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.

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.

EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy.

Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence-based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non-life-threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines.

Additional indications for the low allergenic properties of the apple cultivars Santana and Elise.

Patients with Oral Allergy Syndrome (OAS) to fresh apple may tolerate low allergenic apple cultivars. We aimed to investigate if the low allergenic properties of Elise and Santana, as previously identified in a Dutch population, could be generalised within North West Europe within the birch pollen region with regard to both the prevalence and degree of sensitization. Prick-to-prick tests (PTP) were performed in eighty-five adult patients with OAS to fresh apple in Great Britain, Switzerland and Northern Italy, before the birch pollen season, using the putatively low allergenic apple cultivars Elise, Santana, Granny Smith, Modi and Mcintosh, as well as the putatively high allergenic apple cultivars Golden Delicious and Kanzi. No significant differences in percentages of negative responses of PTPs were found between the three countries. Negative responses did not differ from negative responses to the different apple cultivars we previously found in 2006/2007 in the Netherlands. The size of the PTPs of all apple cultivars tested were correlated to the size of the skin prick tests with birch pollen. These results add to the indications for the low allergenic properties of the low allergenic apple cultivars Santana and Elise, as the number of negative responses were reproducible in three countries within the birch pollen region and were similar to previous results in the Netherlands. These results justify oral challenge studies with Elise and Santana within the birch pollen region, to establish the low allergenic properties for the benefit for apple allergic consumers for definite conclusions.

Aspirin and salicylate in respiratory disease.

This article describes the natural history, pathogenesis and diagnosis of Aspirin Exacerbated Respiratory Disease. The evidence base for the role of oral aspirin and nasal L-Lysine-aspirin desensitisation is reviewed. Evidence for the role of dietary salicylic acid and its avoidance is also reviewed.

The prevalence of PFS and prevalence and characteristics of reported food allergy; a survey of UK adults aged 18-75 incorporating a validated PFS diagnostic questionnaire.

BACKGROUND: Pollen-food syndrome (PFS), a food allergy affecting pollen-sensitized individuals, is likely to be the most prevalent food allergy in adults, estimated to affect 50-90% of people allergic to birch tree pollen. OBJECTIVE: A validated PFS diagnostic questionnaire (PFSDQ2) was used to determine the prevalence of PFS and also to characterize those who report reactions to foods. METHODS: Five UK General practices each sent the PFSDQ2 by post to 2000 patients aged 18-75 years randomly selected from their practice database. The validated questionnaire was accompanied by an additional set of questions to ascertain the demographic of the population, the foods involved and the age of onset. RESULTS: There were 3590 subjects who returned completed questionnaires, with an average return rate from each practice of 36% (range 22-47%). Of these, 73 were diagnosed with PFS according to the questionnaire (PFS+ve) giving a population prevalence of 2%. A further 482 subjects reported reactions to foods but did not fulfil the diagnostic criteria for PFS. The greatest prevalence of PFS was in the Croydon (SE England) urban practice (4.1%) and the lowest in the Aberdeen (Scotland) urban practice (0.8%) (P < 0.001).The most frequently reported trigger foods were apples, hazelnuts and kiwifruit and the majority of those with PFS first experienced symptoms below the age of 20 years. PFS+ve subjects were also more likely to be female and have a higher socio-economic status than those who did not report reactions to foods. CONCLUSIONS: The UK prevalence of PFS was 2%, although this varied according to the location of the practice population. The majority of PFS+ve subjects first reported symptoms in their teens. The reported age of onset has important implications for the diagnosis of primary and cross-reactive peanut and tree nut allergies in teenagers and young adults. The continuing rise in aeroallergen sensitization is likely to result in an increased frequency of PFS presenting in both primary and secondary care.

Development and validation of a structured questionnaire for the diagnosis of oral allergy syndrome in subjects with seasonal allergic rhinitis during the UK birch pollen season.

BACKGROUND: Birch pollen-associated oral allergy syndrome, also known as pollen-food syndrome (PFS), is the most common food allergy in adults in the United Kingdom. Because of its characteristic rapid onset of oro-pharyngeal symptoms associated with specific plant foods, it was hypothesized that a history-based questionnaire could accurately diagnose PFS in subjects with rhino-conjunctivitis symptoms in the UK springtime. OBJECTIVE: In this study of diagnostic accuracy, we aimed to validate a simple PFS diagnostic questionnaire and algorithm against a reference diagnostic test method (RTM) comprising diagnosis by expert evaluation of clinical history, skin prick tests and oral food challenge, in subjects reporting allergic rhinitis (AR) in the UK birch pollen season from March to May. METHODS: Participants were UK adults reporting symptoms of spring time-AR (hayfever). They self-completed a diagnostic questionnaire in addition to undergoing an RTM comprising clinical history, skin prick testing to foods and pollens and oral food challenge. Subjects who reported anaphylaxis were excluded on the basis that they required specialist referral. RESULTS: One hundred and twenty three subjects took part in the study. Data from 110 participants were analysed; of the 13 exclusions, four provided insufficient data and nine reported anaphylaxis such that they warranted specialist assessment. Fifty-two participants (47%) were diagnosed with PFS by the RTM in comparison with 51 (46%) by a diagnostic questionnaire and algorithm (P=1.000, McNemar's test). The diagnostic questionnaire and algorithm had a sensitivity of 0.90 (0.78-0.96), a specificity of 0.93 (0.82-0.97), a positive predictive value of 0.92 (0.80-0.97) and a negative predictive value of 0.91 (0.80-0.96) when measured against the RTM. CONCLUSION AND CLINICAL RELEVANCE: The diagnostic questionnaire and algorithm is a practical and robust tool, which enables rapid identification, and therefore management, of individuals with PFS who experience rhino-conjunctivitis symptoms in the UK birch pollen season. Registered with CinicalTrials.Gov. registration number NCT00854958.

British Society for Allergy and Clinical Immunology guidelines for the management of egg allergy.

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 and the detection of egg white-specific IgE (by skin prick test or serum assay) will confirm the diagnosis in most cases. Egg avoidance advice is the cornerstone of management. Egg allergy often resolves and re-introduction 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 measles, mumps and rubella (MMR) vaccination. Influenza and 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 but 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.

Ventilatory efficiency is unchanged after physical training in healthy persons despite an increase exercise tolerance.

BACKGROUND: In chronic heart failure, exercise training results in an improvement in exercise capacity and a reduction in the ventilatory response to exercise. The effects of a physical training programme on the ventilatory response in healthy persons is not known. METHODS: Metabolic gas exchange and ventilation were measured in 27 young healthy persons aged 31.4 +/- 7.6 years before and after a 19-week training programme of aerobic exercise; exercise was undertaken three times a week for 40 min. Ventilation, the slope of the relationship between ventilation and carbon dioxide production (VE-VCO2 slope) and the ventilatory equivalent for carbon dioxide were measured using respiratory mass spectroscopy. The peak expiratory flow rate in 1 s and forced vital capacity were also measured. RESULTS: Mean +/- SEM peak oxygen consumption increased from 39.5 +/- 1.5 to 45.4 +/- 1.7 ml/kg/min(P<0.001). Exercise time increased from 817 +/- 188 to 896 +/- 186 s (P<0.001). The respiratory exchange ratio at peak exercise was slightly lower after training: 1.30 +/- 0.02 compared with 1.36 +/- 0.03 (P = 0.02). Ventilation at equivalent stages of exercise was unchanged by training. The VE-VCO2 slope did not change (24.52 +/- 0.67 before training, 25.01 +/- 0.80 after training; NS). There was no change in the ventilatory equivalent for carbon dioxide either at rest (38.6 +/- 1.4 compared with 36.2 +/- 1.1; NS) or at its lowest point (23.3 +/- 0.6 compared with 22.9 +/- 3.2; NS). Neither exercise capacity nor the training response correlated with any of the measured ventilatory variables. CONCLUSION: In contrast to the situation in patients with chronic heart failure, there is no relationship between ventilatory variables and exercise capacity in healthy persons and no change in ventilatory performance as a result of physical training.

Treatment of steatorrhoea in cystic fibrosis: a comparison of enteric-coated microspheres of pancreatin versus non-enteric-coated pancreatin and adjuvant cimetidine.

Enteric-coated microspheres of pancreatin were compared with non-enteric-coated pancreatin combined with cimetidine taken 40 min before meals in the treatment of patients with cystic fibrosis. Fourteen adults with steatorrhoea due to cystic fibrosis were investigated in an open, randomized crossover study, over two consecutive 28-day treatment periods. Lipase intake was adjusted to each patient's previous requirements and was the same during both months; they were instructed to continue with their normal diet. Patients collected faeces for 72 h at the end of each month and completed diary cards daily throughout. Bowel actions were less frequent on enteric-coated microspheres of pancreatin than on non-enteric-coated pancreatin/cimetidine (1.7 vs. 2.4/day; P less than 0.001) and stool character was improved (P less than 0.001). Mean daily faecal weight was similar on enteric-coated microspheres of pancreatin to that on the combination (254 g vs. 291 g; N.S.), whereas daily faecal fat excretion tended to be less on enteric-coated microspheres of pancreatin (21 g vs. 27 g; N.S.), and percentage fat absorption tended to be greater (81% vs. 73%; N.S.). Mean body weight increased by 0.3 kg on enteric-coated microspheres of pancreatin and fell by 0.1 kg on the combination (N.S.). These data indicate that enteric-coated microspheres of pancreatin are at least as effective as non-enteric-coated pancreatin with cimetidine in the treatment of steatorrhoea in cystic fibrosis.

Enteric coated microspheres of pancreatin in the treatment of cystic fibrosis: comparison with a standard enteric coated preparation.

In an open, randomised crossover study enteric coated microspheres of pancreatin were compared with a standard preparation of enteric coated pancreatin over two consecutive 28 day treatment periods in 23 adults with steatorrhoea due to cystic fibrosis. Lipase intake was equal to the patients' previous requirements and was the same during the two months. Patients performed 72 hour faecal collections at the end of each month and completed diary cards daily throughout. Comparison of the month of treatment with enteric coated microspheres with the month of standard enteric coated tablets showed a significant increase in body weight on microsphere capsules (p less than 0.02). There was also a reduced frequency of bowel actions (p less than 0.001) and abdominal pain (p less than 0.05), and improvement in stool character (p less than 0.001) on microsphere capsules. Faecal fat excretion was reduced by 44% with the microsphere capsules (p less than 0.01), and 86% of patients showed an increased coefficient of fat absorption (mean increase 13%, 95% confidence limits 6.5-19.1%; p less than 0.001). Eighty one per cent of patients preferred microsphere capsules of the two treatments. Thus enteric coated microsphere capsules are more effective in treating steatorrhoea in cystic fibrosis than standard enteric coated tablets.

The effect of diet upon serum concentrations of theophylline.

Eight patients with airways obstruction were investigated to determine if dietary components had any significant effect upon serum concentrations of theophylline when taking a slow release formulation. A high carbohydrate, low protein diet, given for 1 week, resulted in the area under the concentration time curve for 12 h being 33.3% greater than a high protein low carbohydrate diet given under the same conditions. In contrast to two previous studies no significant effect upon the elimination half-life was detected after changing from one diet to the other and an effect of dietary components upon absorption and/or distribution needs to be considered. Morning and afternoon trough levels were significantly different from each other on both diets suggesting that theophylline kinetics are different at night. Individualising of theophylline dosing is particularly needed when treating patients on a varied dietary intake.