Wednesday, September 26, 2007

House of Lords Reports on Allergy And Allergic Disease

Imagine having a Ferrari that you are only ever allowed to drive in a velodrome. Imagine further, that there is a noise-limiter on the engine and that you are not allowed to exceed 12 miles an hour. The UK is in the somewhat remarkable position of having some of the most well-respected and expert clinical allergists and immunologists in the world yet employing them within a National Health Service that is infamous for its lack of adequate allergy services and the poverty of available resources.

A House of Lords Committee has been investigating allergy and allergic diseases in the UK. The House of Lords (HoL) committee has issued a comprehensive report (HL 166-1 or pdf) and made some strong recommendations that seem wholly appropriate to the scale of need within the UK.

It is breathtakingly difficult to obtain a referral to a clinical allergist in the UK. In the whole of the UK, we have the equivalent of 26.5 consultant posts: approximately 5 of those are specialists in paediatric allergy. Clinical allergists frequently express their concern that it is this lack of provision that is driving some desperate people towards inappropriately qualified advisers who may lack a full understanding of allergy, anaphylaxis, intolerance and their appropriate diagnosis and management. The lack of timely access to NHS allergy diagnosis and management pushes people who suspect that they have allergies towards the more dubious fringes of CAM or to testing laboratories that claim clinical validation and "sound science" for their product range of tests.

Both allergies and intolerances can have a dramatic and deletrious impact on quality of life. Allergy can kill. It is difficult to write about less severe forms of allergy because it is not practical to predict whether or not a mild allergy might suddenly become a life-threatening allergy.

A number of children 'grow out of' allergies but many of them don't although there is some indication that timely intervention for allergic rhinitis might mitigate the onset of asthma. Some children have allergies that are multi-systemic and this puts them at particular risk.

Allergies are typically managed, not cured. An exception to this is the laborious process of immunotherapy for some allergens which is rarely available on the NHS in the UK and is reserved for those people for whom medical management has failed. However, allergic rhinitis and hayfever respond well to immunotherapy. Immunotherapy can take a long time: people with allergies are exposed to small doses of the substance which causes a reaction in order to "desensitise" them and the exposure is increased gradually to erode the response. Immunotherapy is a well-established standard of care in other countries and known to lighten the disease burden for some allergies. Dr Lourdes de Asis has provided an excellent overview of allergen immunotherapy and reports that where it is used appropriately:
Immunotherapy is successful in up to 90-95% of patients with seasonal allergies and up to 85% of patients with year-round allergies.
Professor Hourihane gave evidence on immunotherapy to the HoL committee; he commented:
The NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases.
The technique, which used be given in GPs' surgeries, fell into disrepute in the UK after the mid-1980s after a report from the Committee on the Safety of Medicines in 1986 found that immunotherapy had caused 26 deaths over the previous 30 years. However, Committee Chair, Baroness Finlay of Llandaff, reports that it seems that immunotherapy was being administered to "the wrong patients by the wrong people in the wrong places".

The report makes interesting reading and there are many useful recommendations that would make a dramatic difference to allergy services within the UK and a significant difference to the appropriate management of allergic disease and the quality of life of many people. One of the most striking recommendations is the unequivocal support for the re-introduction of immunotherapy as a management technique for allergy and allergic disease with appropriate caveats governing the people and conditions for whom/which this is most effective and the setting for such treatment (a specialist tertiary centre, see pg 79 pdf).
Immunotherapy is a valuable resource in the prophylactic treatment of patients with life-threatening allergies, or whose allergic disease does not respond to other medication. Although initially expensive, immunotherapy can prevent a symptomatic allergic response for many years, and may prevent the development of additional allergic conditions, so its wider use could potentially result in significant long-term savings for the NHS. We recommend that NICE should conduct a full cost-benefit analysis of the potential health, social and economic value of immunotherapy treatment. [pg 81, pdf.]
This is a comprehensive and fine report with many important recommendations that I shall explore in other posts (not least, the importance of food-labelling; the call for responsible professionals and charities to stop endorsing direct to consumer allergy and intolerance tests and an outline plan to set up a national network of specialist allergy centres).

However, one dispiriting note is that the HoL Committee can only make recommendations. The National Allergy Strategy Group (NASG) represents clinicians working in the field of allergy, and cautions that this is the fourth national report highlighting deficiencies and the Department of Health has failed to act on any of them despite increasing evidence of the marked increase in allergies in the UK. The NASG representative said:
Health Ministers must act now.

Unless health authorities and trusts are directed to develop services and funding is identified, patient care will not improve.

Investment to train more specialists in allergy and to support GP education is needed.

Failure to diagnose and treat allergy is resulting in continuing illness and cost to the NHS.
These clinicians are experts; they have a very clear view of the desperate state of allergy services on the NHS. It is long past time that the Dept. of Health should stop making these people tootle round velodromes; these clinicians deserve better and so do millions of people throughout the UK who need the provision that they recommend.

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Friday, July 06, 2007

Asthma, Allergies: Links and Stories

Gene Variation, Childhood Asthma Risks and Dubious Press Coverage British researchers made an announcement about some exciting advances in childhood asthma:
We are confident that we have discovered something new and exciting about childhood asthma.... These novel findings do not explain completely how asthma is caused, but they do provide a further part of the gene-environment jigsaw that makes up the disease. We and our colleagues are currently preparing even bigger studies to find other genes of smaller effect, and to relate these to environmental factors that protect against asthma.
Wired gives an excellent overview of the press coverage, some of which was notable for its unwarranted hyperbole. The Daily Telegraph is commended as one of the few papers that gave sensible coverage: Gene May Diagnose Childhood Asthma Early.
... there have been many false dawns in the quest for better treatments. When scientists first began to locate the genetic traits for asthma more than a decade ago, commentators suggested that their work would lead to a cure for asthma within five years, a prediction that proved optimistic.
Encouraging Results for Atopy Patch Test for Children with Food-Allergy-Related Gastro-intestinal Symptoms This has great potential. It can be heart-breaking for clinicians to attempt to administer a skin-prick test (SPT) to unco-operative or frightened young children; it is wretched for parents to watch while this happens. The researchers evaluated the diagnostic accuracy of food challenge, SPT, serum-specific IgE determination, and an atopy patch test (APT) using fresh food and commercial food extracts in parallel in children referred for suspected food allergy-related gastrointestinal symptoms. There are also known concerns about the accuracy of SPT in indicating food allergies. The different methodology with APT seems to by-pass some of these problems.
Atopy patch test is a useful tool in the diagnostic work up of children with food-allergy-related gastrointestinal symptoms. The diagnostic accuracy of ATP was higher with fresh food than with commercial food extracts.
Facial Thermography for Assessing Food Challenge Outcomes Another one of those fascinating ideas that prompt the "Why didn't anyone think of that before?" reaction. You might recall the Radio 4 deeply distressing account of William and the oral food challenge test that went horribly awry, partly because of the time-lag between the subtle onset of symptoms to the point where they become flagrant.
Oral challenge is widely used for diagnosing food allergy but variable interpretation of subjective symptoms may cause error...Facial thermography consistently detects a significant early rise in nasal temperature during positive compared with negative food challenges, which is evident before objective symptoms occur. Thermography may therefore provide a sensitive method to determine outcome of food challenges and investigate the pathophysiology of food allergic reactions.
Techniques like this have great potential for detecting earlier onset of symptoms during challenge tests and making the procedure much safer.

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Wednesday, July 04, 2007

Warner Despairs That Allergy Is Still a Cinderella Subject

Art illusions, anaphora etc.
Prof. John Warner is Professor of Paediatrics at Imperial College London and has contributed to several jeremiads about the state of allergy services in the NHS. Warner is particularly concerned about the parlous state of paediatric allergy and has written a strong editorial in the latest edition of Pediatric Allergy and Immunology: Allergy – still a Cinderella subject.

There are frequent newspaper articles about the scale of need for allergy services in the UK; they range from the sensible to the ludicrous but they do highlight the level of concern that there is. There is increasing coverage of the profound quality of life issues that children with allergies face on a daily basis.

I admire allergy specialists in the UK for their continued restraint in the face of many rebuffs for their repeated and well-reasoned argument that the NHS desperately needs to improve its provision of allergy services. In his editorial, Warner claims that:
the incredibly high prevalence of allergic disease...dwarfs that of any other chronic condition.
Ironically, despite the paucity of allergy provision in the UK, we have researchers who are acknowledged as world experts; nonetheless, their expert advice is routinely ignored by the Dept. of Health which claims that decisions about allergy services should be made at a local level rather than be part of a national framework.

It is all the more frustrating because researchers are confident that they have a good, comprehensive understanding of the basic mechanisms that contribute to allergies and allergic disorders in children. Researchers and clinicians have developed a number of new treatments that are designed to target the specific mechanisms involved. There is a catch, however. Some of these targeted treatments are comparatively expensive and they should only be used after diagnosis by appropriately trained allergists and under their supervision.

UK Health Trusts have a dilemma. They can refuse to fund the treatments at all, which may make them unpopular but is the simplest option for a cash-strapped health service, particularly if they have been asked to find unplanned savings. If a Health Trust agrees to fund a treatment, then they may have to pay not only for that treatment, but also for an 'out of area' referral to a specialist service for which they need to pay a premium price. If a Health Trust is trying to plan for the future, then they may realise that agreeing to provide a novel medical treatment will involve further costs because that treatment necessitates an increase in training and consultant posts to make the best and most cost-effective use of these highly effective new treatments.

I have occasionally wondered what the history is that would account for the poor status of allergy services in the UK. As a partial explanation, Warner gives an interesting overview of how allergy emerged as a medical discipline in several countries in his editorial.
The problem has arisen because as the scientific basis of medicine has become ever more sophisticated, there has been a progressively increasing focus on specialization. In most countries this has evolved system by system. Thus tertiary specialization has carved up the holistic approach to medicine into organs. Allergy being a discipline which covers many systems and considerable co-morbidity, requiring a holistic approach, has been left behind as the remit of the generalist. As the scientific basis of allergy has advanced the generalist has unfortunately not kept pace with new knowledge leaving sufferers without any recourse to expert advice.
In the UK, this means that too many GPs are left to manage allergies without appropriate support or adequate resources, such as the option to refer to allergy or immunology consultants in secondary or tertiary levels of care. Unfortunately, this can have significant impacts for the most profoundly affected patients, especially those who are unfortunate enough to have multi-systemic allergies that affect more than one system, such as the skin, the respiratory system or the gut. I have met too many parents who feel betrayed by NHS provision for their atopic children. Even parents who are financially-strapped feel the need to purchase private diagnosis and medical management for their children in order to ease their children's sufferings (e.g., chronic urticaria or unstable asthma) and their own concerns.

Warner gives an overview of the origins of allergy services in different countries and discusses their relative merits. He presents the options of developing either "a cadre of mono-specialists in adult and paediatric allergy" or a network of allergy clinics that act as a one-stop shop for appropriately-qualified respiratory specialists, dermatologists, otorhinolaryngologists, etc..

Warner emphasises that allergy services in the USA and France are linked to aggressive programmes of allergen immunotherapy-a treatment modality that is rarely available in the UK. Such a system is clearly effective in those countries but it is not clear that such a model is wholly appropriate in the UK which lacks that history. Warner acknowledges that the UK needs a good immunology service to back up allergy clinics, but highlights the issue that clinical immunology covers a very much wider area including immunodeficiency, rheumatology and in some circumstances infectious disease. It would be too easy for allergy services to be subsumed into immunological services despite the tremendous level of need.

Warner speculates that medical trends over the last 100 years indicate that:
the discipline of allergy will be progressively split and we will have experts exclusively focusing on food allergy, respiratory allergy, dermatological allergy, etc. However, this will be at the expense of the patient with concurrent allergic problems in several systems which are all too frequent.
Warner sounds a salutary warning note as to the disadvantages of such specialisation:
I am referred ever larger numbers of children who have already been seen by a range of specialists and prescribed treatment relevant to the individual system problem. The cumulative effect of the drugs and particularly topical steroids is having a significant adverse influence on growth and development. I believe the future lies in ensuring that the discipline of paediatric allergy retains its integrity as a holistic discipline working harmoniously alongside systems specialists and clinical immunologists.
This is yet another well-reasoned plea for an improvement to paediatric allergy services in the UK along with a summary of what a reasonable clinical service would look like. There is a verifiable need for better allergy provision on the NHS. For how much longer will the Dept. of Health ignore these specialists? For how much longer will they ignore parents such as Claire who left this comment on a previous post:
The patient charities Allergy UK and The Anaphylaxis Campaign and many doctors and patients have made this point until they're blue in the face (no pun intended). Donna Covey of Asthma UK stated recently that an astonishing proportion of people contacting them don't know know if they have a diagnosis of allergic or non-allergic asthma. But very little seems to change and I recall HoC health comittee report warned that the situation might even deteriorate, as some of the small number of clinical allergists near retirement. Appeals for central funding and direction to boost provision to the levels recommended in the 2003 RCP report ('Allergy: the unment need") continue to fall on deaf ears, as evidenced most recently in the BBC Radio 4 'Allergic Reactions' broadcast, where Minister Andy Burnham simply passed the buck back to the PCTs, even though Dr Ewan had explained why this is not working and why allergy could be considered as a special case (historic cinderella status in NHS, now faced with rising numbers of affected patients, increasing incidence of severe and/or complex disease).

Clutching at straws, I fear, but, given that there is now an overall surplus in NHS funds, perhaps Gordon Brown could mark his accession to power by earmarking some of this to kick start the process of building up NHS allergy provision? I know lots of people who would respond to such a move with undying gratitude.

I've described my concerns about CAM and allergy [elsewhere], particularly my theory that the overstated and inaccurate claims made by some of these practitioners is actually reinforcing the scepticism people can encounter when they raise concerns about allergies with their doctors. On a more personal note, one of the burdens a parent of an allergic child has to bear is the constant torrent of unsolicited advice about CAM 'cures' from friends and family, mostly based on something they have come across in the media. Often, this is accompanied by uninformed opinions about the dangers of conventional medications. I realise this is well meant but it drives me mad: parents doing their best to work with their doctors to deal with these difficult conditions don't need to be undermined by suggestions that they are harming their children. I have taken to telling people who offer me unsolicited advice on ear candling, homeopathy, kinesiology, fad diets etc that what would really help me would be easier access to a clinical allergy service, and if they really want to help, please would they kindly write to their MPs about this.

Click on the image or visit Flickr for further information about the images. 1. IMG_2441, 2. IMG_2446

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Tuesday, July 03, 2007

Asthma, Allergy, Immunology, The Menace of Cats, Links and Stories

Cat lies on duvet: symbol of virtue and idleness and simple pleasure. Caption exhorts us to smell the duvet
Cats Are a Ubiquitous Source of Irritation for People with Allergies I have previously made my position on cats very clear: You're Not Free of Cats Just Because You Don't Own One. I will grudgingly admit that the report needs to be verified but it merely confirms me in my prejudice that cats are a force for evil, irritation, anti-histamine and air-freshener sales. It seems that allergen avoidance advice that has concentrated on avoiding house dust mite might have neglected the ubiquitous nature of cat allergens which may be a more relevant trigger, even in the absence of an apparent allergy. Cats may trigger an asthmatic airway response even in people who are not specifically allergic to cat dander.
Cat allergen exposure at moderate levels may be harmful to all atopic adults...The clinical implication is that it is insufficient to test patients with asthma for cat sensitization. [A]dvice should be against cat ownership in those showing sensitization to any allergen.
Not that that can protect you, oh no. Cats and their ghastly allergens get everywhere. No one is safe. Except at the North Pole. Maybe. If you are not visited by anyone wearing clothes anywhere that a cat has been at some point.

Allergy to Electromagnetic Emissions People report adverse reactions to electromagnetic emissions (EME) emitted from power lines, etc. The editor for the American Academy of Allergy, Asthma and Immunology dryly comments:
I do not know what to make of this story. Some individuals have attributed a variety of their medical problems to emissions from nearby power lines. The term "allergy to EME" may prompt some individuals to seek testing for such an "allergy." This situation may be analogous to the "multiple chemical sensitivity" complaints. which were postulated by some patients and "alternative" practitioners in recent years to cause a variety of ill-defined symptoms without definitive proof.
Whole Grains in Diet Prevent Inflammatory Diseases Or do they? I enjoyed the editor's comment about this epidemiologic study and its observations about the anti-oxidants in wholegrains and putative impact on inflammatory disorders:
I am not sure that one can draw definitive conclusions from these large "guilt by association" epidemiologic studies. Although anti-oxidants in dietary whole grains may be protective against inflammation, I think that a prospective controlled intervention study is needed to get more definitive evidence.

For more information about the image click on it to see the detail about the contributor on Flickr.

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Tuesday, June 26, 2007

Eczema, Asthma, Allergy Links and News

Gotham thugs and a forgotten benefit of vaccination Similar historical oddities may be found in speech as well as comics. I have elderly relatives who still say, "Harder to get rid of than the measles" or "It follows you around like the measles". P.G. Wodehouse has several quotations about measles:
Boyhood, like measles, is one of those complaints which a man should catch young and have done with, for when it comes in middle life it is apt to be serious.
Interactions between breast-feeding, parental atopy, and sex on development of asthma and atopy An intriguing paper that I havered about mentioning but the results are too thought-provoking to ignore. There is an extensive observation and research history which reports both that breast-feeding protects against allergy and asthma and that it increases the risk. This study looked at 1037 children from a 1972–1973 New Zealand birth cohort: the authors report that whether breast-feeding carries an increased risk for atopy and asthma for a child depends on their gender and the family history of the disease.

Breast-fed boys had a 63% increased risk of atopy by age 13 years, and those with atopic mothers had a 95% increased risk but neither of these reached a recognised significance value.

Breast-fed boys with atopic fathers had a significantly increased risk for atopy of 639% when compared with those who were not breast-fed. However, breast-feeding did not increase the risk for atopy among boys with atopic mothers.

For girls, the risk of atopy at age 13 years was not affected by breastfeeding, maternal atopy, or paternal atopy alone. However, breast-fed girls with atopic mothers had a 213% increased risk when compared with those who were not breast-fed. Breast-feeding did not have a reportable effect in girls with atopic fathers.

The authors report that the findings need to be replicated in larger cohorts. They comment that the findings have implications for how other researchers design and report trials of asthma and atopy epidemiology. the findings may also indicate some useful questions for clinicians although it is difficult to assess their practical significance at present.
For clinicians, it may be important to inquire about the history of breast-feeding in the context of assessing risk factors for the development of asthma and allergy.

However… breast-feeding is to be encouraged for its numerous other benefits.
The authors suggest that it is possible that the mechanism of action is the level of oestrogen in the mother's milk; however, like their other findings, this awaits further work and confirmation by others.

Eczema gene may predict asthma medication needs in children and young adults Asthma frequently co-exists with dermatitis or eczema. Previous research has suggested that it is possible that filaggrin (FLG) mutations can impair the formation of skin barriers and strongly predispose to childhood skin complaints such as eczema and atopic dermatitis. Mukhopoadhyay and fellow researchers report that this FLG status might identify asthma patients with severe disease who frequently need to use reliever medication.
Filaggrin (FLG) status influences controller and reliever medication requirements in children and young adults with asthma...

If skin barriers play a key role in preventing sensitization in asthma, a greater entry of allergens through a poorly formed epidermal barrier may speed up or intensify the activation of the immunologic changes of asthma.
The team evaluated the role of two FLG null alleles in asthma by assaying 874 patients in Scotland. They discovered that more of the patients with these markers were treated in accordance with the BTS recommendations for greater asthma severity (steps 3 and 4). 40% of those with the FLG null carriers were receiving treatment that implies greater asthma severity as compared with 23% of those who had wild-type FLG status.

The authors conclude:
An understanding of the possible relationships between filaggrin gene defects, a TH2-dominant cytokine response, and asthma could begin to test the exciting hypothesis that primary prevention strategies for asthma and allergy may be more cost-effective for genotype-stratified populations.
It would be interesting to know how much more development is needed before this becomes a recognised and affordable test at (say) secondary care levels. Nonetheless, it is interesting research and is further weight towards the argument that it is past time to abandon the idea of asthma as a single disease concept.

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Wednesday, June 20, 2007

Eczema and Allergy Links and News

When I attended the Allergy Show last week I picked up an information leaflet about allergies in small children that is starting to be distributed in pharmacies and similar places. The slogans that aroused an Amen Corner response were:
Allergy care starts with early diagnosis

Early testing prevent allergy symptoms becoming severe
The irritating thing was that there is no follow-up relevant website. The leaflet was supported by an educational grant from Pharmacia Diagnostics. It is not surprising that the leaflet contained the summary advice:
Find out to what your child is allergic!

Only a doctor can confirm the diagnosis of allergies, using skin testing or appropriate blood tests.

Go and visit your doctor for an allergy test!

Your child will be tested to identify the substances (allergens) causing the allergy.

The appropriate treatment (eviction, immunotherapy, medication...) can begin to help your child feel much better!
I have no idea what eviction is in this context. I would also say that the leaflet places too much reliance on the value of tests: there is no substitute for a good clinical history taken by an appropriately qualified and experienced clinician. Tests are valuable for confirming a diagnosis, they are rarely sufficient by themselves. So, early diagnosis and appropriate management are good things but parents should be wary of the over-stated clinical significance of some tests. If you're concerned about your child, you might contact one of the allergy charities to ask for details of your best NHS referral that you can discuss with your GP.

Action Against Allergy Parent Workshops These workshops are for the parents of allergic children: the venue is St Thomas' Hospital in central London. The workshops will be led by consultants, dietitians and nurses from the deservedly-renowned Children's Allergy Service at the Evelina Children's Hospital based at St Thomas'. The sessions are scheduled for 2 hours and will take place in the afternoon or evening. The anticipated cost is £10 per participant. The first 3 workshops are planned for autumn 2007: they focus on eczema, asthma and food allergy. Register at their website to be kept up-to-date with developments. These sound very promising; I hope that they fulfil their potential and meet the needs of parents.

Do lifestyle choices such as frequent washing, harsh soap and biological washing powders contribute to eczema and allergies? Specialists from Great Ormond St Hospital argue that too much washing with strong soaps, the use of exfoliants and other such skin care products, and even biological washing powders (as promoted for low-temperature, energy-saving laundry) may be stripping away the skin's outer protective layer, resulting in allergic responses to allergens in susceptible individuals. There was a nicely specialist argument in the original paper about the role of Langerhans cells that raises some interesting questions about the widely-accepted hygiene-hypothesis. However, the take-home message for parents is that you might be well advised to avoid using harsh soaps or exfoliating products with your children and switch to less abrasive emollients. I would also add that you may have to give up low-temperature laundry and use gentler washing-aids. Take advice from suitable sources such as the National Eczema Society and GP.

Apply corticosteroid creams only once daily for atopic eczema Atopic eczema affects many adults and up to 20% of children; the health costs are comparable to diabetes and asthma. Corticosteroid creams are a mainstay of treament: usually applied twice or more a day, recent studies indicate that once a day is adequate.

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Tuesday, June 19, 2007

Children's Health, Asthma, Eczema and Allergy Links and News

Blossom - Stop Allergies Spoiling Childhood A campaign to reduce the social exclusion of children with allergies. The members promise reliable and regularly updated information, advice resources and support. The site is a little light on content at present but it will be interesting to see how this site and campaign mature.

Food allergies reported to have increased 12-fold in australian children since 1995 It's a gallimaufrey of numbers and it is hard to avoid the speculation that some of the increase reflects increasing awareness of the symptoms of allergies and a greater readiness by parents to request allergy testing for their children. Nonetheless, it is worth looking at the paediatric trends in food allergy in a community-based allergy practice.

Omegas 3 and 6 exposure from early life do not influence asthma, eczema or atopy levels at age 5 Last year, there was some surprise when the Childhood Asthma Prevention Study failed to show any protective benefits for omega-3 fatty acid supplementation and restriction of dietary omega-6 fatty acids in children. The interventions did not prevent asthma, eczema, or atopy at age 5 years. This related observational analysis of the cohort, adds further weight to the negative findings of the randomised controlled trial. Both the study and trial report that modifying or supplementing dietary polyunsaturated fatty acids in early childhood does not protect against atopy and asthma in children.

Wales has one allergy specialist to deal with an estimated one million people with allergies This is an interesting story made ridiculous by the implication that the excellent Dr Paul William, a clinical immunologist at Cardiff University, is solely responsible for the secondary/tertiary care of these people and yet he has only an 8 month waiting-list. The rest of the article is pretty run-of-the-mill except for some gratuitous and inappropriate advice at the end about garlic, lavender, chamomile, eucalyptus, royal jelly and honey.

Backlash against bipolar diagnoses in children After recent enthusiasm for this diagnosis, it was inevitable that it would fall into disfavour once people considered the wisdom/experienced the reality of prescribing antipsychotic medication to very young children. The article offers a recent overview of the issues and mentions that Biederman's insight was correct as it is now acknowledged that bipolar disorder can strike before puberty. However, the 2001 guidelines also state the difficulties in validating a diagnosis in children is challenging because normal children are prone to be irritable, aggressive, or giddy. It does contain some details of the death of a child who may have been over-medicated by her parents in an attempt to wrest control of her behaviour.

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Thursday, June 14, 2007

Laughter, Children, Babies and Eczema

Young girl on playround equipment with an ear to ear grin: she is an example of happiness through explorationWhen a young child had eczema the sleepless nights can disturb the whole family (and neighbours in several directions if the child is particularly vocal about distress). Every so often, I come across a researcher who publishes in some quirky areas and I'm intrigued. I wonder about their research group, who funds their research, how easy they find it to attract research fellows, stuff like that. Sometimes, I think ?!? but most of the time, I wonder about what they are doing with their findings and how they might hope to investigate the biological mechanisms involved or to apply their findings to a wider population.

Kimata has published several papers on laughter and eczema; this is the sort of area that piques my interest. When an abstract blips on my quirk-meter, I don't always consult the full paper because I don't want to be disillusioned and learn that underneath the charming eccentricity lies something that is terribly staid. I'm about to mention a couple of Kimata's papers that I haven't seen in their full form, so please be aware of that.

Eve Van Cauter has reported studies that show short sleep duration in young, healthy men is associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite, and cortisol disturbances that influence the ability to cope with stress and also promote the laying down of a personal duvet of body fat.

Kimata measured ghrelin levels in a comparison group of healthy children and those with atopic eczema and night-time wakenings. Kimata discovered that the children with eczema had higher ghrelin levels at 02:00 when compared with healthy children.
Neither viewing control non-humorous film nor viewing humorous film had any effect on healthy children. In contrast, viewing humorous film improved night-time wakening and reduced elevation of salivary ghrelin levels in patients with atopic dermatitis, while viewing control film failed to do so.
There are so many possible mechanisms of action here that it nudges across into being a substantial part of PNI (aka, psychoneuroimmunology, psychoendoneuroimmunology, PENI). Are parents desperate enough to add humorous films into their usual night-time routine (whatever that involves)?

Babies seem to laugh a lot; probably at the notion that parents have plans that involve sticking to meticulous timetables that disintegrate with the first unscheduled nappy-change. Babies have eczema but, sophisticated as children's marketing is, I doubt that there is a readily accessible range of humour for the neonate and infant. So, what do you do if your baby has eczema?

If you are Kimata, you recruit currently breastfed babies with atopic eczema and allergies to latex and house dust mite (HDM) in the 5-6 months of age demographic (my first typo of that was demongraphic which seems quite apposite). You arrange matters so that half of mothers have atopic eczema and half are free of it.

You show the mothers an 87 minute video of either Charlie Chaplin or non-humorous weather reporting. After that, you collect and analyse samples of the breastmilk at 2 hourly intervals and measure the amount of melatonin in it. You also study skin wheal responses to HDM an latex in the infants.
Laughter increased the levels of breast-milk melatonin in both mothers with AE and healthy mothers, and feeding infants with increased levels of melatonin-containing milk reduced allergic responses in infants.
I don't want to know any more about this study. I'm entertained just by knowing that Charlie Chaplin is still so popular in Japan. I'm intrigued by the reported results.

Yes, the boring, tedious, obvious response to this paper would be to experiment with ways of delivering melatonin to babies with eczema to dampen their allergic response and enable them to get a good night's sleep. But I like the notion of mother and baby chuckle clubs.

I've written frequently about the inadequacy of allergy services in the NHS. Prof. Hourihane was recently giving evidence to the House of Lords committee that is looking into allergy and allergic diseases. He commented:
The NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases.
Several other experts made similar comments about other aspects of the provision of allergy services in the UK. Despite this awareness of the need for proper, clinical diagnosis and management of allergies, sadly, one eczema related document is likely to elicit snorts of derision rather than laughter: the National Institute for Health and Clinical Excellence Guideline for the Management of atopic eczema in children from birth up to the age of 12 years. There is no recommendation that children with atopic eczema should be referred to an allergy specialist; not even when a child has hit the trifecta of eczema, allergic rhinitis and asthma that needs especially careful management, particularly if the child has unstable asthma.

I don't know why the members who drew up this guideline decided not to recommend allergy assessment: given the paucity of paediatric allergists in the UK, it was perhaps inevitable that there was only one in this group. In light of this, it is particularly disappointing that the group will consider:
What is the place of complementary therapies in the treatment of atopic eczema? This will include consideration of homeopathy, and Chinese and Western herbal medicine.
Too many desperate parents feel that they have no option but to consult CAM practitioners precisely because they can not obtain timely access to allergy services on the NHS.

Click on the image or visit Flickr for further information about the image.

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Sunday, June 10, 2007

We Do Not Have Adequate Provision of Allergy Services in the UK

Art illusions, anaphora etc.
There are so few clinical allergists in the UK and such a surge in need for them that it is hardly surprising that Jo Revill has a dramatic headline for her story: NHS Swamped by an Epidemic of Allergies. There are the equivalent of 26 fulltime posts in clinical allergy in the UK. I don't fully agree with her overview of the situation but you can understand the scale of the mismatched resources when Revill claims that:
One in three people in Britain can expect to suffer from some form of allergy during their lifetime - including 2 million people in the UK thought to have some allergy to food - but there has been barely any increase in NHS services to cope with this. Experts will warn this week that demand for care is outstripping the NHS's ability to cope, and many patients go to private clinics or dietitians that may offer unconventional diets.
I'm sure that Registered Dietitian, Catherine Collins, might argue that most of these 'dietitians' who are advising "unconventional diets" are nutritionists rather than registered dietitians (the latter is a protected term, the former isn't - anyone can declare themselves to be a nutritionist). However, the larger point holds; the NHS provision for allergy services is completely inadequate with 12 million people thought to be in need of appropriate diagnosis and management advice.
Britain has one of the highest rates of allergy in the world, along with America, Australia and New Zealand. For reasons not understood, in the last 20 years the rate of eczema and asthma has at least doubled, and there has been at least a threefold increase in nut allergies. Before the mid-Nineties nut allergies were rare, but one in 50 schoolchildren now has one. In the last four years the number of adults with food allergies has also shot up, partly as a result of more awareness, with thousands suffering reactions to shellfish, vegetables, seeds, nuts, kiwis and plums.
Food intolerance or sensitivity is frequently described as hidden or delayed food allergy by many writers. There are claims that there are clinically validated tests for it but most of these have yet to be fully substantiated (e.g., IgG food intolerance tests). Because there is a perception that normal physiological responses to food or sensititivies have become medicalised into an illness, Dr. Jonathan Brostoff acknowledges that:
there [is] still enormous scepticism within the health service about whether patients 'truly' [have] an allergy or [are] just imagining it.
Allergy provision with the NHS is scarce. Clinical allergists frequently express their concern that it is this lack of provision that is driving some desperate people towards inappropriately qualified advisers who may lack a full understanding of allergy, anaphylaxis, intolerance and their appropriate diagnosis and management. It is long past time for the provision of adequate allergy services on the NHS.

Edited to include Claire's comment (doesn't show in Haloscan):
"It is long past time for the provision of adequate allergy services on the NHS."

Hear, hear. The patient charities Allergy UK and The Anaphylaxis Campaign and many doctors and patients have made this point until they're blue in the face (no pun intended). Donna Covey of Asthma UK stated recently that an astonishing proportion of people contacting them don't know know if they have a diagnosis of allergic or non-allergic asthma. But very little seems to change and I recall HoC health comittee report warned that the situation might even deteriorate, as some of the small number of clinical allergists near retirement. Appeals for central funding and direction to boost provision to the levels recommended in the 2003 RCP report ('Allergy: the unment need") continue to fall on deaf ears, as evidenced most recently in the BBC Radio 4 'Allergic Reactions' broadcast, where Minister Andy Burnham simply passed the buck back to the PCTs, even though Dr Ewan had explained why this is not working and why allergy could be considered as a special case (historic cinderella status in NHS, now faced with rising numbers of affected patients, increasing incidence of severe and/or complex disease).

Clutching at straws, I fear, but, given that there is now an overall surplus in NHS funds, perhaps Gordon Brown could mark his accession to power by earmarking some of this to kick start the process of building up NHS allergy provision? I know lots of people who would respond to such a move with undying gratitude.

I've described my concerns about CAM and allergy on your other blog (HW), particularly my theory that the overstated and inaccurate claimes made by some of these practitioners is actually reinforcing the scepticism people can encounter when they raise concerns about allergies with their doctors. On a more personal note, one of the burdens a parent of an allergic child has to bear is the constant torrent of unsolicited advice about CAM 'cures' from friends and family, mostly based on something they have come across in the media. Often, this is accompanied by uninformed opinions about the dangers of conventional medications. I realise this is well meant but it drives me mad: parents doing their best to work with their doctors to deal with these difficult conditions don't need to be undermined by suggestions that they are harming their children. I have taken to telling people who offer me unsolicited advice on ear candling, homeopathy, kinesiology, fad diets etc that what would really help me would be easier access to a clinical allergy service, and if they really want to help, please would they kindly write to their MPs about this.
Click on the image or visit Flickr for further information about the images. 1. IMG_2441, 2. IMG_2446

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Thursday, May 31, 2007

BrainPOP and Educational Films About Asthma, Allergies and the Immune System

Yahoo has an interesting item about an immunologist, Dr. Avraham Kadar, who has set up BrainPOP, a company that produces online, animated shorts about asthma, allergies, the immune system and a variety of other topics.
Visit BrainPOP and join teen-robot duo Tim and Moby for a plane ride on which a seemingly innocent bag of almonds prompts an in-depth discussion of allergies. Viewers learn about the physiology of an allergic reaction, the role of the immune system, the different types of allergens and the symptoms, diagnosis and treatment of allergies. Additional BrainPOP films tackle related subjects like asthma and the immune system itself.

For allergic little ones in grades K-3, there's a BrainPOP Jr. film on the subject as well. Find out why Moby has cupcake frosting all over his metal face at BrainPOP Jr.. There, he and leading lady Annie explain the basics of allergies in terms this age group can relate to. Interactive games and activities supplement the film's lessons.
There is a time-limited offer on free access to the films. Log-in information expires June 7:

Username - Journalist

Password - Allergies

I have no connection with this company or anyone associated with it: I do not know anyone who has used or recommended these films. I like the fact that they have close-captioned the films.

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R4's Allergic Reactions Was Spotty and Irritating in Parts

A young boy and his dog in a position of prayer
And please let Shinga find some decent coverage of allergy issues before she explodes.

A valued correspondent has been kind enough to send me a partial transcript of Radio 4's recently broadcast Allergic Reactions. The clinical experts were interesting but the reporter repeated the cliched investigations that do nothing to educate or to inform the debate: consequently, judging by the reactions and comments, he has achieved very little. Allergic Reactions was (sadly) spotty and irritating in parts - I could say that it probably seemed like a good wheeze at the time but that is probably going too far.

Allergic Reactions (BBC Radio 4 Tues 22 May, 8pm, reporter Matthew Hill)

Partial transcript

Beginning of broadcast: Prof. Gideon Lack and Dr. Pam Ewan provide an overview of the current inadequate NHS service for allergies and allergic diseases.

[06.25] A mother describes the uncertainties and difficulties in obtaining an accurate diagnosis. Her one year-old son had an allergic reaction to fish which is even more worrying than normal because her son has eczema and asthma; as such, the boy has hit the trifecta for multi-system allergies and needs high-quality, careful, medical management.

The mother's apprehensions and fears were not allayed when she took her son to A&E following the allergic reaction to fish and the Senior House Officer (as the grade then was) examined the child and suggested a diagnosis of hydrocephalus and defended that diagnosis in the face of the mother's frank disbelief.

[07.00] Dr. Ewan provided an overview of the lack of adequate provison at all levels in the NHS.
The lack of provision is at a series of levels, first of all in primary care. GPs are not well informed about allergy at all, but particularly about food allergy and that is because they are not trained in it. So GPs have gained knowledge by self learning or self interest, then if a GP wishes to refer to a specialist he will have a problem finding a specialist because there is a very small number of these.
[07.35] Another chilling case history of a little boy, William, in NE England. William was known to have peanut allergy. For some unclear reason, the General Paediatrician decided that it would be appropriate to check if he still had an allergic reaction by setting up an open challenge with peanut. In an account that must have dropped ice-water down the back of parents in a similar position, the challenge was conducted in a hospital (as per the guidelines) but without constant observation/monitoring.

As the amount of peanut was incrementally increased, William's mother was more and more convinced that he was showing signs of an allergic reaction. The nurse discounted the mother's observations and refused her request to terminate the test, arguing that William was just anxious and that abandoning the test would mean having to repeat the stress at a later date.

The subsequent events were wretched and resulted in anaphylaxis. William was in a life-threatening condition and taken to HDU; nobody could tell the mother whether or not William was expected to survive (thankfully, he did).

[09.35] Dr. Ewan reveals that both the Royal College of Physicians and even the Department of Health itself have warned there are not enough specially trained doctors: there are only six specialist centres in the UK. Despite the recommendations and reports, there are only 7 trainee allergy consultants at present, although the recommendations called for 40.

[10.17] Prof. Lack provides further detail on just how poor NHS allergy provision is in the UK. E.g., there are 5 paediatric allergy specialists in the UK; the comparable figure for Germany is 500 allergy specialists.

[10.34] There was some discussion of private tests which, by default, because of the poor NHS clinical provision, tend to be offered by CAM therapists. Prof. Lack was sufficiently concerned about this that he conducted a survey of the allergy advice parents have received before they attended his paediatric allergy clinic.
We found almost 50% had received alternative health care advice about allergies before coming to see us. I would say that of the children who come to our clinic at least 10% and possibly up to 20% have received unsound advice; these children will face nutritional problems.
Martin Hill presents a case study of Carol who was so desperate that she went to her local health food store for a Vega food allergy/intolerance test. She was advised to give up milk and she did - for 6 months. However, the symptoms didn't go away and, on past experience, there seemed to be little point in returning to consult her GP. Later in the programme, about 12:36, Carol reveals that her problems were related to undiagnosed coeliac disease; she obtained her diagnosis while she was pregnant. While she had been avoiding milk, Carol had unwittingly consumed more cereals, and these had exacerbated her gut problems.

At about 12:30, MH talks to Dr. Joe Unsworth, who is a clinical immunology consultant with a special interest in allergy, about the dangers of eliminating dairy without appropriate dietary supervision and guidance on other sources.

[14:58] Martin Hill introduces a disproportionately long section that deals with the YorkTest foodscan test for food intolerance. He does the horribly cliched split test by taking two samples at the same time and submitting them under different names.]
There is one test available via the internet that does sound very scientific [sound effects of conducting a YorkTest foodscan 42]. YorkTest labs claim their food intolerance test has been found to relieve symptoms in a wide variety of conditions by identifying problem foods and avoiding them. I decided to put it to the test. I ordered 2 kits and then sent back two samples…42 foodscan test…suggested on the website for children and people with restricted diets. Costs £125 [more sound effects].
The samples came back with different results so Martin Hill arranged to meet John Graham, the chairman of YorkTest labs to discuss the results.
John Graham (JG): We’d like to explain what we do.

Martin Hill (MH): I’m Martin Hill, I was the patient. It was my blood that was taken and there’s my result [I should avoid cow’s milk and rotate wheat]. Same blood, same day, same test, Martin Redfern [my alias], [I should avoid] cow’s milk, no mention of wheat.

JG: OK, so what we’d like to do now is send it off to the lab, investigate it properly. I’ll be able to respond shortly
[17:20] Dr. Gill Hart can be heard giving a presentation in the background]

[17:50] Alistair ?, the lab manager arrives and presents the raw data from the original lab tests. He reports that the results for the two samples, in arbitrary units, were: Milk – Martin Hill 12.9, Martin Redfern 10.4; Wheat Martin Hill – 5.4, Martin Redfern 5.2.

Personal note: For the remainder of this YorkTest segment, the discussion was disappointingly irrelevant and the quality was poor. Neither MH nor JG displayed much understanding of the issues; this entire segment failed on so many fronts that it was neither informative nor educational. I will put some comments in where I can't help it but for the most part, this nonsense speaks for itself.

It would have helped enormously if they had explained that they had measured the levels of IgG for particular foods; YorkTest had presumably established the levels in (say) U/ml, and they had mapped these to their scale of 0-4, where 4 is 'very reactive' or similar. I would like to know the measurements that map to the sensitivities and this section of the programme would have been clearer if they had announced where MH's results were on the 0-4 scale.
MH: So, John, your saying they’re quite similar, the results.

JG: Yes, as you can see [for] the results in 42 foods mentioned, 41 produced identical results. One produced a result that isn’t identical and that is very close to a zero result or a treat with caution result. My advice to you in both cases would be to do nothing other than to seek to avoid the one food you have a positive reaction to.
OK, my silence didn't last long. With respect, we know that 2 results were not identical; we don't know any such thing about the others. We just know that we didn't get the figures because they were not around the boundary level where they acquired any degree of significance. They may or may not have been identical.

This would have been an ideal point at which to discuss whether or not YorkTest's foodscan is recognised by the appropriate pathology services in the UK and what the normal lab. tolerances are for variation in the results of split tests. It is difficult to confirm this, but I'm told that the usual permissible variation is 10%.

I would like to point out that there was an almost 20% variation in the measurement of IgG levels for cows milk and a negligible difference for wheat. It isn't at all clear whether the difference in the cows milk was written off because it didn't affect the category on the sensitivity scale, but somehow the negligible variation in the wheat measurement crossed some threshold of significance.

I'm also losing the will to persevere because MH hasn't stated, clearly and simply, that he does or does not have any clinical symptoms that might indicate that he does have intolerance to cows milk.
MH: But there was a difference in [the] advice I got from your nutritionist. One test; no milk. The other [test results, I'm advised] no milk and rotate wheat…so you don’t think that’s an issue?

JG: You contacted a nutritionist and you haven’t got anything wrong with you…Correct?

MH: She rang me back…as part of the package you get a free consultation. In that consultation she was giving the different advice on what foods to have. On the one hand [the outcome of one test profile recommends that I] don’t have cow’s milk, on the other hand [the outcome of a separate test on the same blood sample recomends that I] don’t have cow’s milk and also rotate wheat.

JG: I can only repeat myself. You’ve got 41 foods which are identical and you’ve got one result where it’s marginal if you should rotate the food or just not do anything with it. When you look at our booklet you will see that you should seek to avoid the one food and…treat with caution the other food. [Presumably the former is milk and the latter is the wheat.]

MH: The treat with caution advice I don’t think was clear in what I was sent...

JG: Could we examine that document and try and establish whether that is clear?
JG reads the YorkTest booklet that was sent out with the test results, noting the advice to eliminate foods with high number reactions first. There is some background chatter in which MH is objecting that he wasn't told to treat the wheat result with caution and Dr. Hart chips in that that is (possibly) implied by the instruction to "rotate". You will not be surprised to learn that neither Dr. Hart nor JG succeeds in clarifying the issue.
MH: It doesn’t specifically say "treat with caution".

JG: No, but that is a problem of nomenclature, it is something actually that [is flagged] in our quality control procedures at the look exactly at the wording we offer. And we can show you evidence of that…today, because the proposal has been made that we should change from ‘rotate’ to ‘treat with caution’.
This discussion is really not improving. Both participants are missing the broader issue that it may be wholly inappropriate to hand out dietary advice that is based on borderline measurements and categories, when those lab results are not interpreted by a skilled clinician who has examined the client and taken a decent medical history.
JG: What you’re dealing with is a very sensitive area right at the centre of all this…the difference between a slight positive result that may have some significance to one person or…no significance to another person.
Seriously people, would it cause you deep distress to clarify whether you are still whittering on about the borderline wheat result? In yet another journalistic cliche, MH pulls out a variation on the "Won't somebody think about the children?!?" card.
MH: But if you’re advising…some of your patients are children, presumably...

JG: Yes.

MH: If you’re advising parents to cut down a lot on the wheat when that is a marginal grey area as you admit in your test…isn’t that a long way to go?

JG: If you look carefully at what we say…eliminate highest food first…concentrate on that. For a marginal [result] seek to rotate or treat with caution. I think we make that very clear...
End of 1st YorkTest segment. Martin Hill reports that he was concerned that avoiding milk products and rotating wheat would be difficult. He decided to take his results to Registered Dietitian Catherine Collins and paediatric dietitian Susan Durham-Shearer. Martin Hill expresses concern that the YorkTest nutritionist had a 2 year diploma in nutrition and that her advice was that he should exclude all dairy products for 3 months, and consume wheat products, 2-3 times per week.

Catherine Collins gave an overview of the core food groups and the difficulties that people can encounter when they are accustomed to a typical UK diet and need to obtain calcium from non-dairy sources. She debunks a piece of advice that is a source of irritation to me: the one where people tell you that you can obtain calcium from eating tinned fish - which is true if you eat the bones, but how many people do?

Martin Hill mentions that he had a IgG test for food intolerance. Catherine Collins explains that your IgG levels reflect the foods that you eat and that your highest levels may reflect the foods that you eat more frequently.

Finally, Martin Hill raises a nagging issue.
MH: The key question is: Can YT distinguish between IgG levels in people without food intolerance and people with food intolerance?
Martin Hill gives an overview of the Gut paper that is frequently cited as clinical evidence and validation by YorkTest (I have previously discussed the Gut paper). He discusses the paper and its findings with Dr. Ewan (PE) who thinks that the significance of the paper's findings are overplayed.
PE: The so-called active or treatment group avoided milk and wheat and it’s well known that milk and wheat are the commonest foods to cause flare-ups…in IBS. So if you remove those, there is a good chance there will be some improvement in those patients but that does not mean it was anything to do with test results; it was not related to IgG antibodies.
Martin Hill put these criticisms to JG who put on a surprising show of bluster that was embarrassing: he seemed to deprecate Dr. Ewan's opinion and knowledge without even attempting to lay a foundation for his criticism. He also glossed over a major issue that Dr. Ewan raised; namely whether the level of IgG antibodies is relevant in the diagnosis of food intolerance.
JG: One criticism we can’t do anything about…elevated antibodies in healthy humans (i.e. they exist). Another one is the systemising of the dietary change because, as you say, you are quite right, it is considered that some foods are more allergenic than others. So we have to give very careful thought to when we change a person’s diet and do the randomising of it that the other – sham – diet would be as difficult for the patient to adhere to...

MH: So, does that mean your Gut Study was flawed?

JG: No, no, every effort was made to do that...

MH: But you’re using…the Gut paper…

JG: Surely one would if…

MH: But that paper, according to experts we’ve spoken to, is flawed.

JG: I know but I’m sorry but the duty of these so-called experts is to produce another paper to demonstrate that [the Gut] paper is flawed and not just to write in with their comments. [My emphasis.]

MH: But to advise that children…

JG: We always advise [people] to see your doctor. We are not in the business of trying to alter young people’s diets...
I have to point out that the foodscan 42 test used to be recommended for use when testing children. As it is, in many places that advertise the foodscan tests, the advice is that they should only be used on children over the age of 2 (see Health Products for Life) so it does seem to me that this is part of their business. JG responds to MH's child card with his own emotive claims.
JG: When these parents come to us they’re desperate, beside themselves. Terrible colic, IBS, diarrhoea, skin complaints, seeing doctors…[They]don’t get better…desperate…[They're] not getting better through conventional medicine...

MH: Should we be considering excluding whole foods until the evidence is better?

JG: Our advice is to consider excluding foods with the highest levels of antibodies…

MH: Your paper says about 75% of people who buy your product show improvement but this is based upon them reporting…how much credibility can you give that?
It is not at all clear whether they are discussing the Gut paper or the more recent published audit of customer satisfaction.
JG: By itself it’s quite a useful piece of indicative information…What we don’t know is [how much of those results should be attributed to the] placebo effect…or regression to mean effect...
Martin Hill than gives an overview of John Graham's contention that some of the tests that are ordered by 'conventional allergists' may result in false positives. This is true but the specificity etc. of these tests is known; and good clinical allergists only ever interpret test results alongside an examination and thorough clinical history. I fail to understand John Graham's point here or why he thinks that a direct-to-consumer lab test is comparable to a test that is conducted and interpreted by experts but I'm not getting any younger and my hair is starting to fall out.

Dr. Unsworth agrees that test results alone are problematic; he emphasises that the best way to diagnose allergy or intolerance is to take a good clinical history before testing.

Martin Hill then discusses YorkTest's collaboration with academic researchers to establish the normal ranges of IgG measurements. He mentions small pilot studies from a London hospital that have just been presented as a poster at a conference in Washington, DC. MH assures us that Dr. Anton Emmanuel (AE) (one of the researchers) has some interesting findings.
AE: What we found is that patients with [inflammatory bowel disease] who report greater sensitivity to food also tend to have highest levels of IgG in their blood. [However], patients with Crohn’s disease seem to have an inverse relationship…the more foodstuffs they report sensitivity to, the lower the IgG count, whereas in ulcerative colitis there is a much more direct relationship. We wonder whether there is some sort of gut permeability problem in Crohn’s...
Martin Hill discusses the findings and questions Dr. Emmanuel on whether these results in people with serious bowel conditions are sufficiently powerful to convince him that YorkTest can predict food intolerance in anyone?
AE: IgG measurement is a strength and a weakness…it reflects exposure in the past…The weakness is that it doesn’t tell us anything about recent exposure. What we need is a normal range [of values].

So, can you say, 'My level was Y in March, [I] went on the diet, now it’s Z?'. Unfortunately we can’t do that. These tests are done with artificial reference points. I think the IgG test is very broadbrush. If you use it as the sole basis on which to alter your diet…that is folly. I’m sure no-one would ever suggest that. Whatever you do has to be allied to input from a physician or dietitian…but [IgG] does open our eyes to something we have ignored [the relationship between diet and symptoms]…It illustrates a trend but needs to be fine tuned. [My emphasis.]
Martin Hill does not comment on the fact that what Dr. Emmanuel calls "folly" is actually happening: IgG results are being used as the sole basis on which people are advised to change their diets and people are doing this without input from a physician or dietitian (a nutritionist does not necessarily count for this purpose). Hill reveals that YorkTest has since informed him they are withdrawing the foodscan 42 test, and changing the language in their booklets from ‘rotate’ to ‘treat with caution’.

The remainder of the programme reverts to the extraordinary difficulty people have in accessing allergy services on the NHS. Despite his clear clinical signs, the little boy with the fish allergy was not referred to an allergy clinic for 4 years and waited all that time for a diagnosis of multi-system allergic disease.

Dr. Ewan explained that she and her colleagues are asking for central funding for trainee specialists but control has been devolved to the local PCTs and resources are being used inefficiently because funding allergy trainees would save the NHS money.
The big problem there is that they are strapped for cash so that there is no way PCTs are going to be able to fund a new consultant or a new trainee post...

The NHS are spending money on allergy patients, but it is in a sense wasted because patients, if they are not properly diagnosed, are somewhere in the system being ill. They are either having acute reactions coming into A&E, there are hospital admissions, there is very good data showing a rise in hospital admissions.

They are frequently attending their GPs with continuing illness. They are using a lot of drugs - now all that is a cost to the NHS and our argument is that a small investment in training more specialists which would enable both the specialist sector and primary care to develop would be actually a cost saving.
Prof. Lack, Drs. Ewan, Unsworth and Emmanuel were interesting although some of those speakers must be weary of repeating the same warnings about the inadequate NHS provision of allergy services. The case studies were interesting but the segment about the YorkTest was profoundly irritating.

Allergy and allergic diseases are distressing and have a remarkable impact on people's quality of life. The BBC did not serve its listeners well by offering them this programme. Listeners both deserve and need better coverage.

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Monday, May 14, 2007

Oil Seed Rape, Fashionable Demon or Time to Break Out the Pitchforks and Torches?

Judging by recent stories about oilseed rape, it is either the latest victim of fashionable demonology (wheat, gluten, dairy) or it is justly reviled and past time for the allergy-bedevilled villagers to take up the pitchforks and torches.

Against a backdrop on an increase incidence of hayfever in the UK, it is a little dispiriting that the stories contain a strong whiff of superstition alongside the science. Two representative accounts are, The rape of spring: Health concerns over crop (Independent) and Teacher forced out by oil seed rape (This Is London).

Oilseed rape is highly visible, its vast gharish swathes do not blend gracefully into the usual british landscape of colours: its vibrant coloration catches the eye, its cloying scent seems to swamp all others. If you're looking for an obvious scapegoat for crimes against your nose, eyes and upper-airways, then oilseed rape couldn't be a more noticeable culprit. If this were a detective story, then oilseed rape would be discovered at the crime scene, looking self-consciously guilty, fingerprints and DNA strewn about the scene along with incriminating documents that provide evidence of motive.

The article in This Is London describes the plight of Peter Hallam who is forced to flee from his home to the refuge of a hotel, 45 miles away because of his "severe allergic reaction to the oil seed rape fields surrounding his house". Except, it is not at all clear that Peter Hallam is allergic to oilseed rape. It seems that the diagnosis of allergy is based upon Hallam's personal conviction (Dr. Ben Goldacre recently commented on the unreliability of intuition):
The doctor couldn't know for sure what was causing it but I'm certain.
Based on his personal certainty, Hallam and his partner call for research and a general alert, "the general public should be made aware of the danger of these oil seed rape".

However, there is no indication that oilseed rape is more dangerous than any other plant. According to a BMJ commentary on the research, there is no clear evidence that oil seed rape affects health adversely:
the [MRC] report shows that there is evidence of health effects associated with the cultivation of oilseed rape but no convincing evidence that rape is a cause of widespread disease or ill health in the general population...

Only in Britain has oilseed rape been suspected by the public of causing ill health effects. In other rape growing countries, such as France, Germany, Denmark, and Canada, no such public concern against oilseed rape exists.
The Independent reports the opinion of prominent scientists. Professor Pamela Ewan, consultant allergist at Addenbrookes Hospital, said:
The amount of allergy to rapeseed is very low. People think they are allergic to it because of its bright colour and powerful smell when they are really allergic to other pollens that they can't see. There could be some adverse reaction to the volatile chemicals the plant produces. But I think the perception is much greater than the reality. Grass pollen is by far the most potent cause of hayfever in Britain.
There is a strong case for requesting a referral to a clinical allergist if you suspect an allergy to oil seed rape. A clinical allergist will be able to distinguish a reaction to oilseed rape from allergy to grass pollen. In combination with a thorough clinical history, a negative allergy test can liberate someone from the expense and inconvenience of unnecessary allergen avoidance. If there is allergy, then the allergist can provide guidance on the most appropriate and effective avoidance techniques and medication.

A clinical allergist can also advise somebody on whether there is evidence that indicates that they do not have a clinical response to a specific allergen (e.g., oil seed rape) but exhibit symptoms when they are exposed to that allergen along with additional allergens at the same time. If somebody does exhibit a reaction threshold, then an allergist can give advice on whether it is possible to reduce the allergen load by avoiding one or more of the allergens to which they are sensitised (it may not be the most obvious one). If selective avoidance is practical then it might be possible both to reduce symptoms and the need for pharmacotherapy.

The Independent piece acknowledges that:
[o]thers take a less rigorous approach to the science, preferring to emphasise sufferers' reported experience. Muriel Simmons, spokeswoman for the charity Allergy UK, said: "Rapeseed very rarely triggers an allergic response, but it may be an irritant"...

"I think it is worrying that we are seeing the yellow tide advancing and the number of fields turned over to rapeseed spreading. Whether it is affecting the immune system or not is irrelevant - it is making a lot of people feel very uncomfortable."
It is difficult to argue the case for funding further research into oilseed rape if there are strong indications that the prejudice against it may be unfounded. This reported attitude is rather more indicative of the pitchforks and torches approach than the scientific approach that one might expect from somebody representing "the leading medical charity for people with allergy".

Oh misery me! mecum omnes plangite!

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Friday, April 27, 2007

GP Referrals: You Shouldn't Need a Secret Decoder Ring

Decoder mosaic
I was chatting to a parent this morning so I will warn you up-front that some of these disguised, transposed and fictionalised details may not make up a coherent piece but the essence of the story remains.

At the heart of the story is a very young child with respiratory problems. The child is still pre-school but apart from the recurrent illnesses, sleepless nights etc., the parents are (naturally) worried about possible future progression of the problems and their impact on school work, social life, general wellbeing and the myriad things that occupy parents's thoughts.

The child has had many courses of antibiotics but the parents are concerned that there is no improvement. They enquired about a referral to a paediatric respiratory consultant and were dismayed by the 'real life' lead times involved: they asked their GP for a private referral.

The GP in question obliged and presented the parents with a list of names; when pressed to pick one, the GP demurred on the grounds of neutrality and apparently refused to say why he had listed the consultants that he had. The parents picked the most geographically convenient consultant with the shortest waiting-list.

The consultant involved has an excellent reputation. He presented 3 options to the parents:
  • wait and see
  • immediate surgery
  • a protracted course of low-dose antibiotics.
None of these options appeal to the parents. They consulted their GP who declined to comment. At their wits end, the parents will take the child for a second opinion, even if it means waiting for some time.

Interestingly, the GP's list includes a couple of clinical allergists with a particular expertise in respiratory matters. The child has not been assessed for allergy on the NHS. The child has some patterns of illness and symptoms that raise questions as to whether the respiratory problems are indicative of underlying allergies. It is plausible that the GP suspects that the child needs an investigation of the allergic status but has felt unable to declare this for a number of reasons. I have met GPs who are reluctant to raise the prospect of allergy because they know that they have no reasonable expectation of making a referral to an appropriate expert on the NHS.

The parents have opted for a second opinion. They shall consult one of the clinical allergists: they will review their child's options after that time as they will have spent some months 'waiting and seeing'.

Dr. Crippen is familiar with the difficulties that patients have in choosing which consultant is appropriate. He is prepared to help his patients make appropriate choices because he has access to information that patients do not and because:
Dr Crippen is a discriminating and educated consumer of specialist medical care.
There really are times when patients need guidance. I feel that the GP may have been giving some implict advice when he compiled a list that contained some allergists. However, the parents did not know this. They did their research based on what they did know and will now have the inconvenience and expense of consulting a second opinion.

I have no way of knowing what the outcome will be and if the second opinion will endorse the first. It may well be the consultant decides that no further investigation is necessary. People consult their GP for medical treatment or guidance. This is a Good Thing. The GP in this case needed to provide direction and guidance to the parents. If the GP was giving a subtle indication that the child's respiratory problems should be assessed for an underlying allergic mechanism, then he forgot to give the parents the secret decoder ring.

Click on the image for further information on Flickr or look at the following. 1. decoder tshirts, 2. Early Enigma Decoder Machine, 3. decoder, 4. DE CODER

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Thursday, April 26, 2007

Holford Recommends a Nutritional Approach to Hayfever: What's the Quality of the Evidence?

A young boy and his dog in a position of prayer
And please let Shinga read some decent research papers before she explodes.

Several valued correspondents have brought Patrick Holford's nutritional recommendations for people with hayfever to my attention. Holford's PR people are to be congratulated because the same press release appears in many places in the form of articles about dealing with hayfever: one of the most recent of these is in the Manchester Evening News, Supplements to Solve Hayfever Sniffles. There is a more detailed account of Holford's claims regarding particular supplements and hayfever on his own site.

I'm going to state right here that there is negligible evidence to support Holford's claim that among these supplements:
MSM has so many benefits for allergy sufferers that it’s hard to know where to start.
I will enlarge upon why I reject this claim, but for now, I would like to digress onto a pet peeve. It is a recurrent irritation that articles such as the above tend to contain several questionable statements and claim a degree of scientific support that does not exist. However, disagreeing with them takes considerably more effort and time than saying, "That's not wholly accurate". Jon of Holford Watch decided to look into Holford's recommendations about obtaining your Omega 3 from "unfried and unbreaded fish": after a diligent look through the relevant literature, he doesn't find any evidence to support that recommendation. Jon spent several hours on this task.

In my more jaundiced moments, I imagine that it took possibly 4 or 5 minutes for Holford or one of his researchers to find and flick through a paper that seemed to support their point of view. It possibly took another about another 5 minutes to put together the text that extols the virtues of MSM for hayfever/allergies. It took me a couple of hours to identify which study Holford was referring to, to locate it and order it from the British Library, and ditto for the follow-up comments and related literature. I spent more time reading the literature so that I could be confident when I write, "There is a dearth of quality scientific evidence to support the claim that MSM has "many benefits for allergy sufferers": such claims rely on anecdote at best".

Holford appears to be excited about MSM as a supplement to reduce allergic symptoms:
MSM has so many benefits for allergy sufferers that it’s hard to know where to start. In one study, 55 volunteers diagnosed with seasonal allergies were given 1,300mg of MSM twice daily for 30 days. A significant reduction in symptoms of both the upper respiratory tract (including nasal congestion) and lower respiratory tract (including cough) was seen. As long as you’re still suffering from any allergic symptoms, or are in pain, it’s well worth supplementing MSM on a daily basis. While therapeutic intakes go up to 6,000mg a day, I recommend you start with 1,000mg, or half this if in combination with the other anti-allergy nutrients.
The study in question is A multicentered, open-label trial on the safety and efficacy of methylsulfonylmethane in the treatment of seasonal allergic rhinitis. It is a little surprising that a study with 55 volunteers, 50 of whom actually completed it, was multi-centered. However, the authors readily acknowledged that their study was open-label which is helpful because it allows the reader to form an impression of the probable clinical value of the study before proceeding to read the abstract and contents.
50 subjects completed the study. Those subjects completing the study consumed 2,600 mg of MSM orally per day for 30 days. Clinical respiratory symptoms and energy levels were evaluated by a Seasonal Allergy Symptom Questionnaire (SASQ) at baseline and on days 7, 14, 21, and 30. Immune and inflammatory reactions were measured by plasma immunoglobulin E (IgE) and C-reactive protein at baseline and on day 30. An additional inflammatory biomarker, plasma histamine, was measured in a subset of subjects (n = 5).
The authors of the paper acknowledge that their results demonstrated no improvement in the objective measurements of biomarkers: "No significant changes were observed in plasma IgE or histamine levels". Despite Holford's enthusiasm for the "significant reduction in symptoms" this paper can really not be interpreted that way because there are considerable confounding factors involved in the interpretation of the results.

A follow-up letter to the paper flagged some of the obvious problems about the reporting of the results: Methylsulfonylmethane as a treatment for seasonal allergic rhinitis: more data needed on pollen counts and questionnaire.

Among the many reasons that this paper does not meet standard criteria for a high quality of scientific or clinical evidence is:
  • seasonal allergic rhinitis fluctuates with the pollen count; on low pollen days and towards the end of the season, symptoms tend to improve
  • the authors monitored the daily pollen counts throughout the study but did not include that data in their analysis
  • participants subjectively rated allergy symptoms on a weekly questionnaire, retrospectively recalling the changes
  • the symptom questionnaire is not clinically validated in the way that (say) the asthma quality of life questionnaires are
  • it was an open-label study which means that there was no placebo intervention group but there was also no control group against whom to compare variations in symptoms scores
It should also be mentioned that the study was funded by a company that sells MSM. Of course, sensibly enough, Holford does happen to have formulated a anti-allergy supplement that contains all of the supplements that he recommends (including MSM), and in the quantities that he recommends.

As for some of the remainder of Holford's advice, I have expressed myself at some length on the inappropriateness of IgG testing in the diagnosis of food intolerance. I am not aware of any high quality research that supports Holford's notion that meat and dairy are "mucus-forming [and] pro-inflammatory": however, Jon has some useful observations on this topic. Holford has recommendations about the fruit and vegetable intake:
Choose local, organic produce. Local because there will be less depletion of antioxidant nutrients and organic to avoid pesticide residue which itself is an allergen. Eat plenty of these foods raw.
I'm not a nutritionist, but if "local" is a proxy for recently harvested and less likely to have lost nutrients then it might be helpful to advise people to look at frozen fruit and vegetables. I'm not convinced that there is scientific evidence that would support the claim that pesticide residue is, of necessity, an allergen. Again, if pesticide residue is a concern, it might be helpful to say that some superficial pesticides and fungicides may be removed by washing or peeling. As for raw foods-cooking improves the bioavailability of vitamins in some vegetables. Cooking can make it practical for people with poor teeth to eat some otherwise difficult fruit and vegetables. Lastly, and with some sense of awkwardness, given Holford's frequent emphasis on testing for food allergies and intolerances, I feel that I should mention that some people with oral allergy syndrome are able to eat the cooked version of fruits and vegetables that they are unable to eat when raw.

It was more work than I wanted to dedicate to the topic to discuss why I do not believe that there is evidence of sufficient quality to recommend MSM supplementation to people with allergies. I leave it as an exercise to the reader to consider/discover whether the evidence for the other suggested supplements is any better or the claims any more reliable. But then again, doesn't the journalist who reproduces this material have any responsibility for uncritically regurgitating these claims? Is the misreporting of science and medicine part of the reason why the public is losing faith in the credibility of research?

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