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Journal ArticleDOI

Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease.

TL;DR: An empiric 6-food elimination diet effectively induced remission of active adult EoE, which was maintained for up to 3 years with individually tailored, limited exclusion diets.
Abstract: Background Although empiric exclusion from the diet of the 6 food groups most likely to trigger allergies achieves eosinophilic esophagitis (EoE) remission in children, data on its prolonged efficacy and effects on adults are lacking. Objective We sought to evaluate the efficacy of a 6-food elimination diet in inducing and maintaining prolonged remission in patients with adult EoE. Methods Sixty-seven consecutive patients with adult EoE were prospectively recruited and treated exclusively with a diet avoiding cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy for 6 weeks. Subsequent challenge was undertaken by sequentially reintroducing all excluded single foods, followed by endoscopy and biopsies, which were developed every 6 weeks in case of response (eosinophil peak count reduction to Results Forty-nine (73.1%) patients exhibited significantly reduced eosinophil peak counts ( Conclusions An empiric 6-food elimination diet effectively induced remission of active adult EoE, which was maintained for up to 3 years with individually tailored, limited exclusion diets.
Citations
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Journal ArticleDOI
TL;DR: Advances and updates in the epidemiology, pathogenesis, diagnosis, and treatment of food allergy over the past 3 years are focused on, with incorporation of extensively heated forms of milk and egg into the diets of children who tolerate these foods represents a significant shift in clinical approach.
Abstract: This review focuses on advances and updates in the epidemiology, pathogenesis, diagnosis, and treatment of food allergy over the past 3 years since our last comprehensive review. On the basis of numerous studies, food allergy likely affects nearly 5% of adults and 8% of children, with growing evidence of an increase in prevalence. Potentially rectifiable risk factors include vitamin D insufficiency, unhealthful dietary fat, obesity, increased hygiene, and the timing of exposure to foods, but genetics and other lifestyle issues play a role as well. Interesting clinical insights into pathogenesis include discoveries regarding gene-environment interactions and an increasing understanding of the role of nonoral sensitizing exposures causing food allergy, such as delayed allergic reactions to carbohydrate moieties in mammalian meats caused by sensitization from homologous substances transferred during tick bites. Component-resolved diagnosis is being rapidly incorporated into clinical use, and sophisticated diagnostic tests that indicate severity and prognosis are on the horizon. Current management relies heavily on avoidance and emergency preparedness, and recent studies, guidelines, and resources provide insight into improving the safety and well-being of patients and their families. Incorporation of extensively heated (heat-denatured) forms of milk and egg into the diets of children who tolerate these foods, rather than strict avoidance, represents a significant shift in clinical approach. Recommendations about the prevention of food allergy and atopic disease through diet have changed radically, with rescinding of many recommendations about extensive and prolonged allergen avoidance. Numerous therapies have reached clinical trials, with some showing promise to dramatically alter treatment. Ongoing studies will elucidate improved prevention, diagnosis, and treatment.

1,132 citations

Journal ArticleDOI
TL;DR: Dietary interventions are effective in producing histologic remission in patients with EoE, and Elemental diets and SFEDs were the most effective, achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively.

404 citations


Cites background or methods from "Empiric 6-food elimination diet ind..."

  • ...Retrospective analyses have shown that food-specific IgE serum measurements and SPTs were neither sensitive nor specific methods for predicting EoE food triggers in adult patients.(37,44) In addition to these 3 major dietary treatment options, other dietary interventions have proven effective in achieving histologic remission of EoE....

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  • ...Available research has demonstrated that one or several different foods can be responsible for EoE(37,44,60) and, although data are still limited, it seems clear that continuous avoidance of foods that trigger EoE allows for a prolonged, drug-free remission of the disease.(44,61) Food-reintroduction protocols generally entail repeated endoscopies with biopsies, which are not always well accepted by patients and should be performed under sedation....

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  • ...This list has been modified in subsequent studies to also include those foods with a positive SPT result(37,40) or according to regional allergy sensitization patterns.(44) The results for the 7 studies that evaluated an SFED were extremely homogeneous, with a combined efficacy rate of 72....

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Journal ArticleDOI
TL;DR: Findings indicate that, in adults, eosinophilic esophagitis is IgG4-associated, and not an IgE-induced allergy, and that omalizumab did not alter symptoms of eos inophilic Esophageal mucosal biopsy samples compared with placebo.

336 citations

Journal ArticleDOI
TL;DR: The limited data on the utility of allergen immunotherapy as a therapy for EoE prevent a recommendation for this treatment option.
Abstract: Background The onset of eosinophilic esophagitis (EoE) after oral immunotherapy (OIT) has been repeatedly described in patients with immunoglobulin E (IgE)-mediated food allergy in recent years, but the relation between the 2 conditions has not been fully assessed and quantified. Objective To provide a systematic review of the evidence for an association between OIT and EoE. Methods Electronic searches were performed with keywords relating to EoE and OIT in the MEDLINE, EMBASE, and SCOPUS databases. Summary estimates were calculated. A fixed-effects model was used depending on heterogeneity ( I 2 ). Risk of publication bias was assessed by funnel plot analysis and the Egger test. Results The search yielded 118 documents, 15 of which were included in the quantitative summary. Most reported information came from children undergoing peanut, milk, and egg OIT. Significant publication bias in favor of studies reporting the development of EoE after OIT was documented. The overall prevalence of EoE after OIT was 2.7% (95% confidence interval 1.7%–4.0%, I 2 = 0%). Differences between medium-to high-quality studies and those of low quality were documented (3.5% vs 2.5%, respectively). EoE often resolved after OIT discontinuation; histologic remission of EoE achieved after allergen immunotherapy also was documented in 2 patients whose topical fluticasone treatment failed. Conclusion New onset of EoE after OIT occurs in up to 2.7% of patients with IgE-mediated food allergy undergoing this treatment strategy. The limited data on the utility of allergen immunotherapy as a therapy for EoE prevent a recommendation for this treatment option.

270 citations

Journal ArticleDOI
TL;DR: The current diagnostic criteria and challenges to diagnosis are explained, including the role of gastroesophageal reflux disease and proton pump inhibitor-responsive esphageal eosinophilia, and the main treatment approaches and new treatment options are reviewed.

186 citations

References
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Journal ArticleDOI
TL;DR: A general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies is presented and tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interob server agreement are developed as generalized kappa-type statistics.
Abstract: This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.

64,109 citations

Book
01 Jan 2001
TL;DR: In this article, the authors present experiments and generalized Causal inference methods for single and multiple studies, using both control groups and pretest observations on the outcome of the experiment, and a critical assessment of their assumptions.
Abstract: 1. Experiments and Generalized Causal Inference 2. Statistical Conclusion Validity and Internal Validity 3. Construct Validity and External Validity 4. Quasi-Experimental Designs That Either Lack a Control Group or Lack Pretest Observations on the Outcome 5. Quasi-Experimental Designs That Use Both Control Groups and Pretests 6. Quasi-Experimentation: Interrupted Time Series Designs 7. Regression Discontinuity Designs 8. Randomized Experiments: Rationale, Designs, and Conditions Conducive to Doing Them 9. Practical Problems 1: Ethics, Participant Recruitment, and Random Assignment 10. Practical Problems 2: Treatment Implementation and Attrition 11. Generalized Causal Inference: A Grounded Theory 12. Generalized Causal Inference: Methods for Single Studies 13. Generalized Causal Inference: Methods for Multiple Studies 14. A Critical Assessment of Our Assumptions

12,215 citations

Journal ArticleDOI
TL;DR: A new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.
Abstract: Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.

1,675 citations

Journal ArticleDOI
TL;DR: There is a marked heterogeneity in the prevalence of food allergy that could be a result of differences in study design or methodology, or differences between populations, according to the method of assessment used.
Abstract: Background There is uncertainty about the prevalence of food allergy in communities. Objective To assess the prevalence of food allergy by performing a meta-analysis according to the method of assessment used. Methods The foods assessed were cow's milk, hen's egg, peanut, fish, shellfish, and an overall estimate of food allergy. We summarized the information in 5 categories: self-reported symptoms, specific IgE positive, specific skin prick test positive, symptoms combined with sensitization, and food challenge studies. We systematically searched MEDLINE and EMBASE for publications since 1990. The meta-analysis included only original studies. They were stratified by age groups: infant/preschool, school children, and adults. Results A total of 934 articles were identified, but only 51 were considered appropriate for inclusion. The prevalence of self-reported food allergy was very high compared with objective measures. There was marked heterogeneity between studies regardless of type of assessment or food item considered, and in most analyses this persisted after age stratification. Self-reported prevalence of food allergy varied from 1.2% to 17% for milk, 0.2% to 7% for egg, 0% to 2% for peanuts and fish, 0% to 10% for shellfish, and 3% to 35% for any food. Conclusion There is a marked heterogeneity in the prevalence of food allergy that could be a result of differences in study design or methodology, or differences between populations. Clinical implications We recommend that measurements be made by using standardized methods, if possible food challenge. We need to be cautious in estimates of prevalence based only on self-reported food allergy.

1,259 citations

Journal ArticleDOI
TL;DR: Chronic gastrointestinal symptoms and histological changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux were improved by the use of elemental formulas.

925 citations

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