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Management of peanut allergy
CORRESPONDENCE
Uterine fibroids should be considered when women present with PTHrP-induced hypercalcaemia.3 *A S Kashyap, Surekha Kashyap Departments of *Medicine and Hospital Administration, Armed Forces Medical College, Pune 411 040, India 1 2
3
4
Stewart EA. Uterine fibroids. Lancet 2001; 357: 293–98. Knecht TP, Behling CA, Burton DW, Glass CK, Deftos LJ. The humoral hypercalcemia of benignancy: a newly appreciated syndrome. Am J Clin Pathol 1996; 105: 487–92. Ravakhah K, Gover A, Mukunda BN. Humoral hypercalcemia associated with a uterine fibroid. Ann Intern Med 1999; 130: 702. Weir EC, Goad DL, Daifotis AG, Burtis WJ, Dreyer BE, Nowak RA. Relative overexpression of the parathyroid hormone-related protein gene in human leiomyomas. J Clin Endocrinol Metab 1994; 78: 784–89.
Management of peanut allergy Sir—P Ewan and A Clark (Jan 13, p 111)1 note the effect of poor management in peanut and nut allergy, which is the most frequent cause of severe or fatal reactions to food. In their long-term study they reviewed management plans to improve outcomes in allergy patients. Previous management consisted of an epinephrine self-injection with little training or advice. They conclude that their management plan was effective and that patients should be referred to specialist allergy centres for advice on nut avoidance. We are unsure about some parts of the study. First, the exact duration of the study is unclear. This information would be useful to assess the efficacy of their management plan. Second, we are concerned that there is no control group. Ewan and Clark thought such a group would be unethical. Without a control, we believe that the conclusions are limited. To include a group of people on standard treatment as a control group would have been ethical. Third, we found the presentation of the results confusing. The results in the table and the text were discrepant, which limited our understanding. Clarification is needed on the number of participants who experienced a moderate to severe reaction requiring the use of epinephrine. We appreciate the importance of this study and the apparent usefulness of education and advice. Further research with use of controls is required before the conclusions can alter current practice.
THE LANCET • Vol 357 • May 12, 2001
*Ingvild Bauge, Charity Cooper, Rakesh Premkumar, Isabel Tresharn
administration reactions.
Department of Epidemiology and Public Health, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK
Pamela Ewan, Andrew Clark
1
Ewan PW, Clark AT. Long-term prospective observational study of patients with peanut and nut allergy after participation in a management plan. Lancet 2001; 357: 111–15.
Authors’ reply Sir—The duration of our study was up to 7 years (median 22 months) and follow-up reached 13 610 patientmonths, as we state in the report. 21 of 23 patients with moderate reactions used an epinephrine inhaler for mild laryngeal oedema, which was always successful. In addition, nine of 26 patients with a moderate or severe reaction received an epinephrine injection. Bauge and colleagues find this confusing. All participants are accounted for in tables referenced in the text. Table 2 shows that three patients self-injected epinephrine, and an additional table published at www.thelancet.com shows a further six patients received intramuscular epinephrine from medical staff. One of these patients had a mild index reaction and, therefore, had no injectable epinephrine available; the remainder received intramuscular epinephrine for mild laryngeal oedema or mild wheeze from medical staff, which was beyond our control. In the report we discuss the use of a control group at length and acknowledge it as a study limitation. We present data to show that repeated reactions occur in the UK in up to 50% of patients who are aware of their diagnosis (and are presumably avoiding nuts) and 50% in the USA among those given self-injected epinephrine, compared with 15% in our series, for whom most further reactions were mild. A control group of patients cannot justifiably be left to fend for themselves when the frequency of follow-up reactions, some of which could be life threatening, is so high. In addition, because of anxiety about fatal or nearfatal allergic reactions, especially among parents, a no-treatment group was unlikely to have been accepted. Finally, there is no standard treatment, and, therefore, there is no consensus as to how the control group would be managed. Our study underscores the importance of providing a complete management package for nut allergy, including detailed advice on nut avoidance together with a treatment plan and medication for self-
in
case
of
further
Department of Allergy and Clinical Immunology, Addenbrooke’s Hospital, Hills Rd, Cambridge CB2 2QQ, UK
Sir—In their Jan 13 commentary, David Hill and colleagues1 reviewed some key issues of peanut and nut allergies. Nut allergy has received less public attention than is merited. There has been much public anxiety, however, about genetically modified (GM) foodstuffs, based on a hypothetical threat of hazards that has yet to be seen or quantified. Public and media concerns over such hazards are inevitable, but attention has been diverted from existing hazards to non-genetic modification of food. Hospital admissions for anaphylaxis and food-related anaphylaxis are increasing.2 Hill and colleagues note that the most common form of food allergy is nut related, especially to peanuts. They make apparent that labelling on foodstuffs about nut hazard is not as adequate as it should be. In view of this finding, we studied the nut presence or contamination in commonly eaten foods. We assessed three common food products—cereal, biscuits, and confectionery—in four major retail supermarket stores in southwest Wales, UK. The food products were classified according to nut risks as follows: contained nuts (obvious nut content); nut-free (no trace of nuts noted on product wrapping); and nut risk (possibly contaminated by nut products, or produced in a unit that handled nuts). The clarity of nut warnings was assessed by looking at the packaging. 630 products were inspected, consisting of 213 cereal products, 296 biscuit types, and 121 confectionery products. 92 (15%) products were marked as containing nuts as ingredients. 161 (25%) were marked as being completely nut-free. 377 (60%) items had warnings of nut contamination, 49 of which were difficult to read. The legibility of nut risk labelling on shops’ own-brand products varied across supermarkets. We noted that a high proportion of common foods eaten by children and sold by the major supermarkets contained nuts or nut products that are hazardous to at least 1% of the population. Major product brands not owned by supermarkets were more likely to be nut-free, and if they did contain nuts, had more obvious labelling. Since fatal anaphylaxis can be induced by ingestion of between 1 mg and 1 g food product, the labelling issue is critical.3
1531
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Uterine fibroids should be considered when women present with PTHrP-induced hypercalcaemia.3 *A S Kashyap, Surekha Kashyap Departments of *Medicine and Hospital Administration, Armed Forces Medical College, Pune 411 040, India 1 2
3
4
Stewart EA. Uterine fibroids. Lancet 2001; 357: 293–98. Knecht TP, Behling CA, Burton DW, Glass CK, Deftos LJ. The humoral hypercalcemia of benignancy: a newly appreciated syndrome. Am J Clin Pathol 1996; 105: 487–92. Ravakhah K, Gover A, Mukunda BN. Humoral hypercalcemia associated with a uterine fibroid. Ann Intern Med 1999; 130: 702. Weir EC, Goad DL, Daifotis AG, Burtis WJ, Dreyer BE, Nowak RA. Relative overexpression of the parathyroid hormone-related protein gene in human leiomyomas. J Clin Endocrinol Metab 1994; 78: 784–89.
Management of peanut allergy Sir—P Ewan and A Clark (Jan 13, p 111)1 note the effect of poor management in peanut and nut allergy, which is the most frequent cause of severe or fatal reactions to food. In their long-term study they reviewed management plans to improve outcomes in allergy patients. Previous management consisted of an epinephrine self-injection with little training or advice. They conclude that their management plan was effective and that patients should be referred to specialist allergy centres for advice on nut avoidance. We are unsure about some parts of the study. First, the exact duration of the study is unclear. This information would be useful to assess the efficacy of their management plan. Second, we are concerned that there is no control group. Ewan and Clark thought such a group would be unethical. Without a control, we believe that the conclusions are limited. To include a group of people on standard treatment as a control group would have been ethical. Third, we found the presentation of the results confusing. The results in the table and the text were discrepant, which limited our understanding. Clarification is needed on the number of participants who experienced a moderate to severe reaction requiring the use of epinephrine. We appreciate the importance of this study and the apparent usefulness of education and advice. Further research with use of controls is required before the conclusions can alter current practice.
THE LANCET • Vol 357 • May 12, 2001
*Ingvild Bauge, Charity Cooper, Rakesh Premkumar, Isabel Tresharn
administration reactions.
Department of Epidemiology and Public Health, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK
Pamela Ewan, Andrew Clark
1
Ewan PW, Clark AT. Long-term prospective observational study of patients with peanut and nut allergy after participation in a management plan. Lancet 2001; 357: 111–15.
Authors’ reply Sir—The duration of our study was up to 7 years (median 22 months) and follow-up reached 13 610 patientmonths, as we state in the report. 21 of 23 patients with moderate reactions used an epinephrine inhaler for mild laryngeal oedema, which was always successful. In addition, nine of 26 patients with a moderate or severe reaction received an epinephrine injection. Bauge and colleagues find this confusing. All participants are accounted for in tables referenced in the text. Table 2 shows that three patients self-injected epinephrine, and an additional table published at www.thelancet.com shows a further six patients received intramuscular epinephrine from medical staff. One of these patients had a mild index reaction and, therefore, had no injectable epinephrine available; the remainder received intramuscular epinephrine for mild laryngeal oedema or mild wheeze from medical staff, which was beyond our control. In the report we discuss the use of a control group at length and acknowledge it as a study limitation. We present data to show that repeated reactions occur in the UK in up to 50% of patients who are aware of their diagnosis (and are presumably avoiding nuts) and 50% in the USA among those given self-injected epinephrine, compared with 15% in our series, for whom most further reactions were mild. A control group of patients cannot justifiably be left to fend for themselves when the frequency of follow-up reactions, some of which could be life threatening, is so high. In addition, because of anxiety about fatal or nearfatal allergic reactions, especially among parents, a no-treatment group was unlikely to have been accepted. Finally, there is no standard treatment, and, therefore, there is no consensus as to how the control group would be managed. Our study underscores the importance of providing a complete management package for nut allergy, including detailed advice on nut avoidance together with a treatment plan and medication for self-
in
case
of
further
Department of Allergy and Clinical Immunology, Addenbrooke’s Hospital, Hills Rd, Cambridge CB2 2QQ, UK
Sir—In their Jan 13 commentary, David Hill and colleagues1 reviewed some key issues of peanut and nut allergies. Nut allergy has received less public attention than is merited. There has been much public anxiety, however, about genetically modified (GM) foodstuffs, based on a hypothetical threat of hazards that has yet to be seen or quantified. Public and media concerns over such hazards are inevitable, but attention has been diverted from existing hazards to non-genetic modification of food. Hospital admissions for anaphylaxis and food-related anaphylaxis are increasing.2 Hill and colleagues note that the most common form of food allergy is nut related, especially to peanuts. They make apparent that labelling on foodstuffs about nut hazard is not as adequate as it should be. In view of this finding, we studied the nut presence or contamination in commonly eaten foods. We assessed three common food products—cereal, biscuits, and confectionery—in four major retail supermarket stores in southwest Wales, UK. The food products were classified according to nut risks as follows: contained nuts (obvious nut content); nut-free (no trace of nuts noted on product wrapping); and nut risk (possibly contaminated by nut products, or produced in a unit that handled nuts). The clarity of nut warnings was assessed by looking at the packaging. 630 products were inspected, consisting of 213 cereal products, 296 biscuit types, and 121 confectionery products. 92 (15%) products were marked as containing nuts as ingredients. 161 (25%) were marked as being completely nut-free. 377 (60%) items had warnings of nut contamination, 49 of which were difficult to read. The legibility of nut risk labelling on shops’ own-brand products varied across supermarkets. We noted that a high proportion of common foods eaten by children and sold by the major supermarkets contained nuts or nut products that are hazardous to at least 1% of the population. Major product brands not owned by supermarkets were more likely to be nut-free, and if they did contain nuts, had more obvious labelling. Since fatal anaphylaxis can be induced by ingestion of between 1 mg and 1 g food product, the labelling issue is critical.3
1531
For personal use. Only reproduce with permission from The Lancet Publishing Group.