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Giovannini M, Skypala IJ, Caubet JC, Du Toit G, Nowak-Wegrzyn A. Diagnosis and Management of Pollen Food Allergy Syndrome to Nuts. J Allergy Clin Immunol Pract 2024; 12:599-604. [PMID: 38280450 DOI: 10.1016/j.jaip.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/29/2024]
Abstract
Oral allergy syndrome or pollen food allergy syndrome (PFAS) represents a common clinical conundrum when the reported trigger food is a tree nut (usually almond or hazelnut) or peanut. The PFAS may give rise to uncertainty about the potential severity of the future reactions, indications for prescribing epinephrine, and the extent of the necessary dietary avoidance. As a food allergy, secondary to cross-reactivity with airborne pollen, PFAS usually manifests toward the end of the first decade of life as contact urticaria of the oropharyngeal mucous membranes. Molecular allergology facilitates diagnosis and risk stratification by establishing the profile of sensitization. Exclusive sensitization to pathogenesis-related proteins family 10 (PR10) and profilins indicates that signs and symptoms are due to PFAS, whereas sensitization to seed storage proteins with or without sensitization to PR10 and profilins may indicate a more severe primary nut allergy phenotype. Management relies on avoidance of the specific nut trigger, advice on the likelihood of more severe local or systemic symptoms, and treatment of reactions according to the severity. Future studies are needed to better delineate the risk of systemic reactions in individuals with nut PFAS and to establish the role of food or pollen allergen immunotherapy for the prevention or moderation of this condition.
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Affiliation(s)
- Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Health Sciences, University of Florence, Florence, Italy
| | - Isabel J Skypala
- Royal Brompton & Harefield Hospitals, Guys & St Thomas NHS Foundation Trust, London, United Kingdom; Department of Inflammation and Repair, Imperial College, London, United Kingdom.
| | - Jean Christoph Caubet
- Pediatric Allergy Unit, Department of Pediatrics, Gynecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
| | - George Du Toit
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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2
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Olivieri B, Skypala IJ. New arrivals in anaphylaxis to foods. Curr Opin Allergy Clin Immunol 2023; 23:357-363. [PMID: 37490617 DOI: 10.1097/aci.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
PURPOSE OF REVIEW More people are excluding wheat from their diet, or turning to a more sustainable diet in which includes meat substitutes or is mainly or wholly plant-based. This increases the availability of new foods and with it the increasing likelihood of novel allergens. RECENT FINDINGS There is a growing body of evidence which suggests that allergies to seeds and legumes are increasing potentially due to their use in concentrated form in vegan or health foods. Insects can be a sustainable source of protein, but mealworm could provoke symptoms in individuals sensitized or allergic to shellfish or house dust mite. Novel plant food allergens such as gibberellin-regulated proteins and thaumatin-like proteins are increasingly being reported as significant causes of severe reactions to fruits. SUMMARY these findings make it even more imperative to take a full dietary history to ensure apparent idiopathic anaphylaxis is not in reality due to a novel food, especially in cases where other forms of the food are tolerated. Given the lack of diagnostic tests for these novel foods, a prick-to-prick skin prick test should be performed with the suspected food. There is currently more work needed to define and sequence many of the allergens involved.
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Affiliation(s)
- Bianca Olivieri
- Department of Medicine, Asthma, Allergy and Clinical Immunology Section, University of Verona, Verona, Italy
| | - Isabel J Skypala
- Royal Brompton & Harefield Hospitals, part of Guys and St Thomas NHS Foundation Trust
- Department of Inflammation and repair, Imperial College, London, UK
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3
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Boyle RJ, Shamji MH, Skypala IJ, Garcia-Larssen V. Nutrition and Allergy. Clin Exp Allergy 2023; 53:982-983. [PMID: 37798259 DOI: 10.1111/cea.14408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Affiliation(s)
- Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mohamed H Shamji
- National Heart and Lung Institute, Imperial College London, London, UK
- NIHR Imperial Biomedical Research Centre, London, UK
| | - Isabel J Skypala
- National Heart and Lung Institute, Imperial College London, London, UK
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4
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Skypala IJ, Reese I, Durban R, Hunter H, Podesta M, Chaddad MCC, Santos AF, Agache I. Food allergy-A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review. Pediatr Allergy Immunol 2023; 34:e14019. [PMID: 37747742 DOI: 10.1111/pai.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/26/2023]
Abstract
Following a diagnosis of IgE-mediated food allergy, to secure the best outcome, the patient should receive individualized advice tailored to their specific needs, which considers the type and presentation of the food involved, level of exclusion required, risk of cross-contamination and any variance required for age, ethnicity, financial issues, and lifestyle. Issues such as food labels "may contain" statements, and variation in the threshold of reaction and impact of cofactors should also be considered. Most important is the need to ensure that the diagnosis is robust, especially given the nutritional, psychological, and socioeconomic issues that can affect an individual with a diagnosis of food allergy. Unnecessary exclusion of one or more foods that have not triggered allergic reactions, especially in individuals with allergic comorbidities, can result in severe IgE-mediated reactions on re-exposure. Given that food allergies may change over time, the diagnosis should be reviewed, to determine whether resolution is likely, or new-food triggers are reported. Regular assessment is vital, especially during childhood, to ensure reintroduction occurs at an appropriate time, thus enabling increased diversity of the diet and improvement in the quality of life. For some, an IgE-mediated food allergy may necessitate the life-long exclusion of foods, and for others, a food habitually eaten suddenly triggers an allergic reaction in adult life. People of all ages, ethnicities, and socioeconomic backgrounds deserve individual advice on the management of their food allergy to support a healthy diet and improve quality of life.
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Affiliation(s)
- Isabel J Skypala
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield Hospitals, part of Guys & St Thomas NHS Foundation Trust, London, UK
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College, London, UK
| | - Imke Reese
- Nutritional Counseling and Therapy, Focus on Allergology, Munich, Germany
| | - Raquel Durban
- Carolina Asthma & Allergy Center, Charlotte, North Carolina, USA
| | - Hannah Hunter
- Department of Allergy, Guys & St Thomas NHS Foundation Trust, London, UK
- Kings College, London, UK
| | | | | | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
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5
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Toscano A, Ebo DG, Abbas K, Brucker H, Decuyper II, Naimi D, Nanda A, Nayak AP, Skypala IJ, Sussman G, Zeiger JS, Silvers WS. A review of cannabis allergy in the early days of legalization. Ann Allergy Asthma Immunol 2023; 130:288-295. [PMID: 36384984 PMCID: PMC9991982 DOI: 10.1016/j.anai.2022.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
Cannabis allergy is a burgeoning field; consequently, research is still in its infancy and allergists' knowledge surrounding this topic is limited. As cannabis legalization expands across the world, it is anticipated that there will be an increase in cannabis use. Thus, we hypothesize that a concomitant rise in the incidence of allergy to this plant can be expected. Initiatives aimed at properly educating health care professionals are therefore necessary. This review presents the most up-to-date information on a broad range of topics related to cannabis allergy. Although the clinical features of cannabis allergy are becoming more well described and recognized, the tools available to make a correct diagnosis are meager and often poorly accessible. In addition, research on cannabis allergy is still taking its first steps, and new and potentially groundbreaking findings in this field are expected to occur in the next few years. Finally, although therapeutic approaches are being developed, patient and physician education regarding cannabis allergy is certainly needed.
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Affiliation(s)
- Alessandro Toscano
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Post-Graduate School of Allergology and Clinical Immunology, University of Milan, Milan, Italy.
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | - Khaldon Abbas
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ine I Decuyper
- Department of Pediatrics and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - David Naimi
- Naval Hospital Camp Pendleton, Oceanside, California
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Dallas, Texas; Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ajay P Nayak
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Isabel J Skypala
- Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Gordon Sussman
- Department of Medicine and Division of Clinical Immunology & Allergy, University of Toronto, Toronto, Ontario, Canada
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Vlieg-Boerstra B, Groetch M, Vassilopoulou E, Meyer R, Laitinen K, Swain A, Durban R, Benjamin O, Bottse R, Grimshaw K, Netting M, O'Manony L, de Jong N, Skypala IJ. The immune-supportive diet in allergy management. A narrative review and proposal. Allergy 2023. [PMID: 36802268 DOI: 10.1111/all.15687] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/27/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023]
Abstract
The role of nutrition is increasingly recognized in the management of chronic immune diseases. However, the role of an immune-supportive diet as adjuvant therapy in the management of allergic disease has not been similarly explored. This review assesses the existing evidence for a relationship between nutrition, immune function, and allergic disease from a clinical perspective. In addition, the authors propose an immune-supportive diet to enhance dietary interventions and complementing other therapeutic options for allergic disease from early life to adulthood. A narrative review of the literature was conducted, to determine the evidence of the relationship between nutrition and immune function, overall health, epithelial barrier function, and gut microbiome, particularly in relation to allergy. Studies on food supplements were excluded. The evidence was assessed and utilized to develop a sustainable immune-supportive diet to complement other therapies in allergic disease. The proposed diet consists of a highly diverse range of fresh, whole and minimally processed plant-based and fermented foods supplemented with moderate amounts of nuts, omega-3 rich foods and animal-based products in proportional amounts of the EAT-Lancet diet, such as (fatty) fish, (fermented) milk products which may be full-fat and eggs, lean meat or poultry, which may be free-range or organic.
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Affiliation(s)
- Berber Vlieg-Boerstra
- OLVG Hospital, department of Paediatrics, Amsterdam, the Netherlands.,Rijnstate Hospital, Rijnstate Allergy Centre, Arnhem, The Netherlands.,Vlieg Dieticians, Private Practice for dietary management of food allergy, Arnhem, Amsterdam, the Netherlands
| | - Marion Groetch
- Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
| | - Rosan Meyer
- Imperial College, Department Paediatrics, London, UK.,Winchester University, Department Dietetics, UK
| | - Kirsi Laitinen
- Institute of Biomedicine & Functional Foods Forum, University of Turku, Turku, Finland
| | - Anne Swain
- Allergy Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Raquel Durban
- Carolina Asthma & Allergy Center, Charlotte, NC, USA
| | - Olga Benjamin
- OLVG Hospital, department of Paediatrics, Amsterdam, the Netherlands.,Hospital Group Noord West, location Alkmaar, department of Paediatrics, Alkmaar, the Netherlands
| | - Rachelle Bottse
- Vlieg Dieticians, Private Practice for dietary management of food allergy, Arnhem, Amsterdam, the Netherlands
| | | | - Merryn Netting
- Women and Kids Theme, South Australian Health and Medical Research Institute (SAHMRI), North Adelaide, South Australia, Australia.,Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Nutrition, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Liam O'Manony
- APC Microbiome Ireland, National University of Ireland, Cork, Ireland.,Department of Medicine, National University of Ireland, Cork, Ireland.,School of Microbiology, National University of Ireland, Cork, Ireland
| | - Nicolette de Jong
- Internal Medicine, Allergology & Clinical Immunology, Paediatric Allergology, University Medical Centre Rotterdam, the Netherlands.,Sophia Children Hospital Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Isabel J Skypala
- Imperial College, Department Paediatrics, London, UK.,Royal Brompton & Harefield Hospitals, part of Guys & St Thomas' NHS Foundation Trust, London, UK
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7
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Olivieri B, Stoenchev KV, Skypala IJ. Anaphylaxis across Europe: are pollen food syndrome and lipid transfer protein allergy so far apart? Curr Opin Allergy Clin Immunol 2022; 22:291-297. [PMID: 35942860 DOI: 10.1097/aci.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Traditionally pollen-food syndrome (PFS) is considered to be a mild cross-reacting food allergy affecting only Northern Europe, with lipid transfer protein (LTP) allergy being more severe and mainly occurring in Southern Europe. This review seeks to update the reader on both types of plant food allergy and to determine whether the stereotypical presentations of these plant food allergies remain the same, with a particular focus on reaction severity. RECENT FINDINGS Recent findings suggest that both these types of plant food allergy occur in children and adults. Although it is true that PFS allergy is more prevalent in Northern Europe and LTP allergy is more well known in Southern Europe, these conditions are not hidebound by geography, and the increasing spread and allergenicity of pollen due to global warming continues to change their presentation. Both conditions have a spectrum of symptom severity, with PFS sometimes presenting with more severe symptoms, including anaphylaxis and LTP allergy with milder reactions. SUMMARY It is important to consider that in many parts of Europe, reactions to plant foods, especially fruits or vegetables, could be mediated either by pollen cross-reactivity or primary sensitization to LTP allergens. All those presenting with symptoms to plant foods will benefit from a detailed clinical history and appropriate tests so that an accurate diagnosis can be made, and correct management implemented.
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Affiliation(s)
- Bianca Olivieri
- Department of Medicine, Asthma, Allergy and Clinical Immunology Section, University of Verona, Verona, Italy
| | - Kostadin V Stoenchev
- Royal Brompton & Harefield Hospitals, Part of Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Isabel J Skypala
- Royal Brompton & Harefield Hospitals, Part of Guys and St Thomas NHS Foundation Trust, London, United Kingdom
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8
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Zeiger JS, Silvers WS, Naimi DR, Skypala IJ, Ellis AK, Connors L, Jeimy S, Nayak AP, Bernstein JA, Zeiger RS. Impact of cannabis knowledge and attitudes on real-world practice. Ann Allergy Asthma Immunol 2022; 129:441-450. [PMID: 35472594 PMCID: PMC9869714 DOI: 10.1016/j.anai.2022.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/18/2022] [Accepted: 04/12/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Increased cannabis consumption worldwide challenges allergists because of an upsurge in cannabis allergy and need to discuss cannabis with patients. OBJECTIVE To determine the knowledge, attitudes, and practices regarding cannabis among allergists and their approach to recognizing and diagnosing suspected cannabis allergy. METHODS The International Allergist Canna Knowledge, Attitudes, and Practices Survey was completed by members from 3 International Allergy Societies. Survey questions included the following: 13 on cannabis attitudes, 7 on cannabis knowledge, and 4 on real-world allergy practices. Knowledge level was dichotomized and Statistical Package for the Social Sciences TwoStep Cluster Analysis grouped participants by attitudes. Multivariate analysis determined the relationship of knowledge and attitude to practice delivery. RESULTS Of 570 eligible surveys started, 445 (78.1%) were completed. Participants were 49.7% of female sex, 65.9% aged 24 to 56 years, approximately 70% in practice for more than or equal to 10 years, and 29.2% practicing in an area where cannabis use is illegal. Of the respondents, 43.1% reported consulting on patients with suspected cannabis allergy and 54.7% had undertaken skin prick testing, in vitro cannabis testing, or both. Statistically significant differences were found between the 3 societies for most variables analyzed. Analysis of attitudes revealed 3 clusters named Traditional, Progressive, and Unsure. Those with more progressive attitudes toward cannabis and who had more knowledge were more comfortable speaking to patients about cannabis and more often asked patients on how often and how they used cannabis (all P < .001). CONCLUSION Varying knowledge and attitudes toward cannabis affecting comfort communicating with patients about cannabis were found in members of 3 allergy societies supporting the need for more cannabis research and education.
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Affiliation(s)
| | - William S Silvers
- Canna Research Foundation, Boulder, Colorado; University of Colorado School of Medicine, Denver, Colorado
| | - David R Naimi
- Naval Hospital Camp Pendleton, Oceanside, California
| | - Isabel J Skypala
- Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Anne K Ellis
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samira Jeimy
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Ajay P Nayak
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Bernstein Allergy Group, Cincinnati, Ohio
| | - Robert S Zeiger
- Canna Research Foundation, Boulder, Colorado; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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Skypala IJ, Hunter H, Krishna MT, Rey-Garcia H, Till SJ, du Toit G, Angier E, Baker S, Stoenchev KV, Luyt DK. BSACI guideline for the diagnosis and management of pollen food syndrome in the UK. Clin Exp Allergy 2022; 52:1018-1034. [PMID: 35975576 DOI: 10.1111/cea.14208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 02/06/2023]
Abstract
Pollen food syndrome (PFS) is a highly prevalent food allergy affecting pollen-sensitized children and adults. Sufferers experience allergic symptoms when consuming raw plant foods, due to the homology between the pollen allergens and unstable proteins in these foods. The triggers involved can vary depending on the pollen sensitization, which in turn is affected by geographical location. The British Society of Allergy and Clinical Immunology (BSACI) Standards of Care Committee (SOCC) identified a need to develop a guideline for the diagnosis and management of PFS in the United Kingdom (UK). Guidelines produced by the BSACI use either the GRADE or SIGN methodology; due to a lack of high-quality evidence these recommendations were formulated using the SIGN guidelines, which is acknowledged to be less robust than the GRADE approach. The correct diagnosis of PFS ensures the avoidance of a misdiagnosis of a primary peanut or tree nut allergy or confusion with another plant food allergy to non-specific lipid transfer proteins. The characteristic foods involved, and rapid-onset oropharyngeal symptoms, mean PFS can often be diagnosed from the clinical history alone. However, reactions involving tree nuts, peanuts and soya milk or severe/atypical reactions to fruits and vegetables may require additional diagnostic tests. Management is through the exclusion of known trigger foods, which may appear to be simple, but is highly problematic if coupled with a pre-existing food allergy or for individuals following a vegetarian/vegan diet. Immunotherapy to pollens is not an effective treatment for PFS, and although oral or sublingual immunotherapy to foods seems more promising, large, controlled studies are needed. The typically mild symptoms of PFS can lead to an erroneous perception that this condition is always easily managed, but severe reactions can occur, and anxiety about the onset of symptoms to new foods can have a profound effect on quality of life.
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Affiliation(s)
- Isabel J Skypala
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK.,Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College, London, UK
| | - Hannah Hunter
- Department of Allergy, Guys & St Thomas NHS Foundation Trust, London, UK.,Kings College, London, UK
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,The Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Helena Rey-Garcia
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK
| | - Stephen J Till
- Department of Allergy, Guys & St Thomas NHS Foundation Trust, London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - George du Toit
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.,Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK.,Department Women and Children's Health (Paediatric Allergy), Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - Elizabeth Angier
- Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Kostadin V Stoenchev
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK
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10
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Skypala IJ, Jeimy S, Brucker H, Nayak AP, Decuyper II, Bernstein JA, Connors L, Kanani A, Klimek L, Lo SCR, Murphy KR, Nanda A, Poole JA, Walusiak-Skorupa J, Sussman G, Zeiger JS, Goodman RE, Ellis AK, Silvers WS, Ebo DG. Cannabis-related allergies: An international overview and consensus recommendations. Allergy 2022; 77:2038-2052. [PMID: 35102560 PMCID: PMC9871863 DOI: 10.1111/all.15237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/10/2022] [Accepted: 01/23/2022] [Indexed: 01/26/2023]
Abstract
Cannabis is the most widely used recreational drug in the world. Cannabis sativa and Cannabis indica have been selectively bred to develop their psychoactive properties. The increasing use in many countries has been accelerated by the COVID-19 pandemic. Cannabis can provoke both type 1 and type 4 allergic reactions. Officially recognized allergens include a pathogenesis-related class 10 allergen, profilin, and a nonspecific lipid transfer protein. Other allergens may also be relevant, and recognition of allergens may vary between countries and continents. Cannabis also has the potential to provoke allergic cross-reactions to plant foods. Since cannabis is an illegal substance in many countries, research has been hampered, leading to challenges in diagnosis since no commercial extracts are available for testing. Even in countries such as Canada, where cannabis is legalized, diagnosis may rely solely on the purchase of cannabis for prick-to-prick skin tests. Management consists of avoidance, with legal issues hindering the development of other treatments such as immunotherapy. Education of healthcare professionals is similarly lacking. This review aimed to summarize the current status of cannabis allergy and proposes recommendations for the future management of this global issue.
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Affiliation(s)
- Isabel J. Skypala
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield Hospitals, and Imperial College, London, UK
| | - Samira Jeimy
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Ajay P. Nayak
- Center for Translational Medicine and Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, Jane and Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ine I. Decuyper
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | - Jonathan A. Bernstein
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine and Bernstein Allergy Group; Bernstein Clinical Research Center, Cincinnati, Ohio, USA
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amin Kanani
- Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ludger Klimek
- Center for Rhinology and Allergy, Wiesbaden, Germany
| | - Shun Chi Ryan Lo
- Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin R. Murphy
- Division of Allergy, Asthma and Pediatric Pulmonology, Department of Pediatrics, Boys Town National Research Hospital, Omaha, Nebraska, USA
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Dallas, Texas, USA,Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jill. A. Poole
- Division of Allergy and Immunology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Medicine and Environmental Health, Nofer Institute of Occupational Medicine, Lodz, Poland
| | - Gordon Sussman
- Department of Medicine and Division of Clinical Immunology & Allergy, University of Toronto, Toronto, Ontario, Canada
| | | | - Richard E. Goodman
- Food Allergy Research and Resource Program, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Anne K. Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - William S. Silvers
- Division of Allergy Clinical Immunology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Didier G. Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium,Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium,Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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11
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Skypala IJ, Taylor CF, Pallister A, Scadding GW. A Pilot Study to Evaluate the Dietary Intake of Adults Attending a Food Allergy Clinic, and Compare the Results Against the Final Diagnostic Outcome. Front Allergy 2022; 2:765029. [PMID: 35387056 PMCID: PMC8974758 DOI: 10.3389/falgy.2021.765029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The impact of poor diet on growth and development in children with a food allergy is well-recognized and researched. Food allergy is an increasing problem in adults, as are food intolerances. Another issue is the rising number of individuals adopting a vegetarian or vegan lifestyle. Studies evaluating the diet of adolescents and adults with food allergy against controls suggest their dietary intakes are similar. We wished to evaluate all patients attending a food allergy clinic to determine whether there were dietary and nutritional differences between those with a food allergy or a food intolerance. Methods: All adults newly referred to a secondary care food allergy clinic in a UK hospital, in a 1-month period, were included in the study. Prior to their appointment, those who consented to take part had their height and weight documented and an assessment made of their habitual food intake. Their subsequent diagnosis was reviewed, and results for those with a confirmed diagnosis of food allergy were compared to those with a food intolerance or where the cause of symptoms was unknown. Results: Thirty subjects were recruited, with full results available for 29 subjects, 15 of whom (52%) were diagnosed with a new/existing food allergy (FA). For the whole cohort, dietary intake was sufficient for protein, and most vitamins and minerals, whereas energy, carbohydrate, unsaturated fat and fiber intakes were well-below the reference range. Those with a FA had lower intakes of iron, zinc and vitamin B12 compared to those with no FA. In addition, iron and energy intakes were depleted in those avoiding nuts, and wheat avoidance was linked to a lower intake of riboflavin. Conclusion: The results from this small exploratory study suggest that whilst the majority of nutrients in the diet are sufficient in adults presenting to the food allergy clinic, intakes of energy and fiber may be below the reference range. Those with a food allergy are more likely to have a reduced intake of iron, zinc and vitamin B12. As others have demonstrated, the exclusion of specific food groups can also affect nutritional intakes.
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Affiliation(s)
- Isabel J Skypala
- Department of Allergy and Clinical Immunology, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Allergy and Clinical Immunology, Imperial College, London, United Kingdom
| | - Cecile F Taylor
- Department of Nutrition and Dietetics, Royal Free Hospital, London, United Kingdom
| | - Anthony Pallister
- Department of Nutrition and Dietetics, Kettering General Hospital, Kettering, United Kingdom
| | - Guy W Scadding
- Department of Allergy and Clinical Immunology, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Allergy and Clinical Immunology, Imperial College, London, United Kingdom
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12
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Álvarez García O, Bartra J, Ruiz‐Garcia M, Skypala IJ, Durham SR, Boyle RJ, Mills EC, Turner PJ. No apparent impact of incremental dosing on eliciting dose at double-blind, placebo-controlled peanut challenge. Allergy 2022; 77:667-670. [PMID: 34614236 DOI: 10.1111/all.15130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/11/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Olaya Álvarez García
- National Heart & Lung Institute Imperial College London London UK
- Complexo Hospitalario Universitario de Ferrol, A Coruña Spain
| | - Joan Bartra
- National Heart & Lung Institute Imperial College London London UK
- Hospital Clínic de Barcelona Barcelona Spain
| | | | - Isabel J. Skypala
- National Heart & Lung Institute Imperial College London London UK
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Stephen R. Durham
- National Heart & Lung Institute Imperial College London London UK
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Robert J. Boyle
- National Heart & Lung Institute Imperial College London London UK
| | - E.N. Clare Mills
- Division of Infection, Immunity & Respiratory Medicine Manchester Institute of Biotechnology University of Mancheste Manchester UK
| | - Paul J. Turner
- National Heart & Lung Institute Imperial College London London UK
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13
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Leech SC, Ewan PW, Skypala IJ, Brathwaite N, Erlewyn-Lajeunesse M, Heath S, Ball H, James P, Murphy K, Clark AT. BSACI 2021 guideline for the management of egg allergy. Clin Exp Allergy 2021; 51:1262-1278. [PMID: 34586690 DOI: 10.1111/cea.14009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 12/19/2022]
Abstract
This guideline advises on the management of patients with egg allergy. Most commonly egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history will confirm the diagnosis in most cases. Investigation by measuring egg-specific IgE (by skin prick testing or specific IgE assay) is useful in moderate-severe cases or where there is diagnostic uncertainty. Following an acute allergic reaction, egg avoidance advice should be provided. Egg allergy usually resolves, and reintroduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive the MMR vaccine. Most adults and children with egg allergy can receive the influenza vaccine in primary care, unless they have had anaphylaxis to egg requiring intensive care support. Yellow Fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence based. Where evidence was lacking, consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.
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Affiliation(s)
- Susan C Leech
- Department of Child Health, Kings College Hospital, London, UK
| | - Pamela W Ewan
- Allergy Clinic, NHS Foundation Trust, Cambridge University, Cambridge, UK
| | | | - Nicola Brathwaite
- Department of Child Health, Kings College Hospital, London, UK.,Department of Child Health, Kings College Hospital, London, UK
| | | | - Sarah Heath
- Department of Child Health, Kings College Hospital, London, UK
| | - Heidi Ball
- University Hospitals Leicester, Leicester, UK
| | - Polly James
- Evelina Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Karen Murphy
- Evelina Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew T Clark
- Allergy Clinic, NHS Foundation Trust, Cambridge University, Cambridge, UK
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14
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Skypala IJ, Bartra J, Ebo DG, Antje Faber M, Fernández‐Rivas M, Gomez F, Luengo O, Till SJ, Asero R, Barber D, Cecchi L, Diaz Perales A, Hoffmann‐Sommergruber K, Anna Pastorello E, Swoboda I, Konstantinopoulos AP, Ree R, Scala E. The diagnosis and management of allergic reactions in patients sensitized to non-specific lipid transfer proteins. Allergy 2021; 76:2433-2446. [PMID: 33655502 DOI: 10.1111/all.14797] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/29/2021] [Accepted: 02/24/2021] [Indexed: 12/12/2022]
Abstract
Sensitization to one or more non-specific lipid transfer proteins (nsLTPs), initially thought to exist mainly in southern Europe, is becoming accepted as a cause of allergic reactions to plant foods across Europe and beyond. The peach nsLTP allergen Pru p 3 is a dominant sensitizing allergen and peaches a common food trigger, although multiple foods can be involved. A frequent feature of reactions is the requirement for a cofactor (exercise, alcohol, non-steroidal anti-inflammatory drugs, Cannabis sativa) to be present for a food to elicit a reaction. The variability in the food and cofactor triggers makes it essential to include an allergy-focused diet and clinical history in the diagnostic workup. Testing on suspected food triggers should also establish whether sensitization to nsLTP is present, using purified or recombinant nsLTP allergens such as Pru p 3. The avoidance of known trigger foods and advice on cofactors is currently the main management for this condition. Studies on immunotherapy are promising, but it is unknown whether such treatments will be useful in populations where Pru p 3 is not the primary sensitizing allergen. Future research should focus on the mechanisms of cofactors, improving diagnostic accuracy and establishing the efficacy of immunotherapy.
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Affiliation(s)
- Isabel J. Skypala
- Royal Brompton & Harefield NHS Foundation Trust London UK
- Department of Allergy and Clinical Immunology Imperial College London UK
| | - Joan Bartra
- Hospital Clinic Barcelona Spain
- IDIBAPS Universitat de Barcelona ARADyAL, Barcelona Spain
| | - Didier G. Ebo
- Department of Immunology, Allergology, Rheumatology Faculty of Medicine and Health Sciences Infla‐Med Centre of Excellence Antwerp University Hospital University of Antwerp Antwerp Belgium
- Jan Palfijn Ziekenhuis Ghent Ghent Belgium
| | - Margaretha Antje Faber
- Faculty of Medicine and Health Sciences Department of Immunology, Allergology, Rheumatology Infla‐Med Centre of Excellence Antwerp University Hospital University of Antwerp Antwerp Belgium
| | - Montserrat Fernández‐Rivas
- Department of Allergy Hospital Clínico San Carlos Universidad Complutense de Madrid IdISSC ARADyAL Madrid Spain
| | - Francisca Gomez
- Allergy Unit IBIMA—Hospital Regional Universitario de Malaga Malaga Spain
- Spanish Network for Allergy ‐ RETICS de Asma Reaccionesadversas y Alérgicas (ARADyAL Madrid Spain
| | - Olga Luengo
- Allergy Unit Internal Medicine Department Vall d'Hebron University Hospital Universitat Autònoma de Barcelona ARADyAL Barcelona Spain
| | - Stephen J. Till
- Peter Gorer Department of Immunobiology King’s College London London UK
- Department of Allergy Guy’s & St Thomas’ NHS Foundation Trust London UK
| | - Riccardo Asero
- Ambulatorio di Allergologia Clinica San Carlo Paderno Dugnano Italy
| | - Domingo Barber
- IMMA School of Medicine Universidad San Pablo CEU, Universities Madrid Spain
- RETIC ARADYAL RD16/0006/0015 Instituto de Salud Carlos III Madrid Spain
| | - Lorenzo Cecchi
- SOS Allergy and Clinical Immunology USL Toscana Centro Prato Italy
| | - Araceli Diaz Perales
- Centro de Biotecnología y Genómica de Plantas Universidad Politecnica Madrid Spain
| | | | - Elide Anna Pastorello
- Unit of Allergology and Immunology ASST Grande Ospedale Metropolitano Niguarda University of Milan Milan Italy
| | - Ines Swoboda
- Biotechnology Section Campus Vienna Biocenter FH Campus Wien, University of Applied Sciences Vienna Austria
| | | | - Ronald Ree
- Department of Experimental Immunology Amsterdam University Medical Centers, location AMC Amsterdam The Netherlands
- Department of Otorhinolaryngology Amsterdam University Medical Centers, location AMC Amsterdam The Netherlands
| | - Enrico Scala
- Experimental Allergy Unit Istituto Dermopatico dell’Immacolata – IRCCS FLMM Rome Italy
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15
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Skypala IJ, Asero R, Barber D, Cecchi L, Diaz Perales A, Hoffmann-Sommergruber K, Pastorello EA, Swoboda I, Bartra J, Ebo DG, Faber MA, Fernández-Rivas M, Gomez F, Konstantinopoulos AP, Luengo O, van Ree R, Scala E, Till SJ. Non-specific lipid-transfer proteins: Allergen structure and function, cross-reactivity, sensitization, and epidemiology. Clin Transl Allergy 2021; 11:e12010. [PMID: 34025983 PMCID: PMC8129635 DOI: 10.1002/clt2.12010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 12/27/2022] Open
Abstract
Background Discovered and described 40 years ago, non‐specific lipid transfer proteins (nsLTP) are present in many plant species and play an important role protecting plants from stressors such as heat or drought. In the last 20 years, sensitization to nsLTP and consequent reactions to plant foods has become an increasing concern. Aim The aim of this paper is to review the evidence for the structure and function of nsLTP allergens, and cross‐reactivity, sensitization, and epidemiology of nsLTP allergy. Materials and Methods A Task Force, supported by the European Academy of Allergy & Clinical Immunology (EAACI), reviewed current evidence and provide a signpost for future research. The search terms for this paper were “Non‐specific Lipid Transfer Proteins”, “LTP syndrome”, “Pru p 3”, “plant food allergy”, “pollen‐food syndrome”. Results Most nsLTP allergens have a highly conserved structure stabilised by 4‐disulphide bridges. Studies on the peach nsLTP, Pru p 3, demonstrate that nsLTPs are very cross‐reactive, with the four major IgE epitopes of Pru p 3 being shared by nsLTP from other botanically related fruits. These nsLTP allergens are to varying degrees resistant to heat and digestion, and sensitization may occur through the oral, inhaled or cutaneous routes. In some populations, Pru p 3 is the primary and sole sensitizing allergen, but many are poly‐sensitised both to botanically un‐related nsLTP in foods, and non‐food sources of nsLTP such as Cannabis sativa, Platanus acerifolia, (plane tree), Ambrosia artemisiifolia (ragweed) and Artemisia vulgaris (mugwort). Initially, nsLTP sensitization appeared to be limited to Mediterranean countries, however more recent studies suggest clinically relevant sensitization occurs in North Atlantic regions and also countries in Northern Europe, with nsLTP sensitisation profiles being broadly similar. Discussion These robust allergens have the potential to sensitize and provoke symptoms to a large number of plant foods, including those which are raw, cooked or processed. It is unknown why some sensitized individuals develop clinical symptoms to foods whereas others do not, or indeed what other allergens besides Pru p 3 may be primary sensitising allergens. It is clear that these allergens are also relevant in non‐Mediterranean populations and there needs to be more recognition of this. Conclusion Non‐specific LTP allergens, present in a wide variety of plant foods and pollens, are structurally robust and so may be present in both raw and cooked foods. More studies are needed to understand routes of sensitization and the world‐wide prevalence of clinical symptoms associated with sensitization to these complex allergens.
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Affiliation(s)
- Isabel J Skypala
- Department of Allergy & Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust Imperial College London UK
| | - Ricardo Asero
- Ambulatorio di Allergologia Clinica San Carlo Milan Italy
| | - Domingo Barber
- IMMA School of Medicine Universidad San Pablo CEU CEU Universities Madrid Spain.,RETIC ARADYAL RD16/0006/0015 Instituto de Salud Carlos III Madrid Spain
| | - Lorenzo Cecchi
- SOS Allergy and Clinical Immunology USL Toscana Centro Prato Italy
| | - Arazeli Diaz Perales
- Departamento de Biotecnología-Biología Vegetal Centro de Biotecnología y Genómica de Plantas (CBGP, UPM-INIA) Universidad Politécnica de Madrid Madrid Spain
| | | | - Elide A Pastorello
- Unit of Allergology and Immunology ASST Grande Ospedale Metropolitano Niguarda University of Milan Milan Italy
| | - Ines Swoboda
- Biotechnology Section FH Campus Wien University of Applied Sciences Vienna Austria
| | - Joan Bartra
- Hospital Clinic de Barcelona IDIBAPS Universitat de Barcelona ARADyAL Barcelona Spain
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and Infla-Med Centre of Excellence Faculty of Medicine and Health Sciences University of Antwerp and Antwerp University Hospital Ghent Belgium
| | - Margaretha A Faber
- Department of Immunology, Allergology, Rheumatology and Infla-Med Centre of Excellence Faculty of Medicine and Health Sciences University of Antwerp and Antwerp University Hospital Ghent Belgium
| | - Montserrat Fernández-Rivas
- Department of Allergy Hospital Clínico San Carlos Universidad Complutense de Madrid IdISSC, ARADyAL Madrid Spain
| | - Francesca Gomez
- Allergy Unit IBIMA- Hospital Regional Universitario de Malaga Malaga and Spanish Network for Allergy - RETICS de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
| | | | - Olga Luengo
- Allergy Unit, Internal Medicine Department Vall d'Hebron University Hospital Universitat Autònoma de Barcelona ARADyAL Barcelona Spain
| | - Ronald van Ree
- Department of Experimental Immunology and Department of Otorhinolaryngology Amsterdam University Medical Centers location AMC Amsterdam The Netherlands
| | - Enrico Scala
- Experimental Allergy Unit Istituto Dermopatico Dell'immacolata IRCCS FLMM Rome Italy
| | - Stephen J Till
- Peter Gorer Department of Immunobiology King's College London London UK.,Department of Allergy Guy's & St Thomas' NHS Foundation Trust London UK
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16
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Patel K, Vila‐Nadal G, Shah J, Shamji MH, Swan L, Durham SR, Patel K, Skypala IJ. Is pollen-food syndrome a frequent comorbidity in adults with irritable bowel syndrome? Allergy 2020; 75:1780-1783. [PMID: 31999843 DOI: 10.1111/all.14209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/28/2019] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kirtika Patel
- Department of Allergy and Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust London UK
- School of Medicine Moi University Eldoret Kenya
| | - Gemma Vila‐Nadal
- Department of Allergy and Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust London UK
- Department of Allergy & Clinical Immunology National Heart and Lung Institute Imperial College London UK
- NIHR Biomedical Research Centre Imperial College London UK
| | - Jasmit Shah
- Department of Population Health Aga Khan University Nairobi Kenya
| | - Mohamed H. Shamji
- Department of Allergy & Clinical Immunology National Heart and Lung Institute Imperial College London UK
- NIHR Biomedical Research Centre Imperial College London UK
| | - Lorna Swan
- Peter Munk Cardiac Center University Health Network Toronto ON Canada
| | - Stephen R. Durham
- Department of Allergy and Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust London UK
- Department of Allergy & Clinical Immunology National Heart and Lung Institute Imperial College London UK
- NIHR Biomedical Research Centre Imperial College London UK
| | - Kinesh Patel
- Department of Allergy and Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust London UK
- Department of Gastroenterology Chelsea and Westminster Hospital NHS Foundation Trust London UK
| | - Isabel J. Skypala
- Department of Allergy and Clinical Immunology Royal Brompton & Harefield NHS Foundation Trust London UK
- Department of Allergy & Clinical Immunology National Heart and Lung Institute Imperial College London UK
- NIHR Biomedical Research Centre Imperial College London UK
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Abstract
Diet and nutrition play an important role in the development and management of food allergy. The diet of expectant mothers can have an effect on their offspring in terms of allergic outcomes. A host of confounding factors may influence this, with a maternal diet rich in fruits and vegetables, fish, vitamin D-rich foods associated with a lower risk of allergic disease in their children. More surprisingly, the consumption of milk and butter has also been shown to have a protective effect, especially in a farm environment. Similarly, the diet of the infant can also be important, not only in terms of breast feeding, but also the timing of the introduction of complementary foods, the diversity of the diet and the effect of individual foods on the development of allergy. One factor which has clearly been shown not to influence the development of food allergy is allergen avoidance by expectant mothers. In the infant diet, the manipulation of the gut microbiome to prevent the development of atopic disease is clearly an area which promises much, although studies have yet to provide a breakthrough in the prevention of atopic dermatitis. More concrete evidence of the value of diet in prevention has come from studies evaluating infant eating patterns which may protect gut health, through the consumption of large amounts of home-processed fruits and vegetables. The consumption of fish during the first year of life has also been shown to be protective. The importance of nutritional issues in children and adults who have a food allergy has become much more accepted in recent years. The primary allergenic foods in infancy and childhood, milk, egg, wheat and soy are also ones which are present in many foods and thus their avoidance can be problematic from a nutritional perspective. Thus, children with a food allergy can have their growth compromised through avoidance, especially pre-diagnosis, when foods may be excluded without any expert nutritional input. The management of a food allergy largely remains the exclusion of the offending food(s), but it is now clear that in doing so, children in particular can be at nutritional risk if insufficient attention is paid to the rest of the diet. Adults with food allergy are often thought not to need nutritional counselling; however, many will exclude a wide range of foods due to anxiety about trace exposure, or similar foods causing reactions. The avoidance of staple foods such as milk and wheat are common, but substitute foods very often do not have comparable nutritional profiles. Adults may also be more susceptible to on-line promotion of extreme nutritional regimes which can be extremely harmful. All food allergic individuals, whatever their age, should have a nutrition review to ensure they are consuming a healthy, balanced diet, and are not avoiding food groups unnecessarily.
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Affiliation(s)
- Isabel J Skypala
- Royal Brompton and Harefield NHS Foundation Trust, London, UK. .,Imperial College, London, UK.
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18
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Michaelis LJ, Skypala IJ, Gardner J, Sheikh A, Fox AT, Holloway JA. Upskilling healthcare professionals to manage clinical allergy. Clin Exp Allergy 2019; 49:1534-1540. [PMID: 31518446 DOI: 10.1111/cea.13497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 02/02/2023]
Abstract
It has long been recognised that given the high prevalence and considerable impact of allergic disease globally, there needs to be a focus on appropriate training for clinical professionals. The health-economic consequences of allergic disease are significant, with both direct healthcare costs (doctor, nurse and dietitian consultations, hospital admissions and prescribed medications) and indirect costs (lost school and work time, reduced productivity and over-the-counter medications). There is also a well-recognised impairment of quality of life, with less tangible costs including anxiety, distress, discomfort, disability and, occasionally, death. To help to mitigate these effects, there is a need to upskill the professional workforce at all levels, and also to equip those trained with the skills to become future healthare professional trainers. Upskilling the workforce from the grass-roots of undergraduate study in Medical, Nursing and Allied Health Professionals (AHP) through the entirety of training to senior consultant levels could have a major beneficial impact on the patient and their families, lead to a reduction in emergency use of clinical service, and help increase economic productivity.
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Affiliation(s)
- Louise J Michaelis
- Department of Immunology, Infectious Diseases and Allergy, Great North Children Hospital, Newcastle, UK
| | - Isabel J Skypala
- Department of Allergy and Clinical Immunology, Imperial College, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - James Gardner
- Department of Immunology, Infectious Diseases and Allergy, Great North Children Hospital, Newcastle, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Adam T Fox
- Department of Paediatric Allergy, Guy's & St Thomas' Hospitals NHS Foundation Trust and King's College, London, UK
| | - Judith A Holloway
- MSc Allergy, Faculty of Medicine, University of Southampton, Southampton, UK.,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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19
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Skypala IJ, Cecchi L, Shamji MH, Scala E, Till S. Lipid Transfer Protein allergy in the United Kingdom: Characterization and comparison with a matched Italian cohort. Allergy 2019; 74:1340-1351. [PMID: 30762886 PMCID: PMC6767535 DOI: 10.1111/all.13747] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 01/06/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although pollen-related food allergy occurs in all European populations, lipid transfer protein (LTP) allergy is considered to manifest mainly in Mediterranean countries. We aimed to characterize adults presenting with LTP allergy in a northern European country. METHOD The clinical history and sensitization patterns of subjects born and residing in the United Kingdom (UK), with a prior diagnosis of LTP allergy and sensitization to the peach LTP allergen Pru p 3, were compared to UK subjects with pollen food syndrome (PFS). The sensitization patterns were also evaluated against a matched cohort of Italian subjects diagnosed with LTP allergy. RESULTS None of the 15 UK PFS subjects had a positive SPT to LTP-enriched peach reagent, compared to 91% of the 35 UK LTP subjects. The UK LTP cohort were also more likely to have positive skin prick tests to cabbage, lettuce and mustard and sensitization to the LTP allergens in peach, walnut, mugwort and plane tree These sensitization patterns to individual allergens were not significantly different to those obtained from the Italian LTP subjects, with significant correlations between Pru p 3 and the LTP allergens in peanuts, walnuts, plane tree and mugwort in both groups. CONCLUSION Native UK subjects with LTP allergy are not dissimilar to those with LTP allergy in southern Europe. Testing to LTP-enriched peach SPT reagent and/or LTP allergens in peach, walnut, mugwort and plane tree may enhance diagnostic accuracy.
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Affiliation(s)
- Isabel J. Skypala
- Royal Brompton & Harefield NHS Foundation Trust London UK
- Imperial College London London UK
| | - Lorenzo Cecchi
- SOS Allergy and Immunology USL Toscana Centro Prato Italy
| | | | - Enrico Scala
- Istituto Dermopatico dell'Immacolata IDI‐IRCCS Roma Italy
| | - Stephen Till
- Guy's & St Thomas’ NHS Foundation Trust London UK
- King's College London London UK
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20
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Abstract
Food anaphylaxis is on the increase, with those who have an allergy to peanuts, tree nuts, milk, and seafood at the highest risk of developing such a reaction. However, the diet in many societies is increasingly varied, much of the food consumed is prepared outside the home, and meals are often composed of many different ingredients. Anaphylaxis may occur to a composite food, and it may be unclear whether the reaction is due to contamination or to a culprit allergen present in an added ingredient. Composite foods can contain many allergic proteins present in small amounts, which do not always have to be labeled, unless they feature in European or US labeling regulations. These “hidden” allergens include mustard, celery, spices, lupine, pea, natural food colourings, and preservatives, but can occasionally include allergenic material from contaminants such as cereal mites. Hidden allergens can provoke severe reactions to seemingly unconnected foods which might then lead to a diagnosis of idiopathic anaphylaxis. The same problem can arise with two well-known types of food allergy; wheat-dependant exercise induced anaphylaxis and allergy to non-specific Lipid Transfer Protein allergens, both of which might only manifest when linked to a cofactor such as exercise. Many of these risk factors for food anaphylaxis have a common link; the public's engagement with popular concepts of health and fitness. This includes the development of a food and exercise culture involving the promotion and marketing of foods for their health-giving properties i.e., meat substitutes, wheat substitutes, supplements and alternative, or “natural” remedies for common ailments. Some of these foods have been reported as the cause of severe allergic reactions, but because they are often viewed as benign unlikely causes of severe allergic reactions, could be considered to be hidden allergens. The best resource to elicit the likelihood of a hidden allergen provoking an allergic reaction is to take a detailed history of the allergic reaction, presence of co-factors, foods suspected, type of food and where it was consumed. A good knowledge of commonly used ingredients, and list of potential hidden allergen suspects are essential tools for the food allergy detective.
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Affiliation(s)
- Isabel J Skypala
- Department of Allergy and Clinical Immunology, Imperial College, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
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21
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Dua S, Garcia MR, Bond S, Durham SR, Kimber I, Mills C, Roberts G, Skypala IJ, Wason J, Ewan PW, Boyle RJ, Clark AT. Reaction thresholds in in peanut-allergic adults and the influence of exercise and sleep deprivation: a randomised controlled trial. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gunawardana NC, Rey-Garcia H, Skypala IJ. Nutritional Management of Patients With Pollen Food Syndrome: Is There a Need? Curr Treat Options Allergy 2018. [DOI: 10.1007/s40521-018-0188-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Skypala IJ, de Jong NW, Angier E, Gardner J, Kull I, Ryan D, Venter C, Vlieg-Boerstra BJ, Grimshaw K. Promoting and achieving excellence in the delivery of Integrated Allergy Care: the European Academy of Allergy & Clinical Immunology competencies for allied health professionals working in allergy. Clin Transl Allergy 2018; 8:31. [PMID: 30151118 PMCID: PMC6102852 DOI: 10.1186/s13601-018-0218-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/14/2018] [Indexed: 12/27/2022] Open
Abstract
The multi-disciplinary team approach is an effective model for patient care. Allied health professionals (AHPs) are an important part of such teams, bringing specific knowledge and skills related to the target patient population. The AHPs most often involved in allergy care are nurses and dietitians. Nurses are often involved in the care of patients with all types of allergy and also with asthma, whilst allergy-specialist dietitians provide vital nutritional and dietary support for the diagnosis and management of food allergy. There are many other AHPs who have a role to play in allergy care, including physiotherapists, psychologists, pharmacists and speech therapists, and their involvement is likely to develop as allergy care becomes more rooted in the community. With the development of multi-professional teams comes the requirement for disease-specific knowledge and skill sets, with all allergy team members required to have baseline knowledge and competency of the condition being managed. Whilst some competencies for AHPs practising in other disease states have been published, none are available for allergic disease against which AHPs can be benchmarked. The European Academy of Allergy & Clinical Immunology (EAACI) recognised this need, and supported the establishment of a Task Force to develop allergy-focussed competencies for AHPs. The varied skills, expertise and professional background of the Task Force members enabled the creation of a set of allergy competencies relevant to all AHPs working in allergy. It is recognised that the training and allergy expertise of AHPs, and their role within the allergy setting, will vary considerably depending on the country. However, it is important for patient care, that all AHP involved in allergy services have access to training, of a sufficiently high enough level to be aspirational and enable the continued growth and development of a wide range of allergy services, given the increasing need. The EAACI competencies will provide an important benchmark for allergy knowledge and skills against which education and training can be designed and health care professionals can subsequently be measured. However, more importantly, the EAACI AHP allergy competencies will enable the development and reach of specialist allergy services, with allergy-specialist AHPs undertaking key roles, especially in the community care setting.
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Affiliation(s)
- I J Skypala
- 1Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP UK.,2Imperial College, London, UK
| | | | - E Angier
- 4University of Southampton, Southampton, UK
| | - J Gardner
- 5Great North Children's Hospital, Newcastle, UK.,6Newcastle University, Newcastle, UK
| | - I Kull
- 7Karolinska Institutet, Stockholm, Sweden.,8Sachs Children's Hospital, Stockholm, Sweden
| | - D Ryan
- 9Usher Institute, University of Edinburgh, Edinburgh, UK
| | - C Venter
- 10Denver School of Medicine, Colorado Children's Hospital, University of Colorado, Denver, USA
| | | | - K Grimshaw
- 4University of Southampton, Southampton, UK.,12Southampton Children's Hospital, Southampton, UK
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Skypala IJ, Williams M, Reeves L, Meyer R, Venter C. Sensitivity to food additives, vaso-active amines and salicylates: a review of the evidence. Clin Transl Allergy 2015; 5:34. [PMID: 26468368 PMCID: PMC4604636 DOI: 10.1186/s13601-015-0078-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/24/2015] [Indexed: 12/31/2022] Open
Abstract
Although there is considerable literature pertaining to IgE and non IgE-mediated food allergy, there is a paucity of information on non-immune mediated reactions to foods, other than metabolic disorders such as lactose intolerance. Food additives and naturally occurring 'food chemicals' have long been reported as having the potential to provoke symptoms in those who are more sensitive to their effects. Diets low in 'food chemicals' gained prominence in the 1970s and 1980s, and their popularity remains, although the evidence of their efficacy is very limited. This review focuses on the available evidence for the role and likely adverse effects of both added and natural 'food chemicals' including benzoate, sulphite, monosodium glutamate, vaso-active or biogenic amines and salicylate. Studies assessing the efficacy of the restriction of these substances in the diet have mainly been undertaken in adults, but the paper will also touch on the use of such diets in children. The difficulty of reviewing the available evidence is that few of the studies have been controlled and, for many, considerable time has elapsed since their publication. Meanwhile dietary patterns and habits have changed hugely in the interim, so the conclusions may not be relevant for our current dietary norms. The conclusion of the review is that there may be some benefit in the removal of an additive or a group of foods high in natural food chemicals from the diet for a limited period for certain individuals, providing the diagnostic pathway is followed and the foods are reintroduced back into the diet to assess for the efficacy of removal. However diets involving the removal of multiple additives and food chemicals have the very great potential to lead to nutritional deficiency especially in the paediatric population. Any dietary intervention, whether for the purposes of diagnosis or management of food allergy or food intolerance, should be adapted to the individual's dietary habits and a suitably trained dietitian should ensure nutritional needs are met. Ultimately a healthy diet should be the aim for all patients presenting in the allergy clinic.
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Affiliation(s)
- Isabel J. Skypala
- />Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP UK
| | - M. Williams
- />Somerset Partnership NHS Foundation Trust, Somerset, UK
| | - L. Reeves
- />Oxford Health NHS Foundation Trust, Oxford, UK
| | - R. Meyer
- />Great Ormond Street NHS Foundation Trust, London, UK
| | - C. Venter
- />The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
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Turner PJ, Dawson TC, Skypala IJ, Fox AT. Management of pollen food and oral allergy syndrome by health care professionals in the United Kingdom. Ann Allergy Asthma Immunol 2015; 114:427-8.e1. [PMID: 25771156 DOI: 10.1016/j.anai.2015.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 02/04/2015] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Paul J Turner
- Section of Paediatrics (Allergy & Infectious Diseases), MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, England.
| | - Tom C Dawson
- Section of Paediatrics (Allergy & Infectious Diseases), MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, England
| | - Isabel J Skypala
- Rehabilitation & Therapies Directorate, Royal Brompton & Harefield NHS Foundation Trust, London, England
| | - Adam T Fox
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Division of Asthma, Allergy and Lung Biology, King's College London, London, England; Department of Pediatric Allergy, Guy's and St Thomas' NHS Foundation Trust, London, England
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Skypala IJ, Venter C, Meyer R, deJong NW, Fox AT, Groetch M, Oude Elberink JN, Sprikkelman A, Diamandi L, Vlieg-Boerstra BJ. The development of a standardised diet history tool to support the diagnosis of food allergy. Clin Transl Allergy 2015; 5:7. [PMID: 25741437 PMCID: PMC4349299 DOI: 10.1186/s13601-015-0050-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/30/2015] [Indexed: 01/26/2023] Open
Abstract
The disparity between reported and diagnosed food allergy makes robust diagnosis imperative. The allergy-focussed history is an important starting point, but published literature on its efficacy is sparse. Using a structured approach to connect symptoms, suspected foods and dietary intake, a multi-disciplinary task force of the European Academy of Allergy and Clinical Immunology developed paediatric and adult diet history tools. Both tools are divided into stages using traffic light labelling (red, amber and green). The red stage requires the practitioner to gather relevant information on symptoms, atopic history, food triggers, foods eaten and nutritional issues. The amber stage facilitates interpretation of the responses to the red-stage questions, thus enabling the practitioner to prepare to move forward. The final green stage provides a summary template and test algorithm to support continuation down the diagnostic pathway. These tools will provide a standardised, practical approach to support food allergy diagnosis, ensuring that all relevant information is captured and interpreted in a robust manner. Future work is required to validate their use in diverse age groups, disease entities and in different countries, in order to account for differences in health care systems, food availability and dietary norms.
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Affiliation(s)
| | - Carina Venter
- The David Hide 6. Asthma and Allergy Research Centre, Isle of Wight, UK
| | - Rosan Meyer
- Great Ormond Street NHS Foundation Trust, London, UK
| | | | - Adam T Fox
- Guy's and St Thomas' Hospitals NHS Foundation Trust and Kings College, London, UK
| | - Marion Groetch
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - J N Oude Elberink
- Department of Allergology, University Medical Centre of Groningen, University of Groningen, Groningen, NL Netherlands
| | - Aline Sprikkelman
- Emma Children's Hospital Academic Medical Centre, Amsterdam, NL Netherlands
| | | | - Berber J Vlieg-Boerstra
- Emma Children's Hospital, Paediatric Respiratory Medicine and Allergy, Academic Medical Centre, University of Amsterdam, Amsterdam, NL Netherlands
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Affiliation(s)
- Paul J Turner
- Section of Paediatrics (Allergy and Infectious Diseases), MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK.
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Skypala IJ, Venter C, Damianidi L, De Jong N, Fox AT, Groetch ME, Meyer R, Elberink HO, Sprikkelman A, Vlieg-Boerstra B. The Development of A Diet-Focused Allergy History Tool. J Allergy Clin Immunol 2013. [DOI: 10.1016/j.jaci.2012.12.1017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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