

to start now – announced that patients were now being enrolled at 2008

AAAAI meeting: just tolerability/safety. They plan to seek FDA approval via

Phase II, III trials.

63. If the safety profile is good, since it is an herbal supplement, it could be

available OTC with no health claims by the end of 2008 according to a

recent Food Allergy Initiative mailer. This needs to be thought through very

carefully though Knock-offs could proliferate with claims for all kinds of

allergies Lead, arsenic, cadmium, adulteration (remember

Zencor/sildenafil??) Takes time for FTC to catch up with those who illegally

make claims

64. A randomized, double-blind, placebo-controlled study of Milk Oral

Immunotherapy (MOIT) for cow’s milk allergy. Skripak JM et al. JACI

2008;S137 20 randomized to milk or placebo (2:1 ratio) after baseline

studies Build up day: started with 0.4 mg milk protein, final dose 50 mg

Daily dosing with eight weekly dose increases to maintenance of 500 mg

Continued daily for 3-4 mo 11 completed, 5 active, 6 placebo Baseline

OFC: all 11 reacted to 40 mg milk protein (the initial dose)

65. Cont’d: MOIT Post OFC active group: cumulative median dose to elicit

reaction in active group: 5,140 mg (range 2,540 – 6,140) 1 patient tolerated

final dose of 8,140 mg with no symptoms. Post OFC placebo group: still

reactive at 40 mg 968 total active MOIT doses: 9.9% local reactions, 3.8%

systemic, epi given in 2 reactions 994 placebo doses: 11.3% local

reactions, 1.2% systemic, no epi given.

66. Rush specific oral tolerance induction in peanut allergic patients at high

risk of anaphylactic reactions. Blumchen K et al. JACI 2008:S136 . 6

children, ages 3-10 Peanut ImmunoCAP range 85->100 kU/l, median >100

All asthmatic, all “high risk” DBPCFC median provoking dose 470 mg

peanut Inpatient rush protocol, allergic symptoms appeared at 96 mg to

480 mg, 3/6 had lower respiratory symptoms, multiple reactions requiring

treatment Discharged after 6 days: on maintenance doses from 24 mg to

160 mg of peanut NOT protective doses! Conclusion: not a good approach

for this type of pt.

Health & Medicine

The subject of food poisoning