Please do only: 4-5 pages own words (minimum 1000 words, double space, time roman), and citation (APA or CBE citation style)Paper should be a synthesis of what other scientists or experts have learned in 4 articles attached, while deriving your own conclusion from the evidence presented.Will tip 70% to 100% of the price if: (1) On time (otherwise, 0% tip), (2) Use your own word via TURNITIN) (otherwise, withdrawn)Attached are 4 articles (pdf), 2 of them related to Peanut Allergy, 2 related to Milk AllergyBelow is what professor wants:You will be expected to identify, evaluate, interpret and utilize the information you obtain through research to critically discuss problems related to those issues. You will be graded on your ability to address complex issues related to food toxicology and our environment using analytical, reasoning and critical thinking skills to develop sound and effective arguments in support of your opinions, and to effectively communicate your ideas through both oral and written communication.The presentation and paper should:include a specific, clearly stated objective statement in the Introduction. For example, the objective of this presentation / paper is to — evaluate current evidence regarding the scientific safety of genetically modified organism or examine current research on the relationship between polychlorinated biphenols contamination and reproductive failure in women;report all findings in the past tense, and your summary in the present tense;not use first or second person or value-based statements (i.e. I believe, I think, etc). Use objective descriptive statements (e.g. the data suggest, the studies provide strong evidence, or the data support the conclusion);be properly referenced – make sure your citations in the text are in the reference list and vise versa.In approaching the issues:1. It is important to narrow your focus and do an in-depth analysis of a specific issue rather than simply describe a problem with broad generalized strokes.Keep the presentation focused on the specific issue in question, do not wander aimlessly around a topic.Distinguish between the purely scientific arguments and arguments from social, political or philosophical positions.Discuss what differences, if any, are there in arguments made by scientist, consumer advocates, sociologist, religious or ethnic leaders?Discuss the issue without prejudice or bias, acknowledge other points of view, but do not be afraid to state and argue for your own.Do not make unsupported statements or claims.Do not assume that the majority view or generally accepted opinion is correct.Discuss the issue thoroughly, provide critical analysis (very important) and then suggest directions for further research.Evaluation of Final Written Report (50 pts)9 pts objectives, point of view or arguments clearly presented?4 pts Research design/methods described?4 pts Was the evidence, arguments, and findings reported without bias?9 pts Was a critical evaluation made of the studies, including methods and interpretation of data? Were strengths and limitations noted?9 pts Was a conclusion clearly stated? Did it draw from the findings?4 pts Was a discussion made of the significance of the findings?7 pts Was the paper written clearly, with few grammatical errors, and in an organized manner?4 pts Was the paper submitted in a professional manner (i.e. with name, date, title, following instructions, and handed in on time)?
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The Journal of Emergency Medicine, Vol. 40, No. 6, pp. 633 636, 2011
Copyright © 2011 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$see front matter
ADVANCES IN THE TREATMENT OF PEANUT ALLERGY: A CASE REPORT
Richard F. Edlich, MD, PHD,* Amy A. Cochran, Jill Amanda Greene, Dayna R. Woode,§
K. Dean Gubler, DO, MPH,? and William B. Long III, MD¶
*Distinguished Professor of Plastic Surgery, Biomedical Engineering, and Emergency Medicine, University of Virginia Health Systems,
Charlottesville, Virginia and Director of Trauma Research, Education and Prevention, Legacy Emanuel Hospital, Portland, Oregon,
Premedical Student, Washington State University, Vancouver, Washington, Registered Nursing Student, Washington State University,
Vancouver, Washington, §Information Specialist, Vancouver, Washington, ?Surgical Critical Care Director, Trauma Specialists, LLP,
Legacy Emanuel Hospital, Portland, Oregon, and ¶President and Medical Director of Trauma Specialists, LLP, Legacy Emanuel
Hospital, Portland, Oregon
Reprint Address: Richard F. Edlich, MD, PHD, 22500 NE 128th Circle, Brush Prairie, WA 98606
e Keywordspeanut allergy; fatal anaphylactic reaction;
asthma attack; inhaled corticosteroids; skin prick testing;
peanut-specific immunoglobulin E
e AbstractBackground: Peanut allergies affect 1.5% of
children. The majority of reactions to peanuts are mild, but
peanut allergy is also the most common cause of fatal
anaphylactic reactions to food. Case Report: The purpose
of this case report was to describe a 1-year old boy who
developed difficulty breathing after eating a peanut food
product. The boy was taken immediately by his mother to
an Emergency Department, exhibiting severe respiratory
distress. After speaking to the childs mother, the emergency physician (EP) realized that the wheezing was due to
a peanut food allergy. The childs respiratory symptoms
responded within 10 min to bronchodilatator inhalation.
The EP gave the mother educational information regarding
the management of asthma and the proper use of metered
dose inhalers with spacer devices. The EP referred the child
to a clinical allergist who specializes in the management of
food allergies. The diagnosis was made by skin prick testing
as well as in vitro measurement of peanut-specific immunoglobulin E. Conclusion: The allergist explained that the mainstay of management of peanut allergy is avoidance of the
allergenic food. Patient education involved teaching the
mother to avoid high-risk situations such as dinner with family members who are not informed about the childs allergy to
peanuts, encouraging the child to wear a Medic Alert Bracelet,
and teaching the family and child to recognize early symptoms
of allergic reactions and to manage an anaphylactic reaction,
including the use of self-injectable epinephrine, as well as
activating emergency services. © 2011 Elsevier Inc.
RECEIVED: 13 October 2007; FINAL
ACCEPTED: 7 January 2008
In 2000, our team of scientists and physicians reported
the dangers of cornstarch on examination and surgical
gloves that could cause a severe allergic reaction (1). We
found that health care workers are at high risk for this
allergy due to occupational exposure to cornstarch on
latex. In this article, we discuss in detail the treatment
and prevention of latex allergies in the hospital setting.
In the present article, we report the case of a child
with a potentially life-threatening reaction to peanuts
who was treated successfully by an Emergency Physician (EP) with the help of a clinical allergist and immunologist. Furthermore, we discuss the management and
prevention of peanut allergies as well as research advances that will hopefully suppress or eliminate the allergic reaction to peanuts. This article includes three
parts: 1) an overview of the frequency and life-threatening
consequences of peanut allergies; 2) A case report of
a child with a potentially life-threatening reaction to
peanuts who was treated successfully by an EP with the
14 December 2007;
R. F. Edlich et al.
help of a clinical allergist and immunologist; and 3) a
discussion of research advances in the management of
peanut allergies that hopefully will suppress or eliminate
the allergic reaction to peanuts.
Peanut allergies affect 1.5% of children. Peanut allergy also has an early onset that can precipitate severe
allergic reactions (2,3). Tree nut allergies are common
and persistent (4 6). Allergy to cashew nuts is increasingly recognized in clinical practice (7). Management of
nut allergy should include a risk assessment to provide
specific avoidance advice as well as emergency medical
care (8). Factors that might influence the severity of
future reactions include the following: 1) age of patient,
2) severity of worst reaction to date, and 3) the amount of
nut that caused the reaction (9). The type of nut that
caused the worst reaction to date may also indicate an
increased risk. The majority of reactions to peanuts are
mild, but peanut allergy is also the most common of fatal
anaphylactic reactions to food (9).
While shopping in a grocery store with her 1-year-old
son, a mother was offered samples of a new food product
containing peanuts. Not realizing that her son was allergic to peanuts, she put the peanut food sample in his
mouth. Her son began to cry a few minutes after consuming the food. He then developed redness and swelling in his cheeks that was associated with some difficulty
breathing. It was fortuitous that a nurse was shopping in
the same grocery store and recognized immediately the
potentially severe allergic reaction. She took the mother
and child to an Emergency Department (ED) that was
only two blocks from the grocery store. The child was
seen and examined by an EP, who quickly recognized
that the child exhibited wheezing that was confirmed by
auscultation of the childs chest. The child had stable
vital signs and no evidence of cardiovascular symptoms or cutaneous findings that suggested an allergic
reaction. His respiratory symptoms responded within
10 min to bronchodilatator administration (albuterol
sulfate [PROVENTIL® HFA; Schering-Plough Corporation, Kenilworth, NJ]; 2.5 mg was diluted with 0.9%
saline to a final volume of 3 mL) and nebulization. The
EP gave the mother education information regarding the
management of respiratory symptoms and proper use of
metered dose inhalers with spacer devices. Because the
mother informed the EP that the respiratory symptoms
occurred immediately after eating a peanut, the EP referred the mother and child to a clinical allergist in the
same hospital. The mother took her son immediately to
the allergist, who specializes in the management of food
Skin prick testing was performed by the skin prick test
method using commercial extract (Hollister-Steri Laboratories, LLC, Spokane, WA) (11). In this childs case,
the skin prick test wheal diameter was 8 mm. Sporik
et al. reported a skin prick test wheal diameter of ? 8
mm to be 100% specific in predicting positive challenges
to peanut allergies in children attending an Allergy
Clinic in Melbourne, Australia (12). Skin prick testing of
the patient was combined with in vitro measurement of
peanut-specific immunoglobulin E (IgE). The child had a
peanut-specific IgE level of 15 kU/L. Sampson and Ho
found that this specific IgE level had a ? 95% predicted
value for a positive challenge in a study of children with
atopic dermatitis (13).
The mainstay of management of the patients peanut
allergy focused on prevention by avoidance of allergenic
food. This avoidance of allergenic foods required extensive education of the parents, family members, and their
caregivers about the proper reading of packaged food
labels. New labeling legislation that came into effect
during the past year in the United States and Europe has
made this task simpler by mandating clear labeling and
enforcing ingredients statements on packaged food labels
and declaring information related to the presence of
possible allergenic residues from processing other foods
by the same food manufacturing company (14).
Patient education also involved teaching to avoid
high-risk situations such as dinner with uninformed family members or friends who do not know about the boys
peanut allergy, encouraging this child to wear a Medic
Alert Bracelet, and teaching the family and the child to
recognize early symptoms of allergic reactions and to
manage an anaphylactic reaction, including the use of
self-injectable epinephrine with an Epinephrine AutoInjector (EpiPen®; Dey L.P., Napa, CA), as well as
activating emergency services (15). A good resource for
educational materials is the Food Allergy and Anaphylaxis Network in the United States.
Due to the development of respiratory symptoms
that were thought to be related to peanuts, the child
was given a monoclonal antibody against IgE, approved for use in patients with moderate-to-severe
persistent allergic respiratory symptoms. This therapy
proved to be useful as adjuvant to allergen avoidance
and may prove to be helpful against other food allergies in the same individual.
Despite educational efforts to prevent peanut allergic
reaction, significant reactions continue to occur. Fortunately, various therapies for IgE-mediated allergies are
being explored and will be used either in conjunction
Peanut Allergy Treatment
with allergen avoidance or to replace it altogether. These
include the following therapies: 1) anti-IgE therapy, 2)
immunotherapy, and 3) traditional Chinese herbal medicine. The pharmacological purposes of the anti-IgE therapy are to neutralize IgE and to inhibit its production to
attenuate type I hypersensitivity reactions (16). The therapy is based on humanized IgG1 antibodies that bind to
free IgE and to membrane-bound IgE on B cells, but not
to IgE bound by the high-affinity IgE.Fc receptors on
basophils and mast cells or by the low-affinity IgE.Fc
receptors on B cells. After nearly 20 years since their use
began, therapeutic anti-IgE antibodies (anti-IgE) have
been studied in about 30 Phase II and III clinical trials
with many allergy indications, and a lead antibody,
omalizumab, has been approved for treating patients (12
years and older) with moderate-to-severe allergic
asthma. Anti-IgE has confirmed the roles of IgE in the
pathogenesis of asthma and helped define the concept
allergic asthma in clinical practice. It has been shown
to be safe and efficacious in treating pediatric allergic
asthma and treating allergic rhinitis and is being investigated for treating peanut allergy, atopic dermatitis, latex allergy, and others. It has potential for use in combination with specific and rush immunotherapy for
increased safety and efficacy. Anti-IgE thus seems to
provide a prophylactic and therapeutic option for moderate to severe cases of many allergic diseases and conditions in which IgE plays a significant role.
Given the high incidence of systemic reactions using
standard subcutaneous immunotherapy for IgE-mediated
peanut allergy, oral immunotherapy has been investigated as an alternative over the past few years, with
variable results. Recent investigations have been encouraging, demonstrating its safety and efficacy in increasing
tolerance to the food allergies. A randomized, doubleblind placebo-controlled study using the sublingual administration of hazelnut extract demonstrated effectiveness with minimal systemic reactions (17).
More randomized studies on oral immunotherapy are
needed to determine the optimal starting and maintenance doses and titration schedules that would provide
an efficacious and safe therapy in the shortest period of
time. Long-term efficacy has yet to be determined.
In 2001, a Chinese herbal formula, food allergy herbal
formula I, containing a mixture of 11 herbs believed to
contain anti-allergenic properties, was tested in a murine
model of peanut anaphylaxis, and was found to block
peanut-induced anaphylaxis and reduce peanut-specific
IgE levels and systemic T helper type II cytokines (18).
More recently, a more simplified formula, food allergy
herbal formula II, containing nine of the original 11
herbs, was tested in the same murine model, and was
found to be equally safe and effective (19). Clinical trials
using this formula in patients with peanut allergy must be
initiated to test its safety and efficacy in humans. Although the past few years have been marked by major
research advances in potential therapies, the mainstay of
therapy for IgE-mediated food allergy remains avoidance
of the offending foods.
It is important to emphasize that one-third of the patients
allergic to peanuts have allergies to other tree nuts and
should be tested for allergies to all types of tree nuts (20).
Children under 5 years of age who are allergic to peanuts
should avoid all nuts, as they may develop sensitivity to
them. Children from families with histories of allergies
and atopy, or those who exhibit milk or egg allergies
early in life, should avoid peanuts at a young age. In
addition, it has been well documented that there is a low
incidence of referral of children to allergists for comprehensive care (21). Finally, it is important that prescriptions for self-injectable epinephrine be given to all patients presenting to EDs with anaphylactic reactions to
1. Jackson EM, Arnette JA, Martin ML, Tahir WM, Frost-Arner L,
Edlich RF. A global inventory of hospitals using powder-free
gloves: a search for principled medical leadership. J Emerg Med
2. Grundy J, Matthews S, Bateman B, Dean T, Arshad S. Rising
prevalence of allergy to peanut in children: data from 2 sequential
cohorts. J Allergy Clin Immunol 2002;110:784 9.
3. Bock SA, Atkins FM. The natural history of peanut allergy.
J Allergy Clin Immunol 1989;83:900 4.
4. Fleischer D, Conover-Walker M, Matsui E, Wood R. The natural
history of tree nut allergy. J Allergy Clin Immunol 2005;116:
5. Sicherer S, Burks W, Sampson H. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998;
6. Ewan P. Clinical study of peanut and nut allergy in 62 consecutive
patients: new features and associations. BMJ 1996;312:1074 8.
7. Clark AT, Anagnostou K, Ewan PW. Cashew nut causes more
severe reactions than peanut: case-matched comparison in 141
children. Allergy 2007;62:913 6.
8. Ewan P, Clark A. Efficacy of a management plan based on severity
assessment in longitudinal and case controlled studies of 747
children with nut allergy: proposal for good practice. Clin Exp
Allergy 2005;35:751 6.
9. Bock S, Munoz-Furlong A, Sampson H. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001;107:1913.
10. Stone KD. Advances in pediatric allergy. Curr Opin Pediatr 2004;
11. Sampson HA. Food allergy. Part 2: diagnosis and management.
J Allergy Clin Immunol 1999;103:9819.
12. Sporik R, Hill DJ, Hosking CS. Specificity of allergen skin testing
in predicting positive open food challenges to milk, egg and peanut
in children. Clin Exp Allergy 2000;30:1540 6.
13. Sampson HA, Ho DG. Relationship between food-specific
IgE concentrations and the risk of positive food challenges in
children and adolescents. J Allergy Clin Immunol 1997;100:
Taylor SL, Hefle SL. Food allergen labeling in the USA and
Europe. Curr Opin Allergy Clin Immunol 2006;6:186 90.
Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol
2006;117(2 Suppl):S470 5.
Chang TW, Wu PC, Hsu CL, Hung AF. Anti-IgE antibodies for the
treatment of IgE-mediated allergic diseases. Adv Immunol 2007;
Enrique E, Pineda F, Malek T, et al. Sublingual immunotherapy for hazelnut food allergy: a randomized, double-blind,
placebo-controlled study with a standardized hazelnut extract. J
Allergy Clin Immunol 2005;116(5):10739.
R. F. Edlich et al.
18. Li XM, Zhang TF, Huang CK, et al. Food allergy herbal formula-1
(FAHF-1) blocks peanut-induced anaphylaxis in a murine model.
J Allergy Clin Immunol 2001;108:639 46.
19. Srivastava KD, Kattan JD, Zou ZM, et al. The Chinese herbal
medicine formula FAHF-2 completely blocks anaphylactic reactions in a murine model of peanut allergy. J Allergy Clin Immunol
20. Fleischer DM. The natural history of peanut and tree nut allergy.
Curr Allergy Asthma Rep 2007;7:175 81.
21. Ewan PW, Clark AT. Efficacy of a management plan based on
severity assessment in longitudinal and case-controlled studies of
747 children with nut allergy: proposal for good practice. Clin Exp
Allergy 2005;35:751 6.
Methods 66 (2014) 2233
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/locate/ymeth
Cows milk allergy: From allergens to new forms of diagnosis, therapy
Heidrun Hochwallner a,?, Ulrike Schulmeister b, Ines Swoboda a,1, Susanne Spitzauer b, Rudolf Valenta a
Division of Immunopathology, Department of Pathophysiology and Allergy Research, Medical University of Vienna, Austria
Department of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Austria
a r t i c l e
i n f o
Available online 15 August 2013
a b s t r a c t
The ?rst adverse reactions to cows milk were already described 2000 years ago. However, it was only
50 years ago that several groups started with the analysis of cows milk allergens. Meanwhile the spectrum of allergy eliciting proteins within cows milk is identi?ed and several cows milk allergens have
been characterized regarding their biochemical properties, fold and IgE binding epitopes. The diagnosis
of cows milk allergy is diverse ranging from fast and cheap in vitro assays to elaborate in vivo assays. Considerable effort was spent to improve the diagnosis from an extract-based into a component resolved
concept. There is still no suitable therapy available against cows milk allergy except avoidance. Therefore
research needs to focus on the development of suitable and safe immunotherapies that do not elicit
severe side effect.
Ó 2013 The Authors. Published by Elsevier Inc. Open access under CC BY license.
1.1. History of cows milk allergy
The introduction of cows milk (CM) into alimentation has a
very long tradition. It is reported that animal milk was included
into the human diet approximately 9000 years ago. The domestication of cattle provided meat and milk as important components of
our diet . The production of cheese started with the ancient
Greeks and Romans . At the same time people in Northern Europe lost their lactose intolerance. Therefore lactase activity, a genetic trait, and animal husbandry, a cultural trait, represent an
example for gene-culture co-evolution . The ?rst adverse reactions to CM that were described by Hippocrates (prior to 370
B.C.) were skin and gastrointestinal symptoms after CM consumption . Five hundred years later, the Greek medical researcher Galen of Pergamum mentioned a causal relationship between these
symptoms and milk consumption . At the beginning of the
? Corresponding author. Address: Division of Immunopathology, Department of
Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and
Immunology, Medical University of Vienna, AKH 3Q, Waehringer Guertel 18-20,
1090 Vienna, Austria.
E-mail address: firstname.lastname@example.org (H. Hochwallner).
Current address: Molecular Biotechnology Section, University of Applied Sciences,
Campus Vienna Biocenter, Vienna, Austria.
1046-2023 Ó 2013 The Authors. Published by Elsevier …
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