Severe reactions to foods in childhood : clinical perspectives, epidemiology and risk management

Food allergy is a public health issue, particularly among children, and seems to be increasing worldwide. Allergic reactions to foods vary in terms of symptoms and severity. Anaphylaxis, the most severe allergic reaction, can be fatal. Food allergy has significant negative impact in the daily lives of allergic children and their families. The overall aim of this thesis was to gain knowledge about severe reactions to foods among Swedish children with regard to epidemiology, clinical perspectives (study I and II respectively), and risk management (study III). Study I (paper I and II) is an emergency department (ED) medical record study based on a retrospective chart review performed at three hospitals in Stockholm targeting children with anaphylaxis and allergic reactions to foods during 2007. Study II (paper III) is a cohort study where children identified in study I were investigated in relation to new ED visits during the follow-up period 1 January 2007 – 30 June 2010. Study III (paper IV) is a qualitative study where 10 focus group discussions were conducted with 31 parents of food-allergic children to explore strategies of risk management. The main findings in relation to the three study areas in this thesis are: Epidemiology: The incidence of anaphylaxis managed at paediatric EDs in Stockholm during 2007 was 32 per 100 000 person-years and food was involved in 92% (paper II). The incidence of subsequent ED visits for reactions to foods among children with a prior ED visit due to reactions to foods was 92 per 1000 person-years. Previously known food allergy was a risk factor for subsequent ED visits (paper III). Clinical perspectives: The current guidelines presented in the European Academy of Allergology and Clinical Immunology position paper on anaphylaxis in children were not entirely easy to apply when classifying and grading the severity of anaphylaxis in our study population. We attribute this difficulty to lack of description of some respiratory and neurological symptoms and use of subjective wordings (paper I). Among 371 children who visited the EDs due to acute reactions to foods, tree nuts and peanuts were the most common eliciting foods. Among children under three years these allergens were actually as common triggers as milk and egg (paper II). Most children prescribed with adrenaline auto-injectors did not use their device when they experienced anaphylaxis (paper II and III). The severity of previous reactions to foods could not accurately predict the severity of subsequent reactions. However, treatment with adrenaline often hampered the classification of change in severity (paper III). Risk management: The management of food allergy risk permeates many aspects of everyday life according to the parents in study III. Although most followed the norm of constant risk avoidance and vigilance, some took calculated risks in specific situations where the parent could observe and manage the danger. Parents did this to counterbalance the burden of the food-allergic condition, not only for the child but also for the family as a whole (paper IV). In summary: This thesis provides novel data on the epidemiology and clinical characteristics of anaphylaxis and severe reactions to foods among Swedish children. In addition, it provides information about the unpredictability of the food allergic condition and the difficulties associated with studying the disease. Finally, it demonstrates the impact of risk management on parents and family life, and also how risk avoidance and calculated risk-taking are intertwined and can be seen as two sides of the same coin: parent responsibility

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a “severe, life-threatening generalized or systemic hypersensitivity reaction”. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur, and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors which might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps which need to be addressed to improve our ability to better identify those most at risk of severe foodinduced allergic reactions

Cashew nut allergy: clinical relevance and allergen characterisation

Cashew plant (Anacardium occidentale L.) is the most relevant species of the Anacardium genus. It presents high economic value since it is widely used in human nutrition and in several industrial applications. Cashew nut is a well-appreciated food (belongs to the tree nut group), being widely consumed as snacks and in processed foods by the majority of world's population. However, cashew nut is also classified as a potent allergenic food known to be responsible for triggering severe and systemic immune reactions (e.g. anaphylaxis) in sensitised/allergic individuals that often demand epinephrine treatment and hospitalisation. So far, three groups of allergenic proteins have been identified and characterised in cashew nut: Ana o 1 and Ana o 2 (cupin superfamily) and Ana o 3 (prolamin superfamily), which are all classified as major allergens. The prevalence of cashew nut allergy seems to be rising in industrialised countries with the increasing consumption of this nut. There is still no cure for cashew nut allergy, as well as for other food allergies; thus, the allergic patients are advised to eliminate it from their diets. Accordingly, when carefully choosing processed foods that are commercially available, the allergic consumers have to rely on proper food labelling. In this sense, the control of labelling compliance is much needed, which has prompted the development of proficient analytical methods for allergen analysis. In the recent years, significant research advances in cashew nut allergy have been accomplished, which are highlighted and discussed in this review.This work was supported by FCT/MEC through national funds and co-financed by FEDER, under the Partnership Agreement PT2020 with grant no. UID/QUI/50006/2013–POCI/01/ 0145/FEDER/007265. Joana Costa is grateful to FCT post-doctoral grant (SFRH/BPD/102404/2014) financed by POPH-QREN (subsidised by FSE and MCTES).info:eu-repo/semantics/publishedVersio

2015 update of the evidence base:World Allergy Organization anaphylaxis guidelines

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized. Advances in epidemiology, diagnosis, and management in healthcare and community settings are highlighted. Additionally, new information about patient factors that increase the risk of severe and/or fatal anaphylaxis and patient co-factors that amplify anaphylactic episodes is presented and new information about anaphylaxis triggers and confirmation of triggers to facilitate specific trigger avoidance and immunomodulation is reviewed. The update includes tables summarizing important advances in anaphylaxis research. Keywords: Anaphylaxis, Epinephrine, Auto-injector, Food allergy, Stinging insect venom allergy, Drug allergy, Latex allergy, Exercise-induced anaphylaxis, Systemic allergic reaction, Adrenalin

Performance management boards on the bank floor : A study on the use of performance management boards as a foundation for continuous improvement in a Swedish bank

Lean production is a production philosophy that is usually associated with theautomotive industry and companies like Toyota and Scania. The Nordic bank Nordeahas chosen to use the same approach to streamline production of their banking servicesand they call their concept Lean Banking. Within the Swedish banking industry Nordeais a pioneer within Lean production and the effects on the result have been verypositive.Nordea Account Products is the division within Nordea where the lean implementationstarted. Work in this division includes administration of loan products, cards, and ATMtransactions and the production takes place in what the report calls team level. Any teamthat has undertaken a transformation process to become lean uses a whiteboard, called aPerformance management board or PM board, to visualize the development ofperformance indicators and what activities the team is working with to achieve localperformance targets. Daily meetings, called performance management meetings, areheld to keep the team on track with the performance indicators, goals and improvementactivities in focus.In this thesis, work with the daily performance management in four teams at NordeaAccount Products has been studied. The findings has been reflected partly in Nordea'sown guidelines for how work should be conducted, and the relevant literature on thesubject. Furthermore, a benchmark made on the truck manufacturer Scania to see howthe daily monitoring and work with lean production is done there. The main scope is tosee if a company working with administrative production can learn anything from anexperienced production company within the industry, given that they both work withlean principles.The findings of the study summarizes that a connection between Nordea and Scania canbe made despite the fact that they work in very different industries. Nordea has comevery far on their lean journey but there is room for improvement. It is proposed thatNordea ensures the interest and commitment of the top managers to get a true chain ofdemand of the performance indicators on team level. And more resources have to beallocated to continuous improvement work on team level. Furthermore, it is suggestedthat Nordea considers the use of improvement teams in order to exploit the truepotential of the staff in the continuous improvement work. It is also suggested that keyindicators, with an emphasis on quality indicators, are made more measurable andtangible in order to stimulate continuous improvement. There is also potential forimprovement in the designs of charts, standards and in use of Value Stream mappin

Performance management boards on the bank floor : A study on the use of performance management boards as a foundation for continuous improvement in a Swedish bank

Lean production is a production philosophy that is usually associated with theautomotive industry and companies like Toyota and Scania. The Nordic bank Nordeahas chosen to use the same approach to streamline production of their banking servicesand they call their concept Lean Banking. Within the Swedish banking industry Nordeais a pioneer within Lean production and the effects on the result have been verypositive.Nordea Account Products is the division within Nordea where the lean implementationstarted. Work in this division includes administration of loan products, cards, and ATMtransactions and the production takes place in what the report calls team level. Any teamthat has undertaken a transformation process to become lean uses a whiteboard, called aPerformance management board or PM board, to visualize the development ofperformance indicators and what activities the team is working with to achieve localperformance targets. Daily meetings, called performance management meetings, areheld to keep the team on track with the performance indicators, goals and improvementactivities in focus.In this thesis, work with the daily performance management in four teams at NordeaAccount Products has been studied. The findings has been reflected partly in Nordea'sown guidelines for how work should be conducted, and the relevant literature on thesubject. Furthermore, a benchmark made on the truck manufacturer Scania to see howthe daily monitoring and work with lean production is done there. The main scope is tosee if a company working with administrative production can learn anything from anexperienced production company within the industry, given that they both work withlean principles.The findings of the study summarizes that a connection between Nordea and Scania canbe made despite the fact that they work in very different industries. Nordea has comevery far on their lean journey but there is room for improvement. It is proposed thatNordea ensures the interest and commitment of the top managers to get a true chain ofdemand of the performance indicators on team level. And more resources have to beallocated to continuous improvement work on team level. Furthermore, it is suggestedthat Nordea considers the use of improvement teams in order to exploit the truepotential of the staff in the continuous improvement work. It is also suggested that keyindicators, with an emphasis on quality indicators, are made more measurable andtangible in order to stimulate continuous improvement. There is also potential forimprovement in the designs of charts, standards and in use of Value Stream mappin

Pedagoger och mobbning. : En kvalitativ studie om pedagogers uppfattningar samt beskrivningar av det förebyggande arbetet mot mobbning.

Vårt syfte med uppsatsen var att ta reda på pedagogernas uppfattningar om vad de anser är mobbning samt hur de beskriver deras förebyggande arbete i förskolan och skolan. När vi tittade på tidigare forskning fann vi hur svårt det kan vara för pedagoger att veta vart gränserna för mobbning går samt hur mobbning ska definieras. Vi har även funnit faktorer som visat sig framgångsrika i det förebyggande arbetet bl.a. ett bra samarbete mellan ledning, personal och föräldrar. För att få svar på våra frågeställningar valde vi en kvalitativ metod där åsikter och uppfattningar är grundläggande. Därför valde vi att intervjua åtta pedagoger i förskolan och skolan. Utifrån resultatet och tidigare forskning kan vi se att flera av pedagogerna ansåg att mobbning kan beskrivas som en medveten handling som sker upprepade gånger för att skada. Pedagogerna tyckte också det var svårt att veta vart gränserna för mobbning går. Det förebyggande arbetet såg vi skiljer sig mellan förskola och skola. På förskolan jobbar pedagogerna mer lekfullt för att förebygga medan dem på skolan jobbar mer organiserat i deras förebyggande arbete