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Feeding intolerance is ubiquitous in neonatal intensive care units with as many signs and symptoms as possible diagnoses. Optimizing nutrition is paramount in both preterm and term infants. Determining the cause of feeding intolerance and adjusting nutrition interventions is an important part of the daily care of newborns. This review discusses the role of malabsorption and food intolerance as possible causes of nutrition difficulties in the newborn.

Although travelling with a food intolerance can disrupt the experience, limited academic research has considered the impact of food intolerance on travel behaviour. Considering the notions of inherent, situational, and pathogenic vulnerabilities; and avoidance motivation, this research note uses an autoethnographic approach to explore the experience of travelling with a food intolerance in rural New Zealand. The findings suggest the situational vulnerability experienced by being in a foreign location exacerbates the inherent vulnerabilities of having a food intolerance and exposes the individual to pathogenic vulnerabilities by food service providers attempting to cater for intolerances. In response, multiple avoidance mechanisms are adopted to reduce the impact on the individual; resulting in a low spend within the rural community. Accordingly, signage that identifies appropriate food alternatives and operators who can provide it, could help alleviate the impact of having a food intolerance while travelling. However, this work is limited in that it explores the experience of one traveller visiting rural destinations in a developed nation. Future work may use a larger sample across different geographic areas to determine how rural destinations may better serve travellers with a food intolerance.

Background Staple-line leaks (SLL) after sleeve gastrectomy (SG) are a rare but serious complication requiring radiologic and endoscopic interventions with varying degrees of success. When failed, a chronic gastrocutaneous fistula forms with decreasing chances of closure with time. Definitive surgical management of chronic SLL after SG include laparoscopic revision to total/subtotal gastrectomy (LTG/LSTG) or a fistulo-jejunostomy (LRYFJ), both with Roux-en-Y reconstruction. Objectives Comparison of SG revisions to LTG/LSTG versus LRYFJ as a definitive treatment for chronic SLL. Setting High-volume bariatric unit. Methods Retrospective review of a prospectively maintained database identified 17 patients with chronic gastric fistula after SG that were revised to either LTG/LSTG or LRYFJ between September 2011 and May 2020. Demographic characteristics, clinical data, quality of life, and laboratory values for both options were compared. Results Of the 17 conversions, 8 were revised to LTG/LSTG and 9 to LRYFJ. Mean age and body mass index at revision were 36.85 years (range, 21–66 yr) and 29 kg/m2 (range, 21–36 kg/m2), respectively. Average preoperative endoscopic attempts was 5 (range, 1–16). The overall average operation time of revision was 183 minutes (range, 130–275 min) with no significant difference between either conversion options. Mean follow-up time was 46.5 months (range, 1–81 mo) and was available for 10 patients (58.8%). Food intolerance was significantly better after revision to LRYFJ (n = 6/6, 100% versus n = 1/5, 20%, P Conclusion Laparoscopic revision to LRYFJ is a safe and feasible treatment for chronic SLL.

This review of the literature was conducted to define avoidant restrictive food intake disorder (ARFID) and provide the current evidence-based treatment modalities and implications for Nurse Practitioners. A specific case is used to illustrate the daily struggles of a pediatric patient with ARFID that include bullying, self-doubt, and anxiety related to eating. There is a need for increased awareness of the disorder to increase identification of the disorder, enhance the research on treatment modalities for the disorder, and most importantly, to increase the quality of life for those with the disorder and their family members.

Background Metal hypersensitivity is a rare complication after spinal implant placement but is related to significant clinical challenges including implant failure and poor wound healing. The incidence is likely underreported secondary to challenges with diagnosis and retreatment options. Case Description We present the case of a 41-year-old woman with metal hypersensitivity 6 years status post anterior lumbar interbody fusion after a previously failed revision procedure who presented with low back pain and abdominal pain with food intolerance. Diagnostics revealed presacral fluid collection, which was negative for infection. A detailed workup ruled out other possible differential diagnoses and confirmed hypersensitivity to nickel. Intraoperatively, the interbody was loose but difficult to remove secondary to scar tissue. Ultimately, it was successfully replaced with a polyetheretherketone interbody, which did not contain nickel. Conclusions Metal hypersensitivity is likely an underreported complication in spine literature that is associated with poor outcomes. Further research to create evidence-based guidelines on diagnosis and retreatment options will facilitate diagnosis, reduce time to revision surgery, and ultimately decrease patient suffering.

Background and aims The only treatment for celiac disease is strict adherence to a gluten-free diet (GFD). We performed a systematic review to investigate the rate of adherence to a GFD in children with celiac disease, risk factors that affect adherence, and outcomes of non-adherence. Methods We searched PubMed, Cochrane Library, EBSCO, and Scopus for studies through January 2019. We included observational studies of ≥50 children diagnosed with celiac disease and recommended for placement on a GFD. We collected data on adherence assessment (self-report, serology tests, structured dietary interview, biopsies, or assays for gluten immunogenic peptides), risk factors, and outcomes related to adherence. Findings were presented with medians, range, and a narrative synthesis. Results We identified 703 studies; of these, 167 were eligible for full-text assessment and 49 were included in the final analysis, comprising 7850 children. Rates of adherence to a GFD ranged from 23% to 98%. Comparable rates (median rates of adherence, 75%–87%) were found irrespective of how assessments were performed. Adolescents were at risk of non-adherence and children whose parents had good knowledge about celiac disease adhered more strictly. Non-adherence associated with patient growth, symptoms, and quality of life. Conclusion In a systematic review of 49 studies of children with celiac disease, we found substantial variation in adherence to a GFD among patients. Rate of adherence was not associated with method of adherence measurement, so all methods appear to be useful, with lack of consensus on the ideal metric. Studies are needed to determine the best method to ensure adherence and effects on long-term health.

Summary Background & aims The mechanisms behind non-coeliac gluten sensitivity (NCGS) are not fully understood although clinical symptoms have shown to subside after wheat withdrawal. Self-prescription of a gluten-free diet (GFD) without medical supervision is common in NCGS subjects, resulting in dietary restrictions that can cause macro- and micronutrient deficiencies. The primary aim was to describe dietary intake, including FODMAP, in subjects with self-reported gluten sensitivity on GFD in whom coeliac disease (CD) and wheat allergy were excluded. Secondary, clinical symptoms and health-related quality of life (HR-QoL) were examined. Methods Baseline characteristics were obtained from 65 adults with self-reported NCGS on GFD recruited to a randomised placebo-controlled challenge trial at Oslo University Hospital. Dietary intake was obtained by a seven-day food record and symptoms recorded by questionnaires. Results Mean proportions of energy were 43 E% from fat, 40 E% from carbohydrate and 17 E% from protein. Intakes of vitamin D, folic acid, calcium, iodine and iron were lower than recommended, mean (SD) 7.3 (5.8) μg, 235 (105) μg, 695 (309) mg, 81 (52) μg and 9.6 (7.5) mg, respectively. Mean (SD) intake of FODMAP was 11.6 g (8.7). Gastrointestinal symptoms as scored by 100 mm visual analogue scale (VAS) were all below 15 mm of which wind and bloating were the most expressed. Tiredness, concentration difficulties, fatigue and muscle/joint pain were scored highest among extra-intestinal symptoms. Gastrointestinal symptoms as scored by gastrointestinal symptom rating scale – irritable bowel syndrome version (GSRS-IBS) were correlated with mild depression (r = 0.43) and inversely correlated with five sub-domains of HR-QoL (−0.29 Conclusion Subjects with self-reported NCGS on GFD had high proportion of energy from fat and sub-optimal intakes of vitamin D, folic acid, calcium, iodine and iron. Despite GFD and moderate intake of FODMAP, the subjects reported various gastro- and extra-intestinal symptoms and reduced HR-QoL. The findings highlight the importance of dietary education and nutritional follow-up of subjects on GFD.

Objectives Naturopathy and dietetics have evolved as two separate but parallel professions that use diet to promote optimal health and manage many illnesses and diseases. Given the increasing recognition of the influence of diet on health outcomes, there is increasing demand for the services of both professions. The aim of this research was to investigate similarities and differences between naturopathic and dietetic approaches to functional bowel disorders (FBDs). Design For this integrative review AMED, CINAHL, the Cochrane Database of Systematic Reviews, EMBASE, Medline and PubMed databases were searched for articles that focused on dietetic or naturopathic diagnosis and treatment of food intolerance expressing as a FBD in adults. (Registration: PROSPERO 2016 CRD42016049469). Results Of the 55 papers in the final review, 10 discussed complementary medicine approaches to FBDs. Both dietitians and naturopaths used similar holistic approaches to diagnosis and treatment, adjusted diets as a primary treatment approach, and individualised treatment for their patients. The professions differed in their use of vitamin, mineral and herbal supplements and in their willingness to recommend other treatments like osteopathy and acupuncture. Conclusions There is much overlap between dietetic and naturopathic approaches to assessment and treatment of FBDs. Further publications that describe naturopathic treatments for FBDs are needed to confirm these results and to provide opportunities for increased recognition and scrutiny of any distinctively naturopathic approaches. Without doing so, naturopathic practices are likely to remain marginalised and poorly understood. Moreover, the opportunity to fully contribute to the management of lifestyle-related diseases will be missed.

Background and objective Multiple chemical sensitivity (MCS) is a complex, acquired, chronic syndrome of multifactorial etiology with multiple symptoms. The aim of the study was to assess the nutritional habits, dietary characteristics and physical activity, as well as their determinants, of a population diagnosed with MCS, which may allow for a more precise approach to nutritional improvement. Patients and method A descriptive, cross-sectional study in patients diagnosed with MCS. Information was collected using adapted questionnaires. Data included presence of comorbidities, nutritional (use of supplements, types of diet) and food purchasing habits. Dietary intake, food intolerances, and physical activity were also recorded. Results The study included of 52 patients (48 female) aged 50.9 ± 10.3 years. Diagnosis of MCS was commonly associated to chronic fatigue syndrome (70.1%), fibromyalgia (65.4%), or electrosensitivity (51.9%). The most common comorbidities were irritable bowel, gastroesophageal reflux, and depression/anxiety-depressive disorder. Exclusion diets were followed by 57.7%, 52.1% commonly used supplements (6.4 ± 5.2 per person), and 16.0% took more than 10 daily. A high proportion of volunteers did not take the recommended amounts of dairy products (84.3%), fruit (82.3%), and cereals (64.7%), the foods to which intolerance was greatest. As regards physical activity, active subjects only represented 12.5%. Conclusions The data collected support the need to improve food pattern and to perform physical activity according to individual characteristics. Nutritional education and diet personalization could prevent incomplete, monotonous, and unbalanced diets which impair quality of life and physiological status.

Summary Background and aims Non-Celiac Gluten Sensitivity (NCGS) is a recently proposed clinical condition causing both intestinal and extra-intestinal symptoms, without gastrointestinal lesions, which improve on avoiding gluten intake, in the absence of celiac disease and wheat allergy. The prevalence of this condition is still a matter of debate, in part due to the very recent introduction of an accepted diagnostic test, a double-blind, placebo controlled gluten challenge. However, this is a lengthy and cumbersome procedure, theoretically burdened by a significant reduction of patient compliance. ALCAT 5 is an automated in vitro test evaluating the toxic effect of gluten on neutrophils by the exposure of these cells to a gluten-containing extract of gluten-containing cereals. The test is very simple to perform, the results are rapidly obtained, and might represent, if sufficiently accurate, a promising alternative to diagnose gluten intolerance. The aim of this study was the comparison of ALCAT 5 results with those of a double-blind, placebo-controlled, gluten challenge, in a group of patients with clinically-suspected NCGS. Methods Twenty-five patients (M/F 3/22, mean age 32 ± 4 yrs) with severe functional abdominal pain and bloating, who had previously undergone the ALCAT 5 test, were enrolled. All the subjects reported their symptoms on a gluten-containing diet and considered gluten the causal agent. Following the Salerno Experts’ Criteria, they underwent a double-blind, placebo controlled trial with gluten vs placebo. A mean value during gluten ingestion >30% of the value during placebo was considered as indicative of gluten sensitivity. Results After blinded administration of gluten, 13 out of 25 (52%) patients showed an increase in the severity of abdominal pain, and 11 out of 25 (44%) showed an increase in the severity of abdominal bloating. Considering these two symptoms together, in 16 patients out of 25 (64%), blinded gluten administration induced an increase of abdominal pain and/or bloating. The ALCAT 5 test proved to be positive in 20 and negative in 5 patients. In sixteen patients out of 25 the result of ALCAT 5 agreed with the double-blind trial (64%). In particular, both tests were positive in 14 patients and negative in 2. Conclusions In this subgroup of patients, ALCAT 5 could be used to support the clinical suspicion of the presence of NCGS and to address these patients to a blinded gluten challenge.

[ES]: [Antecedentes y objetivo] La sensibilidad química múltiple (SQM) es un síndrome complejo, adquirido, crónico y multifactorial, con amplia sintomatología. El objetivo del presente estudio fue conocer los hábitos alimentarios, las características dietéticas y la actividad física, así como sus condicionantes en un colectivo afectado de SQM, lo que permitirá un abordaje más preciso para la mejora de su estado nutricional. [Pacientes y método] Estudio descriptivo y transversal en pacientes con SQM. Se recogió información mediante cuestionarios adaptados sobre presencia de comorbilidades, hábitos dietéticos (consumo de complementos/suplementos, tipos de dietas) y de compra, así como registro de ingesta dietética, intolerancias alimentarias y actividad física. [Resultados] Se incluyó a 52 pacientes (48 mujeres) de 50,9 ± 10,3 años de edad media. Fue habitual el diagnóstico conjunto de SQM con síndrome de fatiga crónica (70,1%), fibromialgia (65,4%) o electrosensibilidad (51,9%). Las comorbilidades más frecuentes fueron colon irritable, reflujo gastroesofágico y depresión/trastorno ansioso-depresivo. El 57,7% seguía regímenes de exclusión. El 52,1% consumía complementos/suplementos habitualmente (6,4 ± 5,2 por persona) y el 16,0% tomaba más de 10 diarios. Fue elevado el porcentaje de voluntarios que no alcanzó las raciones aconsejadas de lácteos (84,3%), frutas (82,3%) y cereales (64,7%), coincidiendo con los alimentos con mayor intolerancia. Con respecto a la actividad física, los sujetos activos solo representaban el 12,5%. [Conclusiones] Los datos obtenidos confirman la necesidad de mejora del patrón alimentario y realización de actividad física según características individuales. La educación nutricional y personalización de las pautas podrían evitar dietas incompletas, monótonas y desequilibradas que empeoren la calidad de vida y situación fisiológica., [EN]: [Background and objective] Multiple chemical sensitivity (MCS) is a complex, acquired, chronic syndrome of multifactorial etiology with multiple symptoms. The aim of the study was to assess the nutritional habits, dietary characteristics and physical activity, as well as their determinants, of a population diagnosed with MCS, which may allow for a more precise approach to nutritional improvement. [Patients and method] A descriptive, cross-sectional study in patients diagnosed with MCS. Information was collected using adapted questionnaires. Data included presence of comorbidities, nutritional (use of supplements, types of diet) and food purchasing habits. Dietary intake, food intolerances, and physical activity were also recorded. [Results] The study included of 52 patients (48 female) aged 50.9±10.3 years. Diagnosis of MCS was commonly associated to chronic fatigue syndrome (70.1%), fibromyalgia (65.4%), or electrosensitivity (51.9%). The most common comorbidities were irritable bowel, gastroesophageal reflux, and depression/anxiety-depressive disorder. Exclusion diets were followed by 57.7%, 52.1% commonly used supplements (6.4±5.2 per person), and 16.0% took more than 10 daily. A high proportion of volunteers did not take the recommended amounts of dairy products (84.3%), fruit (82.3%), and cereals (64.7%), the foods to which intolerance was greatest. As regards physical activity, active subjects only represented 12.5%. [Conclusions] The data collected support the need to improve food pattern and to perform physical activity according to individual characteristics. Nutritional education and diet personalization could prevent incomplete, monotonous, and unbalanced diets which impair quality of life and physiological status.

Background Breastfeeding positively influences maternal and infant health. Considerable research with preterm infants is available, however, differences between preterm and term infants’ breastfeeding duration and factors influencing cessation has not been fully evaluated. This information is needed for developing focused interventions. Objective To compare factors affecting breastfeeding duration/cessation in preterm and term infants, including infant (latching, eating, food intolerance, weight gain), maternal (medications, weight loss concerns, stress/fatigue), and environmental (convenience, time, returning to work, family support) factors. Study Design, Setting, Participants A cross-sectional survey using SurveyMonkey distributed through social media and online breastfeeding support groups included mothers ≥18 years old, with a child 12-24 months old, US born, who received breastmilk at any point during the first year of life. Measurable Outcome/Analysis Breastfeeding rates at 0 through 12 months, reasons for cessation, breastfeeding education and demographics are reported. Chi-square was used for comparisons. Results The majority of respondents (n = 531) were non-Hispanic White (78.7%), college-educated (61.6%), and from southern states (63.3%). Fifty had preterm ( 37 weeks) infants. No significant difference was found for exclusive breastfeeding between preterm and term infants at any point, 0-5 months; a significant difference at 6 months (40.0% vs 22.7%), χ² (1, n = 531) = 7.4, P Conclusion Differences exist in exclusive breastfeeding rates between preterm and term infants at 6 months. Maternal medications and multiple births may influence early breastfeeding cessation. Participation in WIC may positively influence breastfeeding duration. Research is needed to confirm findings in a more diverse sample.

Background Knowledge of optimal diagnostic workup, etiology, and response to treatment of chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) is limited. Objective To define the etiology of chronic abdominal pain presenting at the 5-year follow-up after RYGB and to evaluate response to treatment. Setting Oslo University Hospital (tertiary referral center for obesity surgery). Methods Of 234 patients operated during a randomly selected 12-month period, 165 (71%) returned for 5-year follow-up, and 160 responded to study questionnaires. Of these, 54 (34%) reported chronic abdominal pain and were invited to participate in a structured diagnostic and treatment algorithm. These patients were contacted for the evaluation of their response to treatment. Results Fifty-one of 54 patients (94%) reporting chronic abdominal pain at the 5-year follow-up were included in the study. Of the 45 patients with onset of symptoms post-RYGB, 28 (62%) underwent one or more radiologic evaluations, 10 (22%) underwent endoscopy, and 13 (29%) underwent laparoscopy. Diagnosis and treatment were established for 34 patients (76%), whereas 11 (24%) had abdominal pain of unknown cause. The most common etiology was internal herniation (n = 6), dumping (n = 6), food intolerance (n = 6), gallstones (n = 5), and irritable bowel syndrome (n = 4). After a median follow-up of 13.0 months (standard deviation, 11.5), 37 (82%) patients reported remission or improvement of symptoms, 6 had unchanged symptoms, and 2 patients were lost to follow-up. Conclusions The etiology of long-term chronic abdominal pain post-RYGB is diverse. A multidisciplinary team can help most patients with dedicated follow-up, but a subset of patients has symptoms of unknown etiology.

There is an increasing number of food allergic reactions occurring in food services including takeaways. This study investigated the food allergy knowledge, attitude and practices of staff in takeaways. Although more than half of the takeaways' staff (n = 28) demonstrated good food allergy knowledge, there still exists some misunderstanding among the respondents. There were confusion about lactose intolerance and milk allergy, a third of the takeaways' staff were uncertain that hands could transfer allergens. Almost half of the respondents were not aware of the danger of offering water to dilute a food allergen to stop the reaction Experienced staff and managers/owners reported more positive attitude and higher frequency of good food allergen management practices. Respondents also strongly agreed that customers should inform staff if they have food allergies. However, takeaways’ staff would enquire customers if they need allergen information when taking orders over the telephone. Clear communication between front service staff, customers and kitchen crew are important and should be established and meals verified with cooks to ensure safe meals are prepared. Managers or owners should also strongly encourage their staff to participate in food allergy training. Food Standards Agency has set up a free food allergy online training that would be a valuable addition to food businesses.

Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population.We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups.Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization.Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

This review summarizes the current state of play with regard to food allergy prevention. Food allergy prevention strategies focused on promoting timely introduction of allergenic foods (predominantly peanut) into the infant diet have recently been introduced in several countries. Additional prevention strategies currently under investigation include optimizing infant vitamin D levels, modulating the gut microbiota through use of probiotics, and preventing eczema to reduce the risk of food sensitization through a damaged skin barrier.

Multiple brands of the same active ingredient may be available for the same strength, administration route and dose form. Generic brands needs to demonstrate bioequivalence to the originator brand, but the appearance of the generic and originator brands are not required to match. This variation is possible because different brands may vary in the excipients used in the formulation. Excipients are inactive ingredients, and typically make up about 90% of the formulation of an individual medication. Individual preferences or requirements may affect tolerance of particular excipients, such as the use of animal products. The different appearance of brands can affect medication management for some people. This review discusses the potential for excipients to alter the individual response to or tolerance of a medication brand.

Background: Roux-en-Y gastric bypass (RYGB)is an effective treatment for morbid obesity, but many patients have increased gastrointestinal symptoms. Objectives: To evaluate gastrointestinal symptoms and food intolerance before and after RYGB over time in a large cohort of morbidly obese patients. Setting: A high-volume bariatric center of excellence. Methods: A prospective cohort study was performed in patients who underwent RYGB between September 2014 and July 2015, with 2-year follow-up. Consecutive patients screened for bariatric surgery answered the Gastrointestinal Symptom Rating Scale (GSRS)and a food intolerance questionnaire before RYGB and 2 years after surgery. The prevalence of gastrointestinal symptoms before and after surgery and the association between patient characteristics and postoperative gastrointestinal symptoms were assessed. Results: Follow-up was 86.2% (n = 168)for patients undergoing primary RYGB and 93.3% (n = 28)for revisional RYGB. The total mean GSRS score increased from 1.69 to 2.31 after surgery (P

Background Mastocytosis comprises a heterogeneous group of disorders characterized by an accumulation of mast cells in 1 or more organs. Symptoms range from mild complaints to severe and life-threatening events. Impact on quality of life seems to vary widely, but influencing factors are poorly understood so far. Objective To examine impairments, psychological burden, health-related quality of life (HRQOL), and possible influencing factors in patients with mastocytosis. Methods In semistructured telephone interviews, patients provided information on impairments in everyday life and psychological burden caused by mastocytosis. HRQOL was measured using the Mastocytosis Quality of Life (MC-QoL) questionnaire. Clinical data were collected from patient files. Results A total of 101 adult patients with mastocytosis (74.3% women; mean age, 47.7 ± 13.5 years) were included. Half of the interviewed patients (50.6%) reported disease-related impairments in everyday life, and 42.4% stated a psychological burden. MC-QoL questionnaire scores showed a broad distribution, with a mean total score at a "mild" impairment level (mean total score, 34.7 ± 22.5). One-third of patients felt moderately (22.8%) or severely (13.9%) impaired, whereas one-third reported no impairment at all (30.7%). Symptoms of mast cell activation and perceived food intolerance had the highest impact on HRQOL. Higher age, higher body mass index, higher tryptase level, and longer duration of symptoms, as well as current drug therapy and pathological bone density, were each associated with reduced HRQOL. Conclusions A high level of suffering and strong associations between impairments and symptom-related factors indicate the importance of addressing patients' concerns and adequate symptom management in mastocytosis.

Background Low postoperative protein intake may represent a modifiable risk factor that leads to fat free mass (FFM) loss postlaparoscopic sleeve gastrectomy (LSG), but data concerning this phenomenon is scarce. Objectives To evaluate the association between daily protein intake and relative FFM loss at 6 (M6) and 12 (M12) months after LSG surgery. Settings Private hospital and university hospital. Methods A prospective cohort study with 12 months follow-up of 77 patients who underwent LSG surgery. Anthropometrics including body composition analysis measured by multifrequency bioelectrical impedance analysis, 3-day food diaries, food intolerance, and habitual physical activity were evaluated at baseline and at M3, M6, and M12. Results Repeated body composition measurements and food diary were available for 77 patients (45 women) at M6 and for 68 patients at M12. Mean age was 42.7±9.4 years and mean preoperative body mass index was 42.2±4.8 kg/m 2 . A protein intake of≥60 g/d was achieved in 13.3%, 32.5% and 39.7% of the study participants at M3, M6 and M12, respectively. FFM significantly decreased at M6 and stabilized at M12. Protein intake of≥60 g/d was associated with a significantly lower relative FFM loss at M6 among women (8.9±6.5% versus 12.4±4.1%; P = .039) and this trend was also reported among men (9.5±5.5% versus 13.4±6.0%; P = .068). A logistic regression for the prediction of FFM loss of≥10% at M6, indicated that protein intake≥60 g/d is a strong protective factor (odds ratio=0.29, 95% confidence interval .09–.96, P = .043). Conclusion Our study supports the currently recommended protein intake goal of≥60 g/d as an efficient strategy for better preservation of FFM post-LSG.

Background Limitations of traditional medicine and rising interest in complementary medicine call for a closer look at the potential relevance of manual medicine, specifically osteopathic manipulative treatment (OMT) in children. Objective To conduct a retrospective observational pilot study of babies who received OMT in the newborn nursery compared to those who did not, by quantifying their outpatient health issues in the first 6 months of life, and to determine the feasibility of further definitive randomized controlled trials of a similar nature. Design Retrospective chart review of the first 6 months of life from pediatric clinic records of 58 case-matched pairs of children, half of whom received OMT as part of their routine newborn care by virtue of their physician “call” assignment to the author. The sample from which the case-matched control group was chosen were babies who had received routine allopathic newborn care without OMT. Both groups received their pediatric care in the same academic ambulatory clinic and received no further OMT. Methods Outpatient paper chart review consisted of tabulation by points of the following variables: mention of spitting/vomiting, gassiness, food intolerance, irritability/sleeplessness, colic suggested or diagnosed, episodes of otitis media, frequency of antibiotics given, frequency of upper respiratory infections, frequency of lower respiratory problems, diarrhea, and rashes, separated by month of visit in which the variable was reported. Results Exploratory analysis by Pearson Chi-square yielded a few statistically significant differences between the 2 groups, in favor of the OMT-treated group, including Month 2 food intolerance (Χ21 = 4.14, P = .04), Month 3 colic suggested (Χ21 = 4.14, P = .04), Month 5 spitting/vomiting (Χ21 = 8.59, P = .003), and Month 5 antibiotic usage (Χ21 = 6.33, P = .012). Conclusions Findings point to the need for further research in this area based on the suggestion that OMT given to a newborn can positively affect that baby's short-term and quite possibly long-term health, specifically related to GI complaints and irritability. Other studies would benefit from a variety of methodologic changes, including correlation of timing of administration of OMT with possible symptoms and changes in those symptoms over longer periods of observation, as well as correlation of anatomic osteopathic findings with specific symptoms.

Lactose intolerance affects 33% to 75% of the world population and may be associated with various genetic factors. Lactose in the diet can be found in milk and dairy products, which simultaneously constitute the primary sources of calcium. Gut microbiota also influences lactose tolerance. Patients with lactose intolerance often stop consuming milk and dairy products, which may lead to calcium and vitamin deficiency and osteoporosis. Insufficient production of lactase also occurs in patients with diseases of the gastrointestinal tract, such as inflammatory bowel diseases. Moreover, Crohn's disease and ulcerative colitis are risk factors for osteoporosis, and the intake of the proper amount of calcium is an essential element in preventing the decrease of bone mineral density. Diet may prevent the development of osteoporosis, thus, educating patients regarding proper diet should constitute a part of the treatment and prevention process. Patients should consume low-lactose, or lactose-free milk and bacterially fermented dairy products. Additionally, plant milk supplemented by calcium and vitamin D, mineral water with calcium, and certain vegetables also may be good sources of calcium.

Background and pilot study Celiac disease (CD) or gluten malabsorption is a well-defined autoimmune disorder characterized by mucosal gastrointestinal reaction to ingested gluten proteins. The necessary treatment for CD is a gluten-free diet. However, up to 30% of celiac patients experience persistent or recurring abdominal complaints despite following an exact gluten-free diet. This condition was named refractory, non-responsive celiac disease. Other food ingredients, such as carbohydrates and biogenic amines, also influence and impair digestion, and may cause these abdominal symptoms. In this retrospective pilot study, we have reported on 20 non-responsive, celiac disease patients, with persistent abdominal complaints, for longer than 6 months. These patients were evaluated for extra food intolerance/malabsorption, including fructose malabsorption, histamine-, lactose intolerance, and Helicobacter pylori (H.p.) infection. Results and conclusions The results demonstrate that 18 of the 20 refractory, non-responsive celiac disease patients presented various, additional food intolerance/malabsorption and/or H.p. infection. Seven NRCD patients demonstrated lactose intolerance, 7 showed fructose malabsorption, 11 had additional histamine intolerance and 6 had signs of H.p. infection or combinations thereof. If present, then eradication of H.p. was performed. Histamine intolerance, was found in more than 50% of patients, and it seems to play an important role in non-responsive celiac disease. A registered dietician continued to help with, and to improve, the patients’ gluten-free diet. Furthermore, additional food intolerance/malabsorption considerations were included in the individual, dietary recommendations.

International audience; Bisphenol (BP) A, a known food contaminant, is a possible risk factor in the epidemic of non-communicable diseases (NCD) including food intolerance and inflammatory bowel diseases (IBD). Regulatory restrictions regarding BPA usage led to BPA removal and replacement by poorly described substitutes, like BPS or BPF (few data on occurrence in food and human samples and biological effect). Oral tolerance protocol to ovalbumin (OVA) in WT mice and Il10-/- mice prone to IBD were used respectively to address immune responses towards food and microbial luminal antigens following BP oral exposure. Both mice models were orally exposed for five weeks to BPA, BPS or BPF at 0.5, 5 and 50 μg/kg of body weight (bw)/day (d). Oral exposure to BPs at low doses (0.5 and 5 μg/kg bw/d) impaired oral tolerance as indicated by higher humoral and pro-inflammatory cellular responses in OVA-tolerized mice. However, only BPF exacerbate colitis in Il10-/- prone mice associated with a defect of fecal IgA and increased secretion of TNF-α in colon. These findings provide a unique comparative study on effects of adult oral exposure to BPs on immune responses and its consequences on NCD related to intestinal luminal antigen development.

Adults with irritable bowel syndrome (IBS) frequently identify foods as exacerbating their gastrointestinal symptoms. In children with IBS, the prevalence of perceived food intolerances and their impact are unknown.Our aim was to determine the prevalence of self-perceived food intolerances and the relationship of these intolerances to abdominal pain, psychosocial distress, and quality of life in children with IBS.We conducted a cross-sectional study. Questionnaire and prospective diary data were collected from 2008 to 2014 by trained research coordinators.Participants were children 7 to 18 years old (pediatric Rome III IBS, n=154; age-sex matched healthy children, n=32) in Houston, TX.Perceived food intolerances and avoided foods were captured using the Childhood Food and Symptom Association Questionnaire. IBS severity was assessed by a ≥7-day pain diary and validated psychosocial questionnaires assessing quality of life, somatization, functional disability, depression, and anxiety.We used descriptive Spearman bivariate correlation, χ(2), and Poisson log-linear generalized model with Wald χ(2) statistics.A greater proportion of children with IBS (143 of 154 [92.9%]) vs healthy children (20 of 32 [62.5%]) identified at least one self-perceived food intolerance (χ(2)=22.5; P0.001). Children with IBS identified a greater number (median=4 [25% to 75% quartile=2 to 6]) of perceived symptom-inducing foods than healthy children (median=2 [25% to 75% quartile=0 to 4]; χ(2)=28.6; P0.001). Children with IBS avoided more foods (median=2 [25% to 75% quartile=1 to 4]) than healthy children (median=0 [25% to 75% quartile=0 to 2.75]; χ(2)=20.8; P0.001). The number of self-perceived food intolerances was weakly associated (r value range= -0.17 to 0.21) with pain frequency, pain severity, somatization, anxiety, functional disability, and decreased quality of life.Children with IBS have a high prevalence of self-perceived food intolerances. The number of these intolerances is weakly associated with measures of IBS severity.

Introduction Autism Spectrum Disorder (ASD) includes a set of disorders characterized by deficits in communication, social interactions and stereotypical behaviors. Recent studies suggest a higher frequency of atopic diseases (asthma, allergic rhinitis, food allergies...). The aim of our study was to assess IgE sensitization to the most frequent allergens in children with ASD. Methodes The study involved 30 children with ASD and 39 controls. The total IgE as well as the IgE specific to the food (FP2, FP5 and FP51) and respiratory (HP1 and GP1) allergen panels were determined in all children by chemiluminescence technique on the Immulite 2000Xpi. Results There was no significant difference between children with ASD and control in total IgE levels (high IgE level in 66.7% TSA vs 51.3%). Overall analysis of IgE sensitization to common allergens showed a higher frequency in ASD children (65.6% ASD versus 28.9% control, P = 0.002). Also, sensitization to house dust allergens (D1, D2 and I6) and to food allergens of FP5 panel (F1, F2, F4, F13 and F210) was more common in children with ASD (46.87% vs 21.05% and 37.5% vs. 13.16%, respectively, P Discussion Recent epidemiological studies have shown a strong statistical correlation between risk for ASD and either maternal or infantile atopic diseases, such as asthma, eczema, food allergies and food intolerance. One explanation for such high rates of allergic diseases in the ASD group could relate to immune sensitivity corresponding to intrinsic stress factors and/or psychosocial stress commonly found in children with ASD. In addition, some research has suggested that stress could aid in releasing neurogenic inflammatory agents, which is also identified in bronchial mucosa or immune cells, and conversely, that the immune system could also modulate the central nervous system function via various molecules, including cytokines. Conclusion Our study found an increased IgE sensitization to common respiratory and food allergens in ASD children.

Allergic proctitis can occur in infants and children. It is expressed by feces streaked with blood without other apparent signs. More than 50% of these patients are being breast-fed. Recently, it has been found that a particular symptom of allergic proctitis is constipation, and it is a major cause of consultations in pediatric gastroenterology departments. We carried out a study, which included a series of patients who were seen for chronic constipation that had not responded to the usual therapy. We found that the majority of these patients had a reduction in the layer of mucus coating the rectum, and this sign was associated with intolerance to cow's milk protein and also to other foods. In patients suffering from chronic constipation associated with proctitis due to food intolerance, reduction in the rectal mucus coating can be considered to be one of the characteristic factors in the pathogenesis of the patient's constipation.

Endometriosis is a chronic and debilitating disorder affecting up to 5-10% of women in reproductive age. Investigators have described deficiency in cellular immunity in women suffering from endometriosis, and in the recent years endometriosis has been linked to other diseases, allergic disease being one of them. The objective of this paper is to systematically review the existing literature on the possible association between endometriosis and allergic disease. This review is based on the recommendations by the preferred reporting of systematic reviews and meta-analysis (PRISMA) statement. PubMed and Embase were searched for studies on women diagnosed with endometriosis and with manifestations of allergic disease who were compared to a reference group. Out of 316 articles screened, 6 were reviewed and 5 ultimately met the inclusion criteria. Four out of the five studies reported a positive correlation between endometriosis and allergic manifestations, including hay fever, sinus allergic rhinitis, and food intolerance/sensitivities (food allergy). Investigators reported an odds ratio (OR) as high as 4.28 (95% CI: 2.93-6.27) for a positive history of allergy among women suffering from endometriosis. Equivocal results were found on asthma prevalence in women with endometriosis. Due to the heterogeneity of the included studies, no meta-analyses could be performed. The available literature clearly indicates that women with endometriosis are at an increased risk of allergic disorders compared to controls, but due to the lack of a concise definition of allergic disease and therefore diagnostic criteria, further studies are needed in order to draw firm conclusions on the association between endometriosis and allergic disease.

"Gluten free" exploded onto the American foodscape in recent years: as of January 2013, 30 percent of U.S. adults reported reducing or eliminating gluten in their diets. How do individuals participate in the expansion of gluten-free dieting, and what are the implications of that expansion? This article is based on 31 in-depth, semi-structured interviews conducted between May and October 2012 with gluten-free and -restricted persons. I identify three interrelated factors contributing to the expansion of gluten-free dieting among non-celiacs. Participants broaden the lay understanding of gluten-related disorders, undermine biomedical authority, and diagnose others. Such participant-driven change, termed self-ascriptive looping, is one factor in the diet's rapid popularization. I show how participants question the doctor-patient relationship and increase social contestability for other dieters. My findings challenge previous work on contested illness and suggest food intolerances may require a reconceptualization of contested illness experience.

What is already known about this topic? Mastocytosis and mast cell activation syndromes are rare diseases or entities manifested by symptoms that mimic allergies, anaphylaxis, and chronic conditions, and can go unrecognized for many years with unnecessary suffering by patients. What does this article add to our knowledge? This article provides the first description of the US mastocytosis and mast cell activation syndromes population based on a survey of patients. Results include the length of time to diagnosis, disease impact, symptoms, specific organ systems affected, and associated conditions, such as allergies and triggers. How does this study impact current management guidelines? This article will provide clinicians with an evidencedbased rationale for a focused investigation of the wide range of symptoms and experiences of patients with suspected or confirmed mastocytosis and/or mast cell activation syndromes. BACKGROUND: Mast cell diseases include mastocytosis and mast cell activation syndromes, some of which have been shown to involve clonal defects in mast cells that result in abnormal cellular proliferation or activation. Numerous clinical studies of mastocytosis have been published, but no population-based comprehensive surveys of patients in the United States have been identified. Few mast cell disease specialty centers exist in the United States, and awareness of these mast cell disorders is limited among nonspecialists. Accordingly, information concerning the experiences of the overall estimated population of these patients has been lacking. OBJECTIVE: To identify the experiences and perceptions of patients with mastocytosis, mast cell activation syndromes, and related disorders, The Mastocytosis Society (TMS), a US based patient advocacy, research, and education organization, conducted a survey of its members and other people known or suspected to be part of this patient population. METHODS: A Web-based survey was publicized through clinics that treat these patients and through TMS’s newsletter, Web site, and online blogs. Both online and paper copies of the questionnaire were provided, together with required statements of consent. RESULTS: The first results are presented for 420 patients. These results include demographics, diagnoses, symptoms, allergies, provoking factors of mast cell symptoms, and disease impact. CONCLUSION: Patients with mastocytosis and mast cell activation syndromes have provided clinical specialists, collaborators, and other patients with information to enable

Summary Background & aims Nasojejunal tube feeding is a standard of care in patients with predicted severe acute pancreatitis (AP) and several recent trials suggested that nasogastric tube feeding (NGT) is as safe and efficient as nasojejunal tube feeding in these patients. The aim was to investigate whether NGT presents any benefit to patients with mild to moderate AP. Methods The study design was a randomized controlled trial. The patients in the intervention group received NGT within 24 h of hospital admission. The patients in the control group were on nil per os (NPO). The severity of acute pancreatitis was determined according to the new international multidisciplinary classification. Results There were 17 patients randomly allocated to the NGT group and 18 to the NPO group. The visual analogue pain score decreased to a significantly greater extent in the NGT group (from median 9 (range 7–9) at baseline to 1 (0–3) at 72 h after randomization) compared with the NPO group (from 7 (5–9) to 3 (1–4) ( p = 0.036). The number of patients not requiring opiates at 48 h after randomization was significantly different ( p = 0.024) between NGT (9/17) and NPO (3/18). Oral food intolerance was observed in 1/17 patient in the NGT group and 9/18 patients in the NPO group ( p = 0.004). The overall hospital stay in the NGT group was 9 (5–12) days as compared with 8.5 (6–13) days in the NPO group ( p = 0.91). Conclusions NGT commenced within 24 h of hospital admission is well tolerated in patients with mild to moderate acute pancreatitis. Further, when compared with NPO, it significantly reduces the intensity and duration of abdominal pain, need for opiates, and risk of oral food intolerance, but not overall hospital stay (ClinicalTrials.gov number, NCT01128478).

Background Autism spectrum disorders (ASDs) are characterized by deficits in social communication and language and the presence of repetitive behaviors that affect as many as 1 in 50 US children. Perinatal stress and environmental factors appear to play a significant role in increasing the risk for ASDs. There is no definitive pathogenesis, which therefore significantly hinders the development of a cure. Objective We aimed to identify publications using basic or clinical data that suggest a possible association between atopic symptoms and ASDs, as well as evidence of how such an association could lead to brain disease, that may explain the pathogenesis of ASD. Methods PubMed was searched for articles published since 1995 that reported any association between autism and/or ASDs and any one of the following terms: allergy, atopy, brain, corticotropin-releasing hormone, cytokines, eczema, food allergy, food intolerance, gene mutation, inflammation, mast cells, mitochondria, neurotensin, phenotype, stress, subtype, or treatment. Results Children with ASD respond disproportionally to stress and also present with food and skin allergies that involve mast cells. Brain mast cells are found primarily in the hypothalamus, which participates in the regulation of behavior and language. Corticotropin-releasing hormone is secreted from the hypothalamus under stress and, together with neurotensin, stimulates brain mast cells that could result in focal brain allergy and neurotoxicity. Neurotensin is significantly increased in serum of children with ASD and stimulates mast cell secretion of mitochondrial adenosine triphosphate and DNA, which is increased in these children; these mitochondrial components are misconstrued as innate pathogens, triggering an autoallergic response in the brain. Gene mutations associated with higher risk of ASD have been linked to reduction of the phosphatase and tensin homolog, which inhibits the mammalian target of rapamycin (mTOR). These same mutations also lead to mast cell activation and proliferation. Corticotropin-releasing hormone, neurotensin, and environmental toxins could further trigger the already activated mTOR, leading to superstimulation of brain mast cells in those areas responsible for ASD symptoms. Preliminary evidence indicates that the flavonoid luteolin is a stronger inhibitor of mTOR than rapamycin and is a potent mast cell blocker. Conclusion Activation of brain mast cells by allergic, environmental, immune, neurohormonal, stress, and toxic triggers, especially in those areas associated with behavior and language, lead to focal brain allergies and subsequent focal encephalitis. This possibility is more likely in the subgroup of patients with ASD susceptibility genes that also involve mast cell activation.

Food allergy is a growing public health concern in the United States that affects an estimated 8% of children. Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a specific food. Nearly 40% of children with food allergy have a history of severe reactions that if not treated immediately with proper medication can lead to hospitalization or even death. The National Institute of Allergy and Infectious Diseases (NIAID) convened an expert panel in 2010 to develop guidelines outlining evidence-based practices in diagnosing and managing food allergy. The purpose of this review is to aid clinicians in translating the NIAID guidelines into primary care practice and includes the following content domains: (1) the definition and mechanism of childhood food allergy, (2) differences between food allergy and food intolerance, (3) the epidemiology of childhood food allergy in the United States, (4) best practices derived from the NIAID guidelines focused on primary care clinicians' management of childhood food allergy, (5) emerging food allergy treatments, and (6) future directions in food allergy research and practice. Articles focused on childhood food allergy were considered for inclusion in this review. Studies were restricted to the English language and to those published within the past 40 years. A cross-listed combination of the following words, phrases, and MeSH terms was searched in PubMed and Google Scholar to identify relevant articles: food allergy, food hypersensitivity, child, pediatric, prevalence, and epidemiology. Additional sources were identified through the bibliographies of the retrieved articles.

Objective To develop a clinic for patients who believe they have a food intolerance that could be administered by practice nurses with minimal experience of dietary change or food intolerance. Methods The clinic consisted of 1 week baseline, 2 weeks healthy eating plan (HE), 2 weeks wheat and dairy free plan (WD). Patients were discharged after the HE plan if their symptoms had improved, otherwise they continued onto the WD plan. Following training 4 nurses ran 4 clinics across the UK. Results 281 patients with perceived food intolerance were recruited. The most common symptoms were bowel symptoms, tiredness, stomach symptoms, and headaches. Of those who completed the programme (n=150), the majority were discharged after the HE plan as their symptoms had improved (n=106, 70.6%). A third also completed the WD plan (n=44, 29%). Symptoms, mood and quality of life improved significantly by the end of the intervention. WD showed added value as symptoms showed further improvement. Conclusion There was a need for the clinic although not on a full time basis. Symptoms improved following both the HE and WD plans. Practice implications A simple dietary based intervention may help relieve symptoms in those who believe they have a food intolerance.

This paper describes an herbal therapeutic approach to addressing food intolerance and immune dysfunction. A case history was chosen to illustrate the therapeutic approach. The patient presented with a long history of allergy and food intolerances. The food intolerances could present in an atypical way. She had a recently diagnosed autoimmune disease, Antiphospholipid syndrome, and was taking prescription drugs. The patient was given herbal prescriptions chosen on an individual basis over a period of 6 months. Herbal treatment included addressing intestinal barrier integrity, improving digestive function and the balance of gut microbiota, reducing stress responses, normalising immune function and lifestyle advice. The treatment was particularly challenging due to the patient’s initial sensitivity to the herbal prescription. With continued treatment, the patient’s food intolerance was greatly improved, as was her general digestive function, fatigue and stress levels. Herbal medicine can play an important role in treating the underlying causes of food intolerance and a supportive role in patients with immune dysfunction, despite taking concurrent prescriptive drugs, whilst preventing the need for eliminative and potentially restrictive diets.

Aims/Background Nuclear transit studies (NTS) allow us to follow transit through the stomach and the small and large intestines. We identified children with chronic constipation with rapid proximal colonic transit and characterized their clinical features. Methods We reviewed NTS from 1998 to 2009 to identify patients with chronic constipation and rapid proximal colonic transit, defined as greater than 25% of tracer beyond hepatic flexure at 6 hour and/or greater than 25% of tracer beyond end of descending colon at 24 hour. This was correlated with clinical symptoms and outcome from patient records. Results Five hundred twenty children with chronic constipation underwent investigation by NTS, and 64 (12%) were identified with rapid proximal colonic transit. The clinical history, symptoms, and outcome in 55 of 64 available for analysis frequently showed family history of allergy (10.9%) and symptoms associated with food allergy/intolerance: abdominal pain (80%), anal fissure (27.3%), and other allergic symptoms (43.6%). Eighteen children were treated with dietary exclusion, with resolution of symptoms in 9 (50%). Conclusions Some children with intractable chronic constipation have rapid proximal colonic transit, have symptoms consistent with possible food allergy/intolerance, and may respond to dietary exclusion. The NTS can identify these patients with rapid proximal transit that may be secondary to food intolerance.

Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food and is distinct from food intolerance. Clinical manifestations of food allergy are varied and involve many systems including respiratory, cutaneous, and gastrointestinal. The double-blinded placebo-controlled oral food challenge remains the gold standard for the diagnosis of IgE-mediated food allergy. Areas of ongoing research include improved understanding of determinants for the development of tolerance versus sensitization for foods, the role of diagnostic testing for specific epitopes for food allergens, and the use of oral immunotherapy for IgE-mediated food allergy.

Adverse food reactions (AFR) are a common problem that may cause cutaneous and/or gastrointestinal signs in dogs and cats. They comprise food intolerance, food intoxication, and food allergy. Response to a dietary elimination trial and recurrence of signs during dietary provocation remain the centerpiece of diagnosis and management of dogs and cats with AFR. Response to an elimination trial is frequently observed in dogs and cats with chronic idiopathic enteropathies. However, only a fraction of them relapse after a dietary challenge. These animals may have mild to enteritis and/or colitis and benefit from various additional properties of the elimination diet.

Food irradiation is the process of exposing food to ionising radiation to eliminate microorganisms or insects. Lectins are the most common agents in food intolerance, and efficient methods to reduce unwanted or intolerant immunological effects of lectins have not yet been described. Sebastiania jacobinensis bark lectin was structurally altered after gamma irradiation. Hemagglutination assays showed that the lectin was stimulated by low doses of radiation (0.1 kGy), while high doses (above 1 kGy) induced a significant loss of activity. The effect of γ-radiation on lectin hydrophobicity was measured by intrinsic and bis-ANS fluorescence. High doses of ionising radiation suppressed the intrinsic fluorescence emission and promoted polypeptide fragmentation and hydrophobic surface modification. The results suggested that changes in the hydrophobic surface induced by gamma irradiation led to protein misfolding and, subsequently, to aggregation. The pioneering viewpoints presented on the stability of a food allergen after gamma irradiation might contribute to the development of harmless and more effective methods to reduce or eliminate food allergenicity.

Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.

Introduction Galactosemia is a rare genetic disorder not frequently encountered in clinical practice. GALT enzyme deficiency is in the spectrum of non IgE mediated food intolerance. However, when encountered with symptoms consistent anaphylaxis, the possibility of an IgE mediated reaction should not be excluded. Case Description Our patient is a 17-year old female who presented for evaluation of food intolerance after ingestion of milk. She was diagnosed as a carrier, or having a mild variant of galactosemia, at birth. She had been strictly avoiding milk since infancy, until her recent exposure to baked goods made with milk. After ingestion she developed immediate urticaria, nausea and vomiting. Physical exam was found to be unremarkable. Her in-vitro testing demonstrated a serum IgE to milk >100 kU/L (normal Discussion This is a unique case that demonstrates both non IgE mediated and IgE mediated intolerance to milk in the same patient. Classic galactosemia and Duarte variant galactosemia are autosomal recessive disorders that lead to the deficiency of the enzyme galactose-1-phosphate uridyltransferase. Diagnosis is made on the newborn screen. Classic galactosemia presents with feeding problems, failure to thrive, liver damage, bleeding, and infections. Duarte variant galactosemia presents as jaundice in infancy that resolves when switching to low-galactose formula. Our patient had symptoms upon introduction of milk later in life that was not fully explained by her diagnosis of Duarte variant of galactosemia, but rather by an IgE mediated milk allergy. To date, she is avoiding milk and carries an epinephrine autoinjector.