Abstracts from the Food Allergy and Anaphylaxis Meeting 2016

s from the Food Allergy and Anaphylaxis Meeting 2016 Rome, Italy. 13–15 October 2016 © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. ORAL ABSTRACT SESSION 1: Food allergens • Anaphylaxis OP01 Fatal anaphylaxis is decreasing in France: analysis of national data, 1979–2011 Guillaume Pouessel, Claire Claverie, Julien Labreuche, Jean‐Marie Renaudin, Aimée Dorkenoo, Mireille Eb, Anne Moneret‐Vautrin, Antoine Deschildre, Stephane Leteurtre Department of Pediatrics, Children’s Hospital, Roubaix, France; Division of Pulmonology and Allergology, Department of Pediatrics, Faculty of Medicine and Children’s Hospital, Lille, France; Allergy Vigilance Network, Vandoeuvre les Nancy, France; Université Lille 2, CHU Lille, EA 2694 ‐ Santé Publique: épidémiologie et qualité des soins, Lille, France; Biostatistic Unit, Maison Régionale de la Recherche Clinique, CHRU Lille, Lille, France; Department of Allergology, Emile Durkheim Hospital, Epi‐ nal, France; Centre d’Epidémiologie sur les Causes Médicales de Décès INSERM, CHU de Bicêtre, Le Kremlin‐Bicêtre, France Correspondence: Guillaume Pouessel ‐ guillaume.pouessel@gmail.com Clinical and Translational Allergy 2017, 7(Suppl 1):OP0

corticosteroid, or antihistamine were compared with recommended adrenalin treatment according to the algorithm in Sampson 1-5. Results: Out of 346 challenges scored as grade 4 anaphylaxis, 296 were terminated due to respiratory symptoms requiring adrenalin according to  i.e. "barky cough, hoarseness, difficulty swallowing" (laryngeal, n = 79), "wheezing, dyspnea, cyanosis" (lower resp. n = 181) or both (n = 36). Nine of the 115 patients with laryngeal symptoms were treated with adrenalin, all due to inspiratory stridor. No patients with lower respiratory symptoms received adrenalin, but the majority were treated with β2 agonists (188/217), whereas in 30 challenges, symptoms disappeared without treatment or only antihistamine for concomitant urticaria were used. Patients solely with laryngeal symptoms received β2-agonists in 16 challenges, but the majority of them (54/79) received no treatment or only antihistamine. The 36 patients with both laryngeal and lower respiratory symptoms were treated in same manner as patients with only lower respiratory symptoms, i.e. β2 agonist for their bronchial wheeze or asthma. Grade 5 anaphylaxis was seen in 11 challenges, 1 caused by non-adrenalin recommended "loss of bowel control". In the remaining 10 cases, 7 patients were treated with adrenalin, either due to "hypotension < 90 mm Hg" (n = 3) or "unconsciousness" (n = 4). Three children fainted, but regained consciousness without administration of adrenalin. Grade 5 anaphylaxis should almost always be treated with adrenalin, whereas adrenalin only was administrated to inspiratory stridor and not to bronchial expiratory wheeze or asthma in grade 4 anaphylaxis. Respiratory signs were instead medicated according to symptoms, i.e. with β2-agonist to relieve bronchoconstriction. All patients were evaluated by experienced specialists, and therefore this practice should be addressed with care in less experienced settings. Conclusion: Inspiratory stridor was the main cause of adrenalin treatment in grade 4 anaphylaxis, whereas the majority of lower respiratory symptoms were treated with inhalant β2 agonists, thereby overcoming the need for adrenalin. This needs to be considered in future treatment recommendations.

Introduction:
The European Food Safety Authority (EFSA) and other international bodies (Codex) define approaches for allergenicity assessment of food and feed derived from biotechnology. As an outcome of the allergenicity assessment, risk assessors estimate whether the novel protein is likely to be allergenic and whether the food derived from biotechnology is likely to be more allergenic than that derived from its appropriate comparator(s). Because it is challenging to predict the allergenicity of novel proteins, a weight-of-evidence approach is used to provide the assessor with a cumulative body of evidence to (a) reduce the uncertainty linked to the allergenicity assessment and, (b) enhance the reliability of predictions regarding the allergenic potential of novel protein(s). Methods: Currently, EFSA is developing supplementary guidance to better define and clarify specific aspects of the allergenicity assessment requirements. In particular, (i) non-IgE-mediated immune adverse reactions to foods; (ii) in vitro protein digestibility; and (iii) endogenous allergenicity, are addressed. Results: Firstly, celiac disease is a well characterised non-IgE-mediated adverse immune reaction to food, and the food proteins involved, as well as the underlying molecular mechanisms, have been described in detail. Secondly, the outcome of in vitro protein digestibility studies is considered relevant information in the weight-of-evidence approach. To date, the "pepsin resistance test" is commonly accepted for the safety assessment considerations by risk assessors. However, EFSA has previously highlighted its limitations for the allergenicity assessment as well as for its capacity to reflect in vivo digestion conditions. Thirdly, high performance methodologies for protein identification and quantification are available for endogenous allergenicity. Conclusion: Firstly, based on the current knowledge EFSA is working on defining a strategy to be followed for the assessment of novel proteins' potential to cause celiac disease. Secondly, EFSA is proactively developing a complementary strategy in order to reduce the resulting uncertainty in the allergenicity assessment. This strategy will be based on state-of-the-art in science, aiming at proposing an enhanced and refined in vitro gastrointestinal digestion test where different physiological conditions will be taken into consideration and more informative read-out procedures will be recommended. Thirdly, high performance methodologies for protein identification and quantification will be proposed as complementary/alternative methods to those based on human sera for the assessment of endogenous allergenicity within the comparative assessment analysis.
Introduction: One of the most frequent fruit and vegetable allergies in the Mediterranean area is non-specific-lipid transfer protein (nsLTP) syndrome where patients suffer allergies not only to peach but other plants-food related to nsLTPs. Specific immunotherapy (sIT) brings a new perspective to treat these patients however little is known whether sIT to one allergen can affect allergy to other plant-derived food. The aim was to evaluate the effect of sublingual immunotherapy (SLIT) with Pru p 3 (Pru p 3-SLIT) to other plants-derived-food in allergic patients to vegetable. Methods: In a group of 36 patients with allergy to peach, 30 (83.3%) had allergies to other plants-food related. Plant-food allergies were evaluated by compatible clinical history, prick-prick to fresh fruit and ImmunoCAPIgE. After one year of treatment with (enriched-Pru p 3-SLIT) we evaluated reactivity to apple, hazelnut, strawberry and tomato by double blind placebo control food challenge (DBPCFC). Results: In the total group of patients, 12 (33.3%) were allergic to apple, 4 (33.4%) had anaphylaxis, 5 (41.6%) urticaria and/or angioedema and three (25%) OAS. Four (11.1%) were allergic to hazelnut, from these 3 (75%) presented anaphylaxis and 1 (25%) urticaria and/or angioedema. Four (11.1%) to strawberry, all the patients presented OAS. Three (8.3%) were allergic to tomato, presenting anaphylaxis one patient (33.3%) and urticaria and/or angioedema 2 (66.75). Prick-prick with the culprit food was positive in all of the patients (100%). sIgE with apple, strawberry and tomato was positive in all the cases (100%). Hazelnut was positive in three (75%). After one year of SLIT all the patients tolerated tomato with peel and 100 gr of strawberries. Regarding reactivity to apple, 7 (58.3%) tolerated the whole apple with peel. Finally 2 patients (50%) tolerated 15 units of hazelnut. These results showed that a percentage of patients with clinical symptoms to other plants-food related to nsLTP that can tolerate this food after receiving enriched-Pru p 3-SLITduring one year. Enriched-Pru P 3-SLIT could be a good tool to improve the clinical symptoms in patients with LTP-Syndrome. Conclusion: These data show clinical changes after the first year of treatment with enriched-Pru p 3-SLIT, not only to peach but also to other food allergens as apple, hazelnut, strawberry and tomato.
Introduction: Peanuts are rarely consumed in their native form and are most commonly, fried or roasted, conditions which favour the formation of Maillard reaction products (MRP's). Quantitative proteomic profiling of these modified proteins will enable MRP formation to be monitored during processing and markers identified. Thermal processing is also thought to modulate the allergenic activity of peanuts by causing protein aggregation and decreasing solubility. The IgE reactivity of thermally processed peanut proteins will be assessed using a panel of peanut-allergic patient serum. Methods: Raw and processed peanuts were extracted under harsh denaturing conditions and subjected to proteomic profiling using data-dependent acquisition (DDA) on an Orbitrap Elite mass spectrometer. Data was processed using Progenesis-QI and peptides identified using a curated peanut database and a predetermined set of variable Maillard modifications in Peaks. Serum samples from peanut allergic patients were obtained from the Manchester Respiratory, Allergy and Thoracic Surgery (ManARTS) Biobank and IgE reactivity assessed by immunoblotting, inhibition ELISA and histamine release. Results: Mass spectrometric analysis revealed processing-induced modification of peanut allergens through the formation of Maillard reaction products and reduced solubility through aggregation. Extensive boiling (>2 h) had complex effects on allergen structure, and caused hydrolysis of allergens, and loss of Ara h 2 into the cooking water. Patients could be classified into those who were sensitised to several allergens and reacted towards aggregates, and those sensitised only to Ara h 2. Many of the latter patients were not reactive to boiled peanuts. Conclusion: This work has identified a number of peptide markers in peanut which are characteristic of different types of thermal processing. It also highlighted the ability of extensively processed protein to retain IgE reactivity in certain sensitised individuals whilst boiled peanuts maybe less reactive in certain patients. Boiled peanuts may provide an alternative for oral immunotherapy with reduced side-effects, especially in patients only reactive to Ara h 2.
Introduction: Gastric digestion assays have been part of the weightof-evidence approach for evaluating the allergenic potential of proteins expressed in GM crops since protein stability in such assays was suggested to correlate with the allergenic status of proteins. EFSA has provided guidance that more physiologically relevant digestion assays should be evaluated for their potential to support the allergenicity risk assessment. Methods: Nine proteins (shrimp and porcine tropomyosin, peanut and green pea albumin, peach and strawberry LTP, fish and bovine collagen, and carp parvalbumin) were subjected to 9 different gastric digestion conditions (pH 1.2/2.5/4.0, with three pepsin/protein ratios [PPR] 10:1/1:1/1:10), followed by duodenal digestion. Samples were taken at different time points and analyzed by SDS-PAGE and immunoblotting (mono-specific polyclonal rabbit antisera). Results: The idea behind the four protein pairs was to pairwise compare an established strong allergen and a related non-allergen or weak allergen. Originally, we set out to do the same for fish parvalbumins, but purification of the hypothesized weak allergenic version from swordfish/tuna turned out to be extremely difficult due to the low content in the fish muscle (which is probably the more likely explanation of the low allergenicity of these fish). For three of the four pairs (tropomyosins, albumins and LTPs), the allergenic protein presented as the more stable during gastric digestion. The optimal conditions for this were pH1.2 and/or pH2.5 in combination with higher physiological PPRs (10 and/or 1). Gastric digestion at p 4.0 was clearly a less discriminative condition. Surprisingly, in case of the collagens, the allergenic one from fish was more labile than its bovine counterpart. Results from the duodenal digestion showed that, after gastric digestion at pH2.5 and/or 4.0 (less so after pH1.2), all proteins including all established allergens, were completely digested, also if they were resistant to preceding gastric digestion. Conclusions: Gastric digestion at low (i.e. optimal) pH still remains the more appropriate but not perfect tool to use in building weight of evidence for the risk assessment of novel transgenes for GM crops. More physiological conditions, like higher gastric pH and/or inclusion of duodenal digestion may in fact be misleading with established strong allergens such as Ara h 2, Pru p 3 and Cyp c 1 being readily and completely digested. Introduction: It is known that parental anxiety & VAFA in siblings of an IC may affect the nutrition and quality of life (QOL). There is no evidence to support investigation and challenge for food allergy in the unaffected siblings. This study explores VAFA, parental anxiety and parental response to possible measures for facilitating new food introduction to the unaffected siblings of an IC. Methods: The data was obtained from 40 families with proven food allergy in the IC attending a hospital in the UK. The parents were practicing VAFA in the unaffected siblings. The families with siblings suffering from eczema and asthma were excluded from the study. The families were offered 3 options: 1. Continue VAFA 2. Introduce suspected food in the hospital restaurant conveniently located near A&E and wait for 2 h 3. Give the suspected food at home during the day time.

Results:
The parental anxiety score (AS) was measured in Likert Scale (0 to 10). Parents of IC with multiple food allergies and strong family history have higher AS to introduce suspected food in the siblings. Peanut, tree nut, milk and fish allergy caused maximum AS. 16 parents with AS >5 requested for allergy test before making the decision. All 16 parents choose to continue VAFA. Additionally, 5 parents in this group preferred VAFA to ensure allergen free household for safety of the IC & 4 witnessed anaphylaxis in the past (Table 1). No allergic reaction was noted during food introduction. Parents reported reduction of AS post introduction. Parents felt less hesitant in introducing new food to the siblings in future. Conclusion: This study highlights the effect of parental anxiety on VAFA. The novel innovative approach of introducing food within the hospital premises restaurant was perceived by parents as less risky and more reassuring. This option positively influenced parental decision to Introduction: Food allergy is causing adverse health effects arising from specific immune-mediated responses, occurring reproducibly upon oral exposure to a given food. In the absence of a cure, sufferers have to rely on the accurate labeling of food to avoid allergens. Egg and cow's milk proteins are common triggers of allergic reactions, especially in children. Following a multimethod comparative study about the latest approaches in food analysis using state-of-the-art technology (see our previous work), one specific goal of this study is to develop and validate a LC-MS/MS method for residual determination of cow's milk and egg allergens in bakery products. Methods: After sample homogenization, proteins are extracted, denatured and reduced by TCEP. Free thiol moieties are then alkylated and proteins digested by trypsin. The peptide mixtures obtained are then purified by Solid Phase Extraction and analyzed by LC-MS/MS using Sciex Q-Trap 6500 mass spectrometer. For our purpose, a Multiple Reaction Monitoring (MRM) method specific for milk β-lactoglobulin (β-lg) and egg ovalbumin was set up. Results: After spiking a mix of β-lg and ovalbumin into different bakery products, specific MRM signals were detected for both proteins. As an example, two XIC graphs for one of the MRM transitions investigated in β-lg are reported below (Fig. 1). The signal is clearly visible in the product spiked with as little as 0,05 mg/kg of β-lg (B), but is absent in the blank (A). The efficacy of the MRM method was assessed by testing a certified material (cake mix, FAPAS) for milk's presence. The material was previously used for a ring test involving different ELISA kits. As ELISA kits suffer from high kit-to-kit variability (as can be seen in many proficiency testing results) a quantitative comparison with the results obtained from ELISAs was not possible. In LC-MS/MS analysis, quantification by MRM is generally more accurate as it is not reliant upon biological interactions like antibodies.

Conclusion:
The LC-MS/MS approach, combined with an efficient extraction method, shows high sensitivity and selectivity under all evaluated conditions, without producing false negatives for neither egg nor milk. The developed method provides a valid alternative to the ELISA kits on the market, bypassing issues associated with antigen-antibody interactions and retaining a low limit of quantification. The method will be validated and considered for accreditation.

Fig. 1 See text for description
Introduction: To evaluate the digestibility as well as the immunogenic and sensitizing potential of thermally treated bovine caseins (TT caseins). Methods: Caseins were dry heated for 30 or 60 min at 140°C. Native and TT caseins were digested in simulated gastric fluid pH 1.2 (10 U of pepsin activity/µg of test protein). Samples of 200 µl were removed after incubation at 37°C. The reaction was quenched by addition of 70 µl of 200 mM NaHCO 3 , pH 11, and 70 µl 5× Laemmli buffer. The zero time points were prepared by quenching the pepsin in the solution before adding the test protein. The samples were subjected to SDS-PAGE electrophoresis using 10-20% polyacrylamide Tris-glycine gels. BALB/c mice (n = 6/ group) were sensitized intraperitoneally without adjuvants through the administration of native or TT caseins in 250 µl of PBS. Sensitizations were performed at days 0, 3, 6, 9, 12, and blood was drawn on day 28. Caseinspecific IgG and IgE antibodies were evaluated using ELISA. Results: There was no effect of incubation of caseins in simulated gastric fluid for 60 min in the absence of pepsin. However, caseins, either native or TT caseins, were very unstable in the presence of pepsin, with a marked loss of full length protein after 0.5 min of incubation. Native and TT caseins were both immunogenic and allergenic at the dose tested (0.05 mg/mouse). Casein-specific IgG and IgE titers were higher in the group of mice sensitized with TT caseins for 30 min than the other groups (p < 0.05). There were no differences between the groups sensitized with native caseins and TT caseins for 60 min (p > 0.05). Specific IgE antibodies in sera from mice sensitized with native casein strongly recognized TT caseins and vice versa (p > 0.05). Extensively heated cow's milk is an alternative to accelerate tolerance acquisition in some milk allergic cases. This is in line with our digestibility results, an indirect parameter of allergenicity, as TT caseins remains as digestible as native caseins. However, there was no reduction of the sensitizing potential of TT caseins. Although this potential was similar between TT caseins for 60 min and native caseins, longer thermal treatments are not suitable for the study because of the loss of protein solubility. Conclusion: Thermal treatment of caseins alone does not reduce their allergenic potential highlighting that heat-induced interactions between milk proteins and other milk components are required to reduce their allergenic potential.
Introduction: Anaphylaxis is still under-recognized and the treatment is often inadequate with underutilization of adrenaline even by medical personnel.
Our aim was to assess physician's knowledge regarding diagnosis and management of anaphylaxis in children and to identify the reasons for the gaps. Methods: Physicians were asked to respond a two-part questionnaire during continuing medical education: 1. A clinical scenario-based questionnaire involving a child experiencing a food-induced anaphylaxis with 5 of 9 true/false questions considered as key questions for an optimal management; 2. Demographic data and questions exploring determinants of an appropriate management. Results: 318 physicians (GPs, 28%; pediatricians, 23%; allergists, 10%; school-mother and child care doctors, 19%; and junior doctors, 20%) were enrolled. They had private (29%), hospital (31%), or both practice (7%) or others (33%). Part 1: 70% of participants agreed that the scenario was consistent with anaphylaxis but 24% refused because hemodynamic or respiratory disorders were missing; 31% chose to administer first adrenaline intramuscularly and 30% agreed with both diagnosis and treatment with adrenaline; 74% chose to administer first antihistamine and bronchodilators. Only 50% chose to call immediately the emergency number. Nearly a third estimated that a one-hour observation period was enough. Only 19% had all 5 key responses correct. Part 2: A correct diagnosis was associated with pediatric specialty (p < 10 −4 ) and hospital practice (p = 0.02); the use of adrenaline in the scenario with a correct diagnosis (p < 10 −4 ), pediatric specialty (p < 10 −4 ), a recent continuing medical education on food allergy (p = 0.005) and experience of adrenaline injection in real life (p = 0.02); all the 5 key responses correct with pediatric specialty (p < 10 −4 ) and a recent continuing medical education (p = 0.04). In case of anaphylaxis in a child, 59% of physicians would immediately inject intramuscularly adrenaline, 22% only after calling an emergency physician, 18% only in case of vital disorders, 3% only in the presence of an emergency physician; 5% would refuse to inject adrenaline themselves (never done or feared side effects). Conclusion: A large proportion of doctors seem to be unaware of the diagnosis criteria and the recent updated EAACI recommendations on Introduction: Cutaneous exposure to food allergens seems to be an important way of sensitization. It has been shown that household consumption of peanut is a risk factor for the development of peanut allergy. Furthermore, peanut protein was found in house dust. Yet there is only little data on other food allergens; therefore, we wanted to investigate whether hen's egg (HE) protein could be found in domestic areas.
Methods: 8 households were included in the study. All households were asked to consume a meal of scrambled eggs in their habitual eating areas. Before and 48 h after hen's egg consumption dust samples were collected in the habitual eating areas and from bed sheets, using a special vacuum cleaner device. HE protein was extracted and HE allergen levels were measured with a commercially available ELISA (limit of detection: 0.05 µg/g). Wilcoxon rank test was used to compare HE levels before and after HE consumption. Results: HE protein was detectable in all 8 households in the habitual eating areas as well as on bed sheets. At baseline, there was a median of 13.05 µg/g HE protein (range 6.5-13.4 µg/g) in the habitual eating area and a median of 12.9 µg/g HE protein (range 2.0-18.4 µg/g) on the bed sheets. 48 h after consumption of scrambled egg significantly increased levels were measured with a median of 214.0 µg/g HE protein (range 17.0-2409.4 µg/g; p < 0.05) for the eating area and a median of 50.3 µg/g HE protein (range 5.9-247.0 µg/g; p < 0.05) in bed sheets. HE allergens were detectable in the house dust of all households not only in dining areas but also in the bed where HE is usually not consumed, indicating a spreading of food allergens. Furthermore, an increase in protein levels measured after consumption of a HE meal was shown. For infants, who spent most time in bed, house dust containing food allergens could be an important risk factor for food sensitization. Conclusion: HE allergen was found in house and bed dust with high levels following HE consumption, indicating a potential risk factor for the development of HE sensitization. Nevertheless, further research is necessary to proof whether HE allergens in house and bed dust can cause sensitization and whether there is a correlation between allergen levels and the level of sensitization. Introduction: The objective of this study is to investigate the impact of the native gliadins on the intestinal electrophysiological parameters as studied in murine allergy model. Methods: Two groups of mice (n = 10 per group) were established: the first group (control) was sensitized with aluminum hydroxide (Alum) diluted in PBS, the second was sensitized with 10 µg of native gliadins adsorbed on alum (NG). Intraperitoneal (IP) sensitizations were performed at days 0, 10, 20 and 30. One week after the last boost, the jejunum fragments were withdrawn and used for histological analysis and the evaluation of the local anaphylactic responses in Ussing chamber by an ex vivo challenge allowing the contact of jejunums with sensitizing antigen and the measurement of electrophysiological parameters (short-circuit current (Isc) (µA/cm 2 ) and conductance (G) (mmho/cm 2 ). Results: Intraperitoneal injection of native gliadins induced significant increase of the short circuit current (Isc µA/cm 2 ) (P < 0.001) and conductance (G) values (P < 0.05). The histological observations of jejunum fragments of sensitized mice show an alteration in intestinal barrier (villous atrophy, Lymphocytes infiltration) compared to the control group. The Isc increase in sensitized mice is probably due to a secretory response and might well reflect local anaphylactic responses. The increase of conductance indicate that immunization alters the tight junctions and increases the paracellular permeability of the intestinal epithelium [1]. Several published studies show that food allergy in mice is characterized by villous atrophy and goblet cell hyperplasia, as well as infiltration of IgEpositive mast cells [2]. Conclusion: Our results suggest that the native gliadins modify permeability of the intestinal tract in native gliadin mice which confirm the allergenic potential of native gliadins Introduction: Our objective was to describe what Portuguese beekeepers do after being stung. The secondary aim was to evaluate their knowledge on adrenaline auto-injectors (AAI), bee venom immunotherapy (VIT), and the medical specialty of Immunoallergology. Methods: Cross-sectional study using a structured questionnaire including beekeepers present in an apiculture meeting. Data on demographic characteristics, number of stings, reaction description and conduct when stung (treatment, admission to ER) were collected. Awareness of AAI, VIT and the medical specialty of Immunoallergology was also questioned. Results: A total of 114 beekeepers were included; 91 (80%) male with a median (interquartile range, IQR) age of 40 (17) years. The median (IQR) time of beekeeping was 3 (7.3) years. Nighty-nine (87%) were amateur beekeepers. All had been stung in the last 12 months; 45 (40%) had systemic reactions (11 anaphylaxis) and 41 had local reactions, including 22 large local reactions. Only 19 (42%) of those with systemic reactions went to the ER. Nine out of the 11 who had anaphylaxis went to the ER, but only one was treated with adrenaline. On discharge, an AAI was prescribed to one beekeeper, 4 reported to already have AAI and solely 2 were referred to an Allergist. Twenty-five (22%) used alternative treatments on the sting site, namely, metal, lemon or grape, ammonia, alcohol, vinegar and urine. Forty-one (36%) were aware of the existence of AAI, 35 (30%) of VIT and 32 (28%) of the medical specialty of Immunoallergology. Beekeepers with systemic reactions have demonstrated a better knowledge of AAI and VIT, p < 0.01 and p = 0.03, respectively. Awareness of AAI, VIT and Immunoalergology was not significantly different between gender, age and education groups.
Conclusions: This group of Portuguese beekeepers showed insufficient knowledge on proper management of sting reactions. Approximately one fifth used alternative treatments. Adrenaline underuse, underprescription, as well as an inefficient referral to a specialist, was evident in the ER. There is a rise in beekeeping in Portugal and so it is imperative to promote education on the risks, sting prevention measures and correct treatment of stings. The increasing awareness of the medical specialty of Immunoallergology and the existence of bee venom immunotherapy should assure a prompt referral in case of systemic reactions which is crucial in this population.

PD23
Are atopy patch tests useful to identify food sensitisation in eosinophilic esophagitis? Luis Amaral 1 , Leonor Carneiro-Leão 1  Introduction: Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus characterized by symptoms related to esophageal dysfunction, eosinophilic recruitment and infiltration of the esophageal epithelium. A combined mechanism of IgE dependent/ cellular mediated hypersensitivity reactions to foods is thought to contribute to disease pathogenesis. Our aim was to assess food sensitization in EoE patients with atopy patch tests (APT); A secondary aim was to find any relation between the results of APT, skin prick tests (SPT) and/or specific IgE (sIgE) with response to the six-food elimination diet (SFED). Methods: A longitudinal study of adult patients diagnosed with EoE was carried out. Patch tests were performed with 9 foods: cow's milk, hen's egg, wheat, soy, peanut, walnut and hazelnut were applied undiluted, 1/10 dilution and 1 drop of allergen extract; shrimp and cod were applied raw, cooked and 1 drop of allergen extract. The APT were delivered using 8 mm Finn Chambers ® . Occlusion time was 48 h and the results were read 20 min and 24 h after removal. Endoscopy results, SPT, sIgE, medical management and patients' responses were collected. Results: Twelve patients agreed to participate, 3 were female with a median (interquartile range, IQR) age of 23 (9) years age, 8 with allergic rhinitis and 2 asthma; 8 were sensitized to aeroallergens, 6 to house dust mites and 4 to pollens. Seven patients had positive food SPT and/or sIgE (3 cow's milk, 2 wheat and 2 LTPs). Ten patients presented Clin Transl Allergy 2017, 7(Suppl 1):10 clinical and histological improvement with the SFED and in 8 symptoms and eosinophils recurred on food reintroduction (6 with cow's milk and 3 with wheat). Only 2 patients presented positive APT: 1 to undiluted hazelnut, who was previously sensitized to LTP; and the other to undiluted soy, which was not clinically relevant since the patient frequently eats soy without any immediate symptoms or worsening of EoE. Conclusions: Standardization on food APT is lacking. In this series, we did not observe any clinical utility for identifying food sensitivity with atopy patch tests in adult patients with Eosinophilic esophagitis. Introduction: Component-resolved diagnosis (CRD) has been shown to improve hazelnut allergy diagnosis. Some allergens have been associated with severity of hazelnut allergy, however few studies have reported the classification accuracy of the markers in discriminating between mild and severe subjects, especially in adults. Our aims were:

PD24
1. to analyze the association between sensitization to single hazelnut allergens and clinical symptom severity; 2. to evaluate their ability to discriminate between mild and severe hazelnut allergy.
Methods: Subjects (n = 731) from 12 European cities reporting reactions to hazelnut (83.6% adults) were included. In all subjects, sensitization against hazelnut extract and in 423/731, IgE against seven single components (rCor a 1, rCor a 2, rCor a 8, nCor a 9. nCor a 11, nCor a 12, rCor a 14) and CCD was measured. Additionally 124/731 underwent a DBPCFC of which 86 were reactive. Symptoms to hazelnut were categorized into mild, moderate and severe symptoms. Associations between sensitization to hazelnut and severity were analyzed using multinomial regression analyses. Introduction: Our aim was to assess the performance of basophil activation testing (BAT) as a diagnostic marker for mugwort pollen-associated peach allergy. Methods: Peach allergic (n = 89), peach-sensitized but tolerant (n = 52) and non-peach-sensitized nonallergic (n = 10) patients underwent sIgE to peach and its components. BAT was performed using flow cytometry.

Results:
The patients with peach allergy had higher IgE levels for peach and Pru p 3 than peach sensitized population (P < 0.01). By stimulation with peach extract, BAT in peach-allergic patients showed a significant dose-dependent upregulation of CD63 compared with peach sensitized but tolerant and non-peach-sensitized nonallergic patients. While stimulated with Pru p 3, BAT could also discriminate between peach allergy and tolerance. Receiver operating characteristic curves showed basophil reactivity had larger area under the curve than IgE to peach (AUC 0.744, 95% CI 0.550-0.937, P = 0.039) and Pru p 3 (AUC 0.865, 95% CI 0.705-1.000, P = 0.002); while BAT stimulated with Pru p 3 had the largest area at 0.981 and stimulation with peach extract (100 ng/ml) at 0.942. Previous studies concerning pollen-associated food allergy have compared between healthy controls and food allergic patients, without addressing the possible effect of immunologic cross-reactivity on the performances of BAT. In this study, we performed a comparative analysis with peach-sensitized but tolerant patients. BAT stimulated with the major allergen is better than that with the crude allergen extract in discriminating between peach allergy and tolerance. Conclusion: BAT stimulated with Pru p 3 is superior to other diagnostic tests in diagnosis of mugwort pollen-associated peach allergy. Introduction: Despite outgrown CMA, we have previously found that many families continue to experience nutritional related problems at a six-month follow-up [1]. Some may develop other food allergies or atopic diseases follow ing the atopic march, and some may fail to progress to unrestricted diet. Our aims were to assess impact on nutrition related issues at a 7 year follow-up in relation to the development of CMA over time.
Methods: Families of children with CMA, who participated in the validation of the Food hypersensitivity famiLy ImPact questionnaire (FLIP), were re-approached 7 years later for follow-up and administered the FLIP. Results: Of the original families (n = 94), at 7-year follow-up 84% (n = 79) agreed to participate. The children had a mean age 8.5 years (r = −11 years) and n = 30 (38%) were girls. The majority (n = 49.62%) no longer needed to follow a cow's milk free diet. The remaining children (n = 0) were still following a special diet due to CMA exclusively (n = 7.9%) or in combination with other food allergy (n = 9.11%) and other food allergy excluding CMA (n = 14.18%). Most children were healthy (n = 67) but n = 8 (10%) had developed other atopic diseases or other non-atopic diseases (n = 3). These findings are in line with those from others [2]. A mixed linear model for the FLIP Nutrition subscale across three time points (baseline, 6-month and 7-year follow-up respectively) in relation to allergy status at 7-year followup (i.e. outgrown vs. persistent) showed only a marginally significant improvement in nutrition related issues for the group outgrown CMA (p = 0.07) at 7-year follow-up. For the group with persistent CMA there was no difference in the experienced impact. Despite outgrown CMA, n = 13 children in the group outgrown CMA had a restricted consumption of dairy due to fear of reactions (n = 4) or dislike of milk as a drink (n = 6), or both as a drink and when contained in food (n = 3). The latter group were still consuming non-dairy special products. Conclusions: There is only a small improvement in nutrition related issues despite outgrown CMA at 7-year follow-up. Many families continue to serve a restricted diet despite outgrown CMA. Nutritional counselling should be considered to all families with children with persistent as well as outgrown CMA in order to ensure optimal nutritional intake, development of eating behaviour and progression to unrestricted diet preventing unnecessary limitations in daily life. Introduction: Self-reported food allergies (srFA) have increased in US adults over the past decade. Information on how this population perceives allergen exposure risks is lacking. We sought to identify adults with srFA and assess responses to questions about allergen advisory statements and thresholds. Methods: We analyzed FDA 2016 Food Safety Survey data in 4619 adults to identify survey respondents with srFA, including reported doctor-diagnosed cases (ddFA). Respondents were asked about knowledge of thresholds or reaction risks and about consumption of products with certain advisory statements or trace allergen amounts. Results: Weighted prevalence of srFA among survey respondents was 13.5% with ddFA representing 8.0%. The most common foods associated with srfA and ddFA were shellfish, milk, fruits, tree nuts, peanuts, wheat, fish and egg. Prior anaphylaxis history was reported in 24.8% of respondents. With regards to allergen exposure risk, only 33.2% of srFA respondents were aware of the concept of threshold levels, yet 59.0% reported belief that a level existed below which allergic reaction would not occur. 43.7, 39.0 and 48.8% of respondents reported having consumed or likely to consume products with advisory statements of "may contain", "made with same equipment" or "produced in same facility" respectively, and 38.2% of respondents reported that they would consume products with trace amounts of the food allergen if there were assurances that allergen amount would not trigger reaction. No significant differences in responses were noted between srFA respondents with or without ddFA except ddFA respondents were more likely to view trace allergen amounts as posing higher risk for severe reactions. Respondents with prior anaphylaxis, shellfish or fish allergy were more likely to avoid products with one or more advisory statements while those with peanut, tree nut, milk or wheat allergy were more likely to have consumed these products. Survey data of adults with self-reported food allergies reveal different perceptions of thresholds and individual exposure risks. More education on understanding allergen exposure risks is needed for this population. Conclusion: Survey data suggest that only one third of srFA respondents understand what allergen thresholds represent, yet over 40% report consuming foods with certain advisory statements. Differences in risk perception may depend on having a ddFA, a prior history of anaphylaxis or on type of food allergen.

PD32
Tolerable dose during oral immunotherapy using IFN-gamma for anaphylactic food allergy: desensitisation and tolerance Geunwoong Noh 1 , Eun Ha Jang 2

Introduction:
The immune health status is strongly determined during early life stages. Many immune-related diseases are thought to find their origin in adverse shifts in immune balances during pregnancy or the first 2-3 years of life, including atopic diseases. Therefore, immune health interventions during these stages of life may be most effective in reducing the loss of health, loss of quality of life and costs to society due to immune-related diseases and disorders. Several starting points for immune health interventions have been identified and are being developed into prophylactic or therapeutic approaches, particularly targeted at the early life stages. Unfortunately, there is no consensus on which parameters should be addressed to assess the safety and/or efficacy of the interventions and how all the available data should be interpreted at the end. Hence, it would be extremely helpful to address this issue by developing a pragmatic, flexible and science-based risk-benefit assessment. Methods: We adapted the risk-benefit approach [1], to develop a framework for risk-benefit assessment of immune health interventions during early life stages. As case studies, we collected all available in vitro/vivo/silico and human data on galacto-oligosaccharides (GOS) and fructo-oligosaccharides (FOS). Results: The severity of hazard and beneficial effects observed and the incidence at which such an effect may be considered acceptable, were used to weigh the risk and beneficial effects. Dose response relationships can be converted to 50% effect doses which, combined with the severity of the effect underlying the dose response curve and concurrent acceptable incidence of this effect, can be used for weighing benefit and risk. In the FOS/GOS case study, several prerequisites of (pre-)clinical data were identified. This risk-benefit framework enables us to evaluate all intervention data available and forms the basis to derive the optimal dose levels of intake. Conclusion: This novel approach enables risk assessors to take the multitude of different types of data available covering toxicity and efficacy studies at early life stages into account, by ranking and weighing all available data. Ultimately, this assessment will help to determine optimal beneficial and safe dose levels of nutritional immune interventions during early life. All children during this period with a positive DBPCFC to peanut were included in the analysis. The food challenges were included if they were performed with the two most frequently used recipes (n = 11 excluded). The recipes used were peanut in cookies and peanut in gingerbread, with a fat content of 23.9% and 5.9% respectively. In children with multiple DBPCFCs, only the first test was included (n = 37 tests excluded). 14 cases were excluded due to missing data. For the severity of reaction during the DBPCFC a previously published scoring system was used, with a severity index ranging from 0 to 12. The influence of the matrix on the severity of reaction and eliciting dose was analyzed by linear regression analysis, with correction for possible confounders. A variable was considered a confounder if it changed the beta coefficient by more than 10%. The alpha significance level was set at 0.05. Results: 210 children were included in the analysis, 141 children were challenged with peanut in cookies (high fat) and 69 children with peanut in gingerbread (low fat). Children challenged with peanut in cookies had more severe reactions during the DBPCFC (β = 0.15, 95% CI 1.49-0.06, p = 0.03), compared to children challenged with peanut in gingerbread. However, there was no significant difference in eliciting dose (β = 0.03, 95% CI-31.91-51.11, p = 0.65). These results were not confounded by age, gender, sIgE, severity of the most severe previous accidental reaction, history of atopic dermatitis, asthma or allergic rhinoconjunctivitis. Conclusion: Children receiving a high fat matrix peanut challenge have more severe reactions than children receiving this test in a low fat matrix. This supports the role of the food matrix as an augmentation factor which may enhance the severity of both diagnostic as well as accidental reactions. It also raises the possibility that matrix effects during oral immunotherapy with peanut could be a cause of adverse events during such treatment.

PD36
The probability of distribution Introduction: Annually number of reports about anaphylaxis caused by food products increases. The development of IgE-mediated reactions to food that is well tolerated in the past, now, sometimes is a true diagnostic and therapeutic challenge for the patient and the doctor. An example of such allergies is delayed allergy to red meat that is associated with the formation of IgE antibody to the oligosaccharide galactose-alfa-1,3-galactose (Alfa-gal). During evolution human body formulated the immunological tolerance to Alfa-gal production through IgG. Factor launch IgE-mediated process are tick bites, which linked the spread of geographical features of this type of food allergy (FA). Proved that serious manifestations of anaphylaxis occur in conditions of consumption of fatty meat or large quantities of meat. Determined that Alfa-gal epitope transmitted through the milk that gives grounds to say about later reaction to this product. It is believed that the alternative cause of sensitization to Alfa-gal infection are different types of parasites. The aim of our study was to determine the probability of distribution associated Alfa-gal allergy among Ukrainian patients.

Results:
We conducted a comparative assessment of different components of the ticks saliva, on which was identified allergic reactions to Alfa-gal in the USA (Amblyomma americanum), Australia (Ixodes holocyclus) and Europe (Ixodes ricinus). The same ingredients not found in these types of ticks, but each of them has a specific immunotropic action. In particular, I. ricinus, prevalence of which in Ukraine in recent years increased by 14-18% containing biological substances that intensified alternative pathway of complement activation, Th2response, inhibited proliferation of B lymphocytes. Conclusion: Ukraine has a high probability of spreading Alfa-gal associated FA. The arguments are the same: rising prevalence of I. ricinus, Ukrainian traditional consumption of fatty foods and dairy products, high prevalence of parasitic invasions. There is a necessity of component diagnostics Alfa-gal, which today is not performed. In this case the only way to diagnose is carefully collected history.
Introduction: Hen's egg (HE) allergy is the most common food allergy in early childhood. Although there is a good prognosis, reported data on the development of clinical tolerance vary between studies. The aim of our study was to analyze the natural history of HE allergy among children with challenge proven HE allergy. Methods: Data of children undergoing double-blind, placebo-controlled food challenge (DBPCFC) in our center were prospectively recorded. Children who had a DBPCFC with raw HE between 01/2010 and 06/2014 were further evaluated. When data on repeated DBPCFC with either raw or baked egg of the children were not available in our data bank, parents were questioned by telephone with a standardized questionnaire whether their child tolerates raw and/or baked HE in their diet. Results: 110 children with a positive DBPCFC to HE could be included (41 girls and 69 boys with a median age of 1.4 years (0.4 to 9.8 years) at the first DBPCFC with raw HE). After a median period of 34 months (9 to 96 months), 54/110 children (49%) tolerated raw HE (45 had a second DBPCFC to raw HE without reaction, 9 reported complete tolerance in the interview). Of the remaining 56 children without known tolerance to raw HE (still allergic n = 40, unknown n = 12), more than half (54%, n = 30) could tolerate heated HE after a median period of 26 months (20 had a negative DBPCFC to heated HE, 10 reported tolerance to heated HE in the telephone interview). Altogether 29/69 of the boys (42%) developed clinical tolerance to raw HE within a median period of 36 months (9 to 96 months), while 25/41 of the girls (61%) tolerated raw HE already after a median period of 26 months (11 to 66 months). Tolerance development to raw HE in this study was slightly longer than reported from the EuroPrevall birth cohort. This might be explained that re-challenges were not scheduled on yearly basis as in EuroPrevall but on request of the child's physician. Conclusion: Around half of the children with challenge proven HE allergy develop tolerance to raw HE within a median period of 3 years and even more to heated HE. Girls seem to have better chances to develop tolerance to HE in a shorter period of time than boys, but larger trials are necessary to confirm these observation.
Introduction: Improving safety of egg oral immunotherapy (OIT) is a source of concern. Our group has previously published data regarding safety in a protocol to raw egg (RE)-OIT, reporting adverse reactions in 7.6% of doses and adrenaline use in 26%. 14% of OIT doses). 7/18 had anaphylaxis, 2 patients required adrenaline use (10.5%), 5 withdrew during induction phase (4 due to anaphylaxis and 1 for poor adherence). Egg OIT is still an experimental treatment and aims to modify clinical reactivity in persistently egg-allergic children. BE-OIT enhances children's diet by including baked and various quantities of fully cooked egg thus improving families quality of life. However, complete tolerance to raw-egg is not attempted. Initial parameters at OFC were comparable to previous RE-OIT group. Adverse events are still a source of concern even with the modified BE-protocol. Conclusions: Gastrointestinal symptoms were the most frequent adverse reactions and anaphylaxis the most common cause of withdrawal. Within similar populations, BE-OIT showed an improvement in safety profile with fewer adverse reactions and less use of adrenaline; proving to be a better OIT alternative for egg allergic children. were not different. The type of food allergen, the number of FA, the severity of food reaction had no effect on asthma control. The subgroup of patients with "asthma-atopic dermatitis-FA" (A-DA-FA) had a higher number of exacerbations (p = 0.009) and daily ICS (p = 0.017) compared to patients with asthma, FA and no AD. We did not observe that FA was associated to worse asthma control or morbidity as previously reported [1,2]. Regular follow-up in a tertiary care centre may explain the results. However, we observed that children with FA and AD had a more severe asthma than those with FA but no AD. Conclusion: Our study does not provide evidence for increase asthma morbidity in children with any FA. The association of A-DA-FA characterized a specific phenotype. requires any medication containing soya-based products (including soya oil) to state that the product is contra-indicated in peanut-allergic individuals, since both are legumes. While clinical allergy to soya in peanut-allergic individuals is considered to be uncommon, only limited published data are available to substantiate this. We therefore sought to determine the rate of soya allergy in children with challenge-proven peanut allergy.

Methods:
We performed open food challenges to soya (total 4.0 g protein) in children with peanut allergy proven through double-blind placebo-controlled food challenge (DBPCFC). All challenges were conducted according to PRACTALL consensus criteria. Where a participant experienced any symptoms during the soya challenge, DBPCFC to soya was undertaken to exclude placebo reactors. Local ethical and regulatory approval was granted, and informed consent was obtained. One child developed oral symptoms to roasted but not unroasted soya; this child was also sensitised to birch pollen. There was no evidence of systemic soya allergy in this cohort of peanut-allergic children at challenge. Conclusion: Co-allergy to soya is uncommon in peanut-allergic children. These data suggest that the EMA requirement for labelling of medicines containing low levels of soya as contraindicated in peanutallergic individuals is unwarranted.

PD44
The Introduction: Allergic sensitisation to foods may occur in infancy without prior oral exposure to the offending food. This has led to the assumption that food allergy sensitisation may occur through alternative routes, such as via the skin. Recently, concerns have been raised regarding the safety of use of cosmetic and personal care products containing hydrolysed wheat proteins. The aim of this study was to develop a skin sensitisation model in naïve Brown Norway (BN) rats. Methods: A high IgE-responder BN rat strain bred on a gluten-free diet for several generations were used as an animal model and two different products, unmodified gluten and acid hydrolysed gluten were used as model proteins. Rat abdominal skin was shaved, lightly scratched with sandpaper and exposed to one of the products. The animal model was optimised for duration of skin exposure, the amount of product applied as well as for the post-immunisation regime. Skin conditions were evaluated by histology and water evaporation. At different time points sera were collected and analysed for the level, avidity and cross-reactivity of specific antibodies by different ELISAs. The antibody specificity was evaluated by immunoblotting and the functionality was examined by an ear swelling test. Results: Both products were able to induce a specific immune response and sensitise through the slightly damaged skin without any use of adjuvant. This was evident before any post-immunisations. The sensitisation response depended on the duration of the skin application as well as on the amount of products applied to the skin. Differences in dose-response relationship were seen between products. The results confirm previous studies showing that acid hydrolysis induced new epitopes while maintaining original epitopes. Antibody avidity differed greatly between the products and showed that the shared epitopes induced antibodies with highest avidity. Oral and i.p. postimmunisation induced different outcomes, with a surprisingly higher response after oral compared to i.p. post-immunisations. The aim of the study, developing an animal model for studying food allergy skin sensitisation, was fulfilled. The model was able to detect differences in the induced response between the two products and further indicated homing of skin immune cells to the gut.

Conclusion:
In BN rats non-tolerant to gluten, unmodified and acid hydrolysed gluten has sensitising capacity through the skin.

PD47
The nature of wheat gliadins modifies the immune response in a mice model of food Introduction: At present, the main treatment for egg allergic patients is based on food avoidance, which poses a risk, since egg is used as an ingredient in a wide range of food products. Oral immunotherapy (OIT) is a promising treatment option, although the use of intact allergens produces frequent side effects. In this respect, egg white protein hydrolyzates are thought to be safer to induce protective mechanisms leading to oral tolerance. The aim of this study was to determine the immunomodulatory effects of pepsin-hydrolyzed ovalbumin (OVA) administered as OIT in a BALB/c model of egg allergy. Methods: BALB/c mice were orally sensitized during 6 weeks with 5 mg of raw egg white (EW) using cholera toxin as adjuvant. On week 7, mice underwent an immunotherapy protocol with either intact or pepsin-hydrolyzed OVA during 3 weeks and were subsequently challenged with EW. The severity of the anaphylactic response was evaluated (clinical signs and body temperature drop) and serum levels of mMCP-1 were determined by ELISA. Allergen-specific antibodies, IgE and IgG1, were monitored throughout the OIT. The expression of the genes TSLP, IL-33, IL-25, TGF-β and IL-10 was analyzed by RT-qPCR in the small intestine. Furthermore, cytokine responses were measured in allergen-stimulated splenocytes and changes in cellular populations (Th1, Th2 and T reg) were assessed in the mesenteric lymph nodes (MLNs) using flow cytometry. Results: Mice orally treated with pepsin-hydrolyzed OVA were significantly protected from anaphylactic reactions compared with the groups of untreated mice and mice treated with intact OVA, which showed anaphylactic signs and a marked decrease of body temperature. Similarly, serum levels of mMCP-1 were lower in mice treated with the hydrolyzate. Desensitization of the allergic mice induced by the hydrolyzate was accompanied by a significant reduction in the levels of EW-specific IgE and IgG1. Administration of hydrolyzed OVA also downregulated the intestinal expression of TSLP, IL-33 and IL-25, and led to higher levels of IL-10 expression. However, the group that received intact OVA showed similar expression levels than untreated control mice. Desensitization by pepsin-hydrolyzed OVA was associated with a shift in the Th2 profile, as shown in ex vivo stimulated splenocytes and flow cytometry analysis of T cell subsets in the MLNs. Conclusion: OIT with pepsin-hydrolyzed OVA desensitizes and prevents allergen-induced anaphylaxis in mice allergic to EW more effectively than the intact protein. Introduction: Inconsistencies in findings on food allergy prevention by breastfeeding may result from variations in duration of breastfeeding induced protection. Here, we assessed in mice how long food allergy was prevented by breastfeeding induced oral tolerance, and whether oral TGF-β supplementation after weaning would prolong it. Methods: We first quantified ovalbumin (OVA) and OVA specific immunoglobulins levels (ELISA) in milk from the French EDEN birth cohort. Since OVA specific Ig were found in all milk samples, we assessed whether OVA-immunized mice exposed to OVA during lactation could prevent allergic diarrhea in their 6 and 13-week-old progeny. In some experiments, a supplement of TGF-β enriched formula was given after weaning.

PD49 Long term reduction in food allergy susceptibility in mice by combining breastfeeding-induced tolerance and TGF-β enriched formula after weaning
Results: We found that, at 6 weeks, only 17% of symptom scores were ≥ 3 (diarrhea) during the last 3 oral OVA challenges in the group of mice breastfed by mothers immunized to OVA and exposed to OVA during lactation versus 43% in the group of mice breastfed by naïve mothers. However, at 13 weeks, the percentage of diarrhea increased to 28%. Supplementation with TGF-β after weaning allowed maintaining a strong protection from allergic diarrhea in 13-week-old mice breastfed by OVA-exposed mothers (13% of diarrhea only). This prolonged protection was only observed in mice rendered tolerant by breastfeeding and was associated with an improved gut barrier.

Conclusions:
In mice, prevention of food allergy by egg antigen exposure through breast milk is of limited duration. Nutritional intervention by TGF-β supplementation after weaning could prolong beneficial effects of breast milk on food allergy.

Cross-talk between Tregs and NKT cells in children with food allergy
Ines Mrakovcic-Sutic 1 , Srdan Banac 2 , Ivana Sutic 3 , Zdenka Baricev-Novakovic 3 , Ingrid Sutic 4 , Valentino Pavisic 1 Introduction: Understanding the mechanisms how the host recognizes countless foreign antigens and remains unresponsive to self, have opened many questions in the field of immunological tolerance. The most specific marker that distinguishes regulatory from conventional T cells is forkhead box transcription factor (Foxp 3). Predominant cell types that expressed Foxp 3 are CD4+CD25+ and characteristic of subpopulations which are Foxp 3 negative are their regulatory function lacked. Natural Tregs have the possibility to suppress multiple cell types involved in immunity and inflammation by inhibition the proliferation, immunoglobulin production, the blocking of NK and NKT-cell cytotoxicity, as well as, the function and maturation of dendritic cells. It seems that the efficacy of Treg-based therapy depends on the antigen specificity of these regulatory T cells. The most common use of Tregs is described in the prevention of allergic diseases, autoimmunity and in possibility to moderate transplantation tolerance. NKT cells represent a unique sublineage of innate lymphocytes, which share the properties of natural killer cells and conventional T cells. Hypothesis about regulatory network of Tregs and NKT cells was studied by flow cytometry, analyzing the characteristics of human Tregs and NKT cells of patients with food allergy, compared to healthy volunteers. Methods: A total of 30 children with food allergy were investigated. None of them was taking any systemically administered medications for at least 3 months before testing. Venous blood samples were taken and peripheral blood leukocytes (PBL) were isolated. Phenotype of lymphocytes was analyzed using intracellular and surface immunofluorescence and flow cytometric analysis (FACSCalibur). Results: Our preliminary study was shown a significant increased in a percentage of regulatory T lymphocytes and NKT cells in peripheral blood of people with described food allergy. Tregs have the ability to suppress allergic immune response. NKT cells perform an important subpopulation of cells which can play both roles: as effectors and as regulatory cells in a wide range of disease settings. Clin Transl Allergy 2017, 7(Suppl 1):10

Conclusion:
We can talk about the new kind of cells NKT-reg cells, whose monitoring may lead to important early diagnosis and/or prognosis of food allergies.
Acknowledgements: This work was supported by grants from University of Rijeka (13.06.1.1.14 and 13.06.1.1.15). Introduction: We recently described a unique Th2 cell subset specifically involved in all allergy disease (TH2A cell subset). We investigate the cellular and molecular mechanisms behind clinical heterogeneity of peanut allergic responses.

Methods:
We combined a CD154-based assay and a single-cell transcriptomes analysis to assess ex vivo and at a single cell level the specific CD4 + T cell responses to each peanut allergic components (Ara h) in adults with or without peanut allergy. Results: Pathogenic responses (Th2 response) were specifically associated with short life terminally differentiated allergen-specific CD4 + T cells, which dominate in allergic subjects but are absent in non-allergic subjects. Protective responses in non-atopic individuals were associated with peanut-specific TH1/TH17 cell responses. Within the peanut allergic group, we observed inter-individual variations of the specific immune response to each peanut allergic component. No direct linkage between CD4 + T cell response and IgE responses against each individual peanut allergic component. Conclusions: Ability to identify immunogenicity and type of response elicited by each peanut allergic component appears to be critical to future success in vaccine development against peanut allergy. Understanding the type of cellular response and the role of genetic restriction may allow to target immune response to critical peanut allergen and to uncover the optimal type of cellular immune response necessary for protection.

PD54
The The aim of this study was to examine the values of enzyme matrix metalloproteinase-2 and 9 in urine from children with described food allergies. Methods: We analyzed 30 patients with children with described food allergies. The method of enzyme immunoassay (ELISA) was used to determine enzymes expression of matrix metalloproteinase-2 and 9 (MMP-2 and 9). Results: The children with described food allergies had a statistically significantly increased level of MMP-2 and 9 in the urine in comparison with healthy volunteers. Matrix metalloproteinases (MMPs) play a key role in the physiology of connective tissue development, in morphogenesis and in wound healing and their unregulated activity has been implicated in numerous disease processes including arthritis, tumor cell metastasis and atherosclerosis. Conclusion: Our data has showed a large increase in the enzyme MMP-2 and 9 in the urine of children with described food allergies, which may be an easy marker for the monitoring of the development of food allergies in children. Clin Transl Allergy 2017, 7(Suppl 1):10 Introduction: Secretion of antibodies belonging to IgG, IgA and IgM class is a natural response of host organism to any protein antigens including those introduced with food. Production of IgE may, however, indicate on sensitivity of the immune system to a particular protein.
Bacteria present in food continuously influence the host body interacting with the immune system. Last reports indicate on possible adverse, IgE-dependent reaction of human immune system with proteins from lactic acid bacteria (LAB), namely Lactobacillus casei. The aim of the study was to investigate whether proteins from LAB species commonly used in food industry react with human both IgG and IgE antibodies. Methods: Whole cell extracts of two LAB strains Lactobacillus delbrueckii subsp. bulgaricus 151 (L151) and Lactobacillus casei LcY (LcY) were a source of proteins. Two pooled human sera were used as a source of human primary antibodies: serum A obtained by pooling seven sera from allergic patients and serum B obtained by pooling sera from ten allergic patients. As a control, a pool of sera from six healthy participants with negative serum parameters for allergy diagnostic tests, with no allergic manifestations and with defined negative family histories of atopy was used. Bacterial proteins were separated (Tricine SDS-PAGE), then transferred onto nitrocellulose membranes. The membranes were probed with human sera (primary antibodies) and then with fluorescently labelled secondary antibodies: goat anti-human IgG antibodies already conjugated with IRDye ® 800CW (Li-COR) and mouse monoclonal anti-human IgE antibodies (Sigma) labelled using the IRDye ® 680RD Protein Labelling Kit (Li-COR). Signal detection was carried out with the Odyssey Infrared Imaging System. Results: Analyses carried out with pooled serum A showed only one protein fraction (ca. 36 kDa) in LcY strain reacting with both IgG and IgE. With the use of pooled serum B, however, IgG and IgE reactive proteins were detected in both LcY and L151 strain. Differences in profiles of immunoreactive proteins obtained with the examined sera indicated that bacterial proteins are characterized by different immunological determinants with different affinity to human antibodies. Conclusions: Immunoreactivity of bacterial proteins, which may be in contact with the human immune system, and studies on immunoreactivity of proteins from bacteria used in food production technology and those comprising the human microbiome should be continued. Introduction: Cow's milk allergy (CMA) is the most common food allergy in infancy. Fundamental to the management of food allergy is complete elimination of the offending proteins. However, due to dietary elimination CMA patients are at risk for inadequate nutritional intake. Management approaches in infants and young children include the use of hypoallergenic formulas that need to be fully tolerated, support normal growth and also assure adequate nutritional status in these patients. Dietary management of CMA with a hypoallergenic amino acid-based formula (AAF) has been proven to be effective and safe. Data on mineral status after dietary management by AAF are however scarce. Methods: In a prospective, randomized, double-blind controlled study, full term infants with diagnosed CMA received an AAF (n = 110) with or without synbiotics (neutral and acidic oligosaccharides, Bifidobacterium breve M-16 V) for 16 weeks. Primary outcomes were growth and formula tolerance and have been reported previously [1,2]. Mineral status was assessed by analyses of blood samples obtained at baseline and 16 weeks, which included calcium, phosphorus, chloride, sodium, potassium, magnesium and total iron. Total protein, albumin, prealbumin, hemoglobin and ferritin were also determined. Formula intake was recorded through diaries at weeks 0, 4, 8 and 16 during the study.

Mineral status of infants requiring dietary management of cow's milk allergy by using an amino acid-based formula
Results: Average age of infants at inclusion was 4.5 ± 2.4 months (mean ± SD). Median study product intake ranged from 704 ml/day in the first week to 789 ml/day at week 16. At baseline, averages (mean, median) of blood levels of calcium, phosphorus, chloride, sodium, potassium, magnesium and iron were within reference ranges. After 16 weeks on AAF, the averages of all mineral blood levels were again within the specified reference ranges set for the corresponding infant ages. Also the averages of total protein, albumin, prealbumin, hemoglobin and ferritin were within reference ranges. For some minerals, a number of individual values at baseline were below references, i.e. calcium (n = 1), phosphorus (n = 1), chloride (n = 1), and sodium (n = 1), whereas at week 16 none of these minerals had individual values below reference ranges.
Conclusion: This study shows that an AAF with or without synbiotics, which have been reported previously to be equally tolerated and to support normal growth [1,2], are effective in managing an adequate mineral status in CMA infants.
Introduction: Serious life-threatening food allergy is still difficult to treat and usually results in a social life with restrictions. Pre-treatment with Anti-IgE has lately been suggested in order to start desensitization for food allergy in some patient cases. The conventional allergy tests though, are not always enough for monitoring the treatment with Anti-IgE and desensitization process. Here, we present a case report of desensitization against serious allergy to milk and monitoring with basophil activation test (BAT) and IgG4. Case report: A 70-years old female patient with serious allergy to milk, allergic asthma who was previously treated with immunotherapy for allergy to pollen and animal dander, was referred for allergological assessment and for possible treatment with desensitization to milk allergy. The patient reacted previously with anaphylaxis due to ingestion of traces of milk protein, even due to airborne milk protein and with contact urticaria due to milk. In 2015 the patient started pre-treatment with Anti-IgE, in a dose of 450 mg every 2 weeks, and was monitored with BAT before eventually desensitization. Before the treatment with Anti-IgE, BAT with prick-test extract for milk (PT) (Soluprick, ALK) was 1.148 units (U) and with fresh milk 467.29 U. After six months of treatment with Anti-IgE, BAT analysis was found very low, compared to the values before starting pre-treatment with Anti-IgE (BAT with PTextract for milk at 1.5U and with fresh milk at 1.8 U), indicating a starting point for desensitization against milk allergy. In addition, sIgE tests showed for milk 580 kU/L, IgG4 for casein 1.55 kU/L after six-months of treatment with Anti-IgE and before starting the desensitization. The patient started desensitization with slow build-up by ingesting fresh milk once a week with target of reaching the cumulative dose of 200 ml after 16 weeks. After 12 weeks of desensitization the patient reacted with mild skin redness in the face and neck when she ingested the dose of 50 ml of fresh milk, and therefore the patient started continuous treatment with H1-antagonstist and anti-leucotrienes daily Clin Transl Allergy 2017, 7(Suppl 1):10 along with Anti-IgE treatment. New BAT analyses with PT-extract and fresh milk was turned out negative after 12 weeks of ongoing desensitization while IgE for milk showed 390 kU/L and IgG4 for casein 2.51 kU/L. The patient reached the dose of 200 ml fresh milk after 16 weeks and continued consuming daily dairy products without any further reactions by now.

Conclusion:
In some patients with serious life-threatening food allergy, pre-treatment with Anti-IgE is required and BAT is suggested as monitoring tool for indicating the starting-point for the desensitization process. BAT along with IgG4 may be used in order to monitor successfully the patient's acquired tolerance for the food allergen during the desensitization and during the follow-up later on, even when Anti-IgE medication would have been suspended.

Consent to publish:
The patient has given consent for presentation and publication of the case. Introduction: Food allergy is reported to affect approximately 2% of the adult population, with the majority having had onset during childhood. There is an increasing recognition of adult onset food allergy, however these typically are associated with pollen-plant association, and are more often food-dependent, exercise-induced, anaphylaxis (FDEIAn). According to recent consensus statements, mast cell activation syndromes are divided into 3 subtypes: Primary Mast Cell Activation Syndromes (MCAS), Secondary MCAS, and idiopathic MCAS. A mast cell activation disorder requires clinical symptomatology that is in keeping with the disorder, a transient, measurable increase in either serum tryptase or other markers of mast cell mediators and a response to agents that interfere with mast cell mediators. Recent attempts have been made to standardize an approach to suspected mast cell disorders, in order to appropriately classify individuals with evidence of mast cell activation that did not meet diagnostic criteria for systemic mastocytosis.The combination of adult onset food allergy with an underlying mast cell disorder has not been described previously in the literature, and this case report demonstrates the investigation of an elderly gentleman who presented with first onset anaphylaxis due to food ingestion with evidence of a suspected underlying mast cell activation syndrome. Case report: A 75-year-old male presented to the local emergency department exhibiting symptoms consistent with anaphylaxis. When found by his son in law he was reported to be flushed and unresponsive. On arrival of emergency medical personnel he was found to be hypotensive with blood pressure values of 80/60, hypothermic at 34.7°C orally, and hypoxemic with a sPO2 of 88% by pulse oximetry. He received a 500 cc IV normal saline bolus with EMS. In the emergency department a blood pressure of 71/44 was recorded. He was treated with 3L of IV crystalloid, epinephrine 1:1000 0.3 mg IM once, diphenhydramine 25 mg IV with a second 50 mg IV dose, ranitidine 150 mg IV once, and methylprednisolone 250 mg IV once with improvement. He suffered a type 2 MI related to anaphylaxis associated hypotension that was manifested by tropinemia. He had no previous history of anaphylaxis, atopy, lymphoproliferative disorder or other neoplasm. His daily medications included aspirin 81 mg daily, and this in addition to his other regular medications were continued post reaction. He did not take additional doses of aspirin, over the counter or herbal products on the day of reaction. There was no family history of atopy. The Allergy and Clinical Immunology Service was contacted by the emergency physician, at which time the food intake history was unclear, and given his profound hypotension at presentation a concern of a MCAS was raised. This is consistent with suggestions to investigate for MCAS in patient's presenting with anaphylaxis with profound cardiovascular derangement and lacking documented uritcaria, even if likely attributed to an IgE mediated reaction. He was therefore discharged on cetirizine 10 mg daily, prednisone 50 mg orally for five days, diphenhydramine 25-50 mg orally q6 h as needed, and an epinephrine auto-injector. He was subsequently followed in the Adult Allergy and Clinical Immunology outpatient clinic. Between the anaphylactic episode and his appointment at the Allergy Clinic [approximate time 1 month] he consumed Atlantic cod without reaction. A food history revealed his initial event had developed 3 h following ingestion of a mixed fish and shellfish stew, which he had consumed without reaction on a regular basis. Due to the concern of a potential underlying MCAS and the severity of his initial reaction, it was felt safest to continue H1 receptor antagonist therapy, as such skin prick testing was deferred for use of ImmunoCAP Ⓡ [serum specific IgE (Phadia, Sweden)] for shellfish, finned fish and hymenoptera venom. A serum tryptase was evaluated. He was given an epinephrine autoinjector to be used in the event of subsequent anaphylactic reaction. At follow up his serum specific IgE was high positive for Shrimp at 13.7 kUA/L, and Crab at 7.3 kUA/L, moderately positive for Lobster at 2.9 kUA/L and Clam at 0. A bone marrow biopsy demonstrated normal trilineage hematopoiesis with normal differentiation and maturation without definitive morphological evidence of mastocytosis or lymphoma, specifically revealing no large lymphoid aggregates, abnormal plasma cells, or spindle cells suggestive of mastocytosis. Accompanying flow cytometry demonstrated revealed a sample composed of 23% lymphocytes, of which 84% were T cells, 8% NK cells, and there was a CD4/8 ratio of 0.9. Remaining cells were polyclonal B cells without evidence of lymphoma, plasma cell neoplasm, or mastocytosis. Tryptase was consistently elevated at 17 ng /ml on repeat testing. Given his elevated tryptase, he was maintained indefinitely on cetirizine, and continued to avoid both fish and shellfish, but did require emergency department monitoring following administration of his epinephrine auto injector in January 2015 following ingestion of a perogy, of which the precise constituents were unknown, and development of a diffuse urticarial rash. He was treated with a 3 day course of 50 mg of oral prednisone. He fulfills the proposed diagnostic criteria for diagnosis of a suspected MCAS based on guidelines published by Valent and colleagues, however we acknowledge the challenge of establishing the diagnosis in the context of a documented IgE mediated food allergy, and he may be best classified as a Secondary MCAS [IgE-dependent disease related].

Conclusions:
The combination of food allergy with a mast cell activation syndrome with onset in the elderly population represents a novel combination that is not well described. It is unclear whether the patient in this case had an underlying mast cell disorder that was previously quiescent and was detected only due to his presentation, or whether this was related to a newly acquired population of nonclonal mast cell hyperplasia secondary to an as yet undiscovered or subclinical triggering source such as malignancy, infection, subclinical thrombosis, an underlying autoimmune condition, increased stimulatory cytokines, or increased vasoactive peptides; as all are postulated triggers of mast cell activation. The increasing prevalence of food allergy worldwide, and the heightened propensity for life threatening anaphylactic reactions in those with underlying mast cell reactivity highlights the importance of an educated, Clin Transl Allergy 2017, 7(Suppl 1):10 stepwise, evidence -based diagnostic approach to older adults presenting with anaphylaxis. This further supports the importance of a high level of suspicion for clonal mast cell disorders in patient's presenting with anaphylaxis with profound cardiovascular manifestations and limited cutaneous manifestations. A case such as this emphasizes the importance of an approach with thorough investigation of all potential allergen exposures, including those to which a patient has been exposed on multiple occasions without systemic or local reaction. It could be theorized that new sensitization to previously tolerated food antigens with resultant anaphylaxis could be associated with underlying mast cell activation disorders in adults without a history of atopy, particularly when presenting with profound hypotension. Further research is needed into the incidence of adult onset IgE mediated food allergies, anaphylaxis, and the rate at which it is associated with underlying mast cell activation, particularly given the association with MCAS and a heightened risk for a more severe anaphylactic reaction.
Consent to publish: The individual described in the above case report has completed and signed a consent form for publication and presentation, currently stored at the Allergy and Immunology clinical offices in the Health Sciences Centre, Winnipeg, Manitoba, Canada. A copy can be made available if required. Case report: A 56-year-old female experienced 2 anaphylactic reactions after eating chicken tikka masala and after a croissant with wild berries topping. She showed immediate nausea, vomiting and diarrhea followed by urticarial rash and facial edema several hours later. Afterwards, patient had, with exception of the wild berries topping, the same food again but without complaints. Skin and immunoCAP (Thermofisher-Phadia) testing were negative with all food allergens relevant to the history, including Tri a19 and galactose-alpha-1.3-galactose. Idiopathic anaphylaxis was diagnosed and an adrenalin auto-injector was prescribed. Several months later, after performing an urea breath test for Helicobacter pylori with a Fortimel ® energy strawberry (Nutricia) drink, which contains as potential allergens milk, rape seed oil, sunflower seed oil, soy lecithin and carmine acid, patient experienced immediate epigastric pain followed by dyspnea, facial edema and generalized urticaria. Skin testing with Fortimel ® energy strawberry was clearly positive (negative in 5 controls) and negative for milk and soy milk. Specific IgE showed positivity for cochineal extract (2.77 kU/L) (retrospective serum analysis one month before: IgE 1.92 kU/L). Flow cytometric analysis of activated peripheral blood basophils (CD63 + CD123 + HLA-DR − ), including a positive control (anti-IgE), a negative control (without allergen), carmine (Sigma-Aldrich) and fast green (E143), showed clear CD63 positivity after stimulation with carmine and not with fast green (Fig. 3). This response was absent in the control patient.

Conclusions:
A rare case of carmine-induced food allergy is described and confirmed by sIgE, skin prick test and basophil activation test. Carmine, used as a natural red dye, can cause severe allergic reactions at very low concentrations, with an uncharacteristic time delay between exposure and clinical manifestations, potentially hours later. Unclear episodes of anaphylaxis may be due to sensitization to carmine. Carmine should be included in the allergy work-up of idiopathic (food-induced) anaphylaxis as it can act as a hidden allergen.

Consent to publish:
Informed consent of the patient is obtained.

Fig. 3 Basophil activation test
Introduction: Termites are insects in the Isoptera suborder, Blattodea family, with 3106 described species. They live in worm regions, including Africa, South America, South Europe and Australia. Besides their use as a dietary supplement in non developed regions, they have become popular in western countries as delicacy.
Case report: A 30-year-old Caucasian woman presented at the emergency department with cough, wheezing and urticaria immediately after termites' ingestion, accompanied by epigastric pain and dizziness 30 min later. It was the first time she consumed termites. The patient had a history of two anaphylactic reactions after honeycomb ingestion. Between the first two episodes she was consuming honey, honeycomb and propolis with no reaction, but subsequently she has banned them. "Slight discomfort" with crustaceans' consumption was also reported. Skin prick tests to food and aeroallergens were positive to grasses, Bermuda grass, Blatella germ, Derm. Pter., Derm. Far., shrimp, crab and shellfish. Additionally prick to prick tests performed with raw and boiled termites turned out positive contrary to 5 negative controls. Total IgE was slightly elevated and baseline tryptase was normal. Specific IgE antibodies for shrimp, fish, grape, latex, honey bee venom and tropomyosin were negative, unlike Bermuda grass, Blat. germ, Derm. pter. and Derm. far. which were positive.However our patient has neither personal or family history of atopic diseases. According to history and laboratory evaluation, we speculated that the common allergen is a minor panallergen, like a calcium-binding protein, common in pollens (Bermuda) Cyn d 7 but also in crustaceans Cra c 4, cockroach Bla g 6, mite Der f 17 and honey bee (calcium binding protein 39), although, to our knowledge, no cross reactivity between animals and plants has been described. Unfortunately, for lack of means, we couldn't identify the common allergen. Accidental exposure in related species could also be a reason for sensitization. Conclusion: This is the first case report of an anaphylactic reaction to termites' ingestion. It is challenging how the food consumption from different cultures and ambient could increase the appearance of new food allergic reactions.
Consent to publish: Consent was obtained from the patient for publication of this case report. Introduction: Food allergy is the most common cause of anaphylaxis in children. Banana is not considered a highly allergenic food and it is usually one of the first fruits introduced in the diet of infants. Case report: A 2-year-old boy had an anaphylaxis episode immediately after eating a banana. He presented with oral discomfort, facial and tongue angioedema, emesis and rash on his legs. On route to the emergency department, his aunt, an Allergist, gave instructions to administer dimethindene and betamethasone with symptom improvement. He remained in observation at the hospital and an adrenaline auto-injector, antihistamine and oral steroid were prescribed on discharge. He had eaten bananas before, but always in small quantities because he did not like bananas and he would refuse to eat them. He tolerates apple, pear, mango, pineapple, melon, clementine and vegetables. His medical history includes atopic dermatitis and the use of a helmet during six months for the correction of plagiobrachycephaly under the supervision of neurosurgery. Skin prick tests (SPT) with commercial extracts were positive for kiwi and banana; and negative for D. pteronyssinus, grass pollens, Pru p 3 and latex. The skin prick-prick tests with banana were also positive. Total IgE and basal trytpase were normal; specific IgE to banana 2.85 kU/L and negative to latex. Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) immunoblotting with banana extract and the patient's serum was performed and an IgE-binding band with a molecular mass of 20 kDa was detected which suggests sensitization to banana. Conclusion: Although banana allergy is well established in adults, often associated with latex allergy in the latex-fruit syndrome, there are few case reports of anaphylaxis to banana in children. Banana pulp is rich in thaumatin-like protein (TLP), an allergen with 20 kDa of molecular mass; it is probably the sensitizer in this case. Curiously, SPT with kiwi extract was positive although he never ate kiwi. This may be explained by the cross-reactivity described among the TLPs. Clin Transl Allergy 2017, 7(Suppl 1):10

PD66
Introduction: Omalizumab (anti-IgE antibody) is an effective treatment for asthma and chronic spontaneous urticaria, but relatively few reports exist of use for prevention of uncontrolled systemic allergic reactions in adults. We report the case of an adult patient with allergy to lipid transfer proteins (LTP) who was successfully treated with omalizumab.
Case report: A 34-year-old Caucasian female started to experience anaphylactic reactions to red wine in 2009, with abdominal cramps, vomiting, urticaria, lips and tongue angioedema. She subsequently experienced pharyngeal discomfort with difficulty in breathing after eating grapes. Over the next 3 years she progressed to similar reactions after eating numerous fruits and vegetables. We first became involved in her case in 2012. She underwent investigation with skin tests to a wide range of fruits/vegetables, component and ISAC testing. A diagnosis of LTP allergy was made. She was provided with an anaphylaxis management plan. She continued to have recurrent and frequent reactions despite extensive dietitian input and then antihistamine prophylaxis, with repeated use of adrenaline injector and emergency department attendances. Her dietary intake became heavily restricted and quality of life was significantly affected, both as a result of allergic reactions but further compounded by new depressive and anxiety symptoms. A decision was made to undertake a trial of subcutaneous omalizumab therapy. She underwent a positive baseline double blinded placebo controlled food challenge (DBPCFC) with raisin, developing nasal congestion and abdominal pain that was reproduced when re-challenged with the same dose (20 mg) but not placebo. Treatment was then initiated with omalizumab (300 mg once monthly), in accordance with the asthma dosage recommendation for weight and total IgE. The DBPCFC was repeated after 6 months of omalizumab and a final dose of 600 mg of raisins was fully tolerated. She has subsequently undergone multiple open oral food challenges to previous trigger foods, which have now been reintroduced into her diet. She continues to receive regular omalizumab and has not experienced a recurrence of systemic allergic reactions. Conclusions: There is currently little data to confirm omalizumab use in patients with anaphylaxis to foods outside of the oral immunotherapy setting. To our knowledge this is the first reported case of omalizumab being used to successfully manage systemic allergic reactions to LTP.
Consent to publish: Written informed consent was obtained from the patient for publication of this abstract and any accompanying images.
Introduction: Hen's egg is the second most common allergen with a mean incidence of allergy of 1.23% (95% CI 1.27-3.47) in the Euro-Prevall birth cohort. There are little data on the risk factors for egg allergy. In this study we aimed to assess the risk factors for egg allergy in the Europrevall birth cohort with a particular focus on eczema. Methods: The EuroPrevall birth cohort was established across nine European countries and children were followed up to 2 years. Questionnaires were undertaken at 12 and 24 months.  (Fig. 4). Clin Transl Allergy 2017, 7(Suppl 1):10 In the analysis of the histories with positive data, in 142 (45.9%) it was diagnosed with a specific allergy (allergologic report or suggestive clinical data) and 167 (54.1%) had diagnosed with secondary known effects or they were registered improperly (recorded without any documents that support it). In these 167 medical histories, 289 records were documented (1.7 average/patient), clinical histories with more than one improperly registration, not mandatorily related between them. Among the wrong registered records (without documents, side known effects or intolerance), 69 (49.6%) were antibiotics, 36 (25.9%) NSAIDs, 34 (24.4%) other allergens (Fig. 5).
Given the clinical, social and economical importance it is a significant fact that 19.5% of the clinical histories revised there is no sign of allergy. In the ones that's is registered, almost half of them have their record incomplete or insufficient, being the most frequent the antibiotics and NSAIDs, which condition the prescription and it can lead to a rise of the costs, having to use alternative drugs.

Conclusion:
The interest of the physicians by allergies it seems is not the expected; a proper register of the allergies/intolerances, as well as a allergologic diagnose when it is indicated, it is fundamental for a good medical practice, quality of the prescription, higher security for the patient and decrease the costs. Introduction: Sensitization to food allergens in patients with persistent allergic asthma followed in a tertiary clinic center. Methods: A cross-sectional study was conducted with asthma patients in a regular follow-up in a tertiary clinic in São Paulo, Brazil. The study included patients older than 18 years with allergic asthma, with or without suggestive history of food allergy. Sensitization to aeroallergens, and food allergens was assessed by the skin prick test and/or specific serum IgE. Food allergens included: milk, egg, wheat, soy, shrimp, fish and peanuts. Data was also researched through clinic's registration system, total IgE levels and severity of asthma, according to Gina 2015. Results: We studied 41 patients with a mean age of 39.5 years and 73% were women. When assessing the severity of asthma, 39% had severe asthma, 39% moderate, and 20% mild asthma. Fourteen percent of the patients had suggestive history of food allergy. The mean total serum IgE was 1171.8 IU/mL. Thirty-nine percent of the patients had sensitization to some of the tested food allergens. Of these, milk and eggs accounted for 25% each, followed by shrimp-20%. Wheat and peanuts accounted for 10% each of them, and soy and fish, 5% each of them. The group sensitized to food allergens had a higher total IgE level (1597 IU/mL), when compared to the group that was not sensitized to food allergens (912 IU/mL). It is well established in the literature that asthma is associated to different phenotypes, and therefore may be associated with varying degrees of treatment difficulties. It has been reported in the literature that food allergy might be a risk for complicated or poorly controlled asthma, not only in children but in adults as well, and was associated with asthma morbidity, including risk of hospitalizations and oral steroid use. Nevertheless, the prevalence of food allergy in adults with asthma is still not known. This study showed that nearly 40% of the allergic asthmatic patients with or without history of food allergy, had sensitization to major food allergens. These patients sensitized to food allergens also had higher levels of total serum IgE when compared with non-sensitized patients.

PP002 Food allergens sensitisation in atopic asthmatic patients
Conclusions: Due to the difficulty of control in some cases of asthma, different risk factors should be investigated, including food allergy. More studies should be performed to research these findings in large population. And it would have implications for the management of asthmatics, particularly those with severe disease. Introduction: Legumes play a major role in the induction of food allergic manifestations. Allergy to red gram has been reported in allergic rhinitis as well as BALB/c mice. Information about the atopic dermatitis (AD) like symptoms induced by red gram is yet to be explored. In this study, attempts have been made to elucidate the AD like symptoms induced by red gram proteins following intraperitoneal route of exposure. Methods: To establish the correlation between red gram allergy and AD, we have studied the coexistence of AD and food allergy in red gram allergic patients (n = 210) and healthy individuals (n = 10 as a control) at the Department of Respiratory Medicine, King George Medical University (KGMU), India. Further, BALB/c mice were sensitized with red gram crude protein extract (CPE) via intraperitoneal route to explore the red gram induced AD like symptoms. Serum levels of specific IgE and IgG1 antibodies were measured by indirect ELISA. Anaphylactic signs and symptoms were evaluated 40 min after the challenge by two investigators using the scoring. Histopathological responses were analyzed in the skin of treated mice. Further, mast cell count was performed in the skin. Moreover, expression levels of cytokines, transcription factors and filaggrin were studied in the skin of treated mice. Results: To observe the clinical prevalence of AD in red gram sensitized patients, 210 allergic patients were screened. Out of which  3.33% patients showed possible symptoms of AD, followed by positive SPT for red gram allergen. In the Balb/c mice, elevated levels of specific IgE and IgG1 in the serum along with symptoms of anaphylaxis were found in the treated mice when compared to their respective controls. Further, histopathological analysis of skin revealed characteristics of AD in the treated groups. Significantly enhanced numbers of mast cells were observed in the skin of treated mice as compared to control. Mixed profiles of GATA-3, T-bet, IL-4 and IL-13 at the mRNA were found in the skin of treatment groups when compared to their respective controls. Similarly, enhanced expressions of GATA-3, T-bet as well as filaggrin were observed at the protein levels in the skin of treated mice. We have endeavored to understand the allergenic potential of red gram in the context of AD because in our previous study, we have observed the health concern related to skin in the pigeon pea's allergic patients. Increased levels of specific IgE and IgG1 antibodies were evident in treated group as compared to control group; illustrate the allergenic potential of red gram CPE. In our study, treated group mice have shown significantly fall in body temperature (4-5 °C) as well as symptoms of systemic anaphylaxis upon challenge with red gram CPE. Histopathological results showed the AD like pathological changes, including epidermal thickening, mixed inflammatory cellular infiltration along with hyperplasia indicating that these changes may be evidences for AD. In this study, elevated levels of mast cells were found in the skin, suggesting the massiveness bearing of red gram specific IgEs bound to mast cell receptors. Further, treated skin also over expressed with IL-4 and IL-13 and associated transcription factors like GATA-3 and reduced expression of T-bet at mRNA level, suggesting that local skin expression of Th2 cytokines have crucial role in the development of AD. Present study showed decreased level of filaggrin in the skin, supporting our finding related to the prevalence of AD induced by red gram. Conclusion: Little is known regarding the association between food allergy and atopic dermatitis. In this report, intraperitoneal exposure of red gram proteins may lead to symptoms of atopic dermatitis in BALB/c mice. Introduction: The Atopic Dermatitis caused by nutrition allergy is noticed in most of children till one year and from the etiological spectrum a nutritious sensitization frequently is caused by cow's milk protein.
Our aim was the evaluation of clinical effectiveness of specialized, hydrolyzed cow's milk albumin in children of early age diseased by atopic Dermatitis (AD). Methods: There were under observation 20 children from 30 day up to one year, with AD. The including criteria were age, artificial feeding and existence of AD. The excluding criteria were: an individual intolerance of formula and mother's refusal. The basis of diagnostics was a diagnostic algorithm of AD by Hanifin and Rajka [1]. A heaviness of AD is evaluated by means of standard criteria according to universally recognized SCORAD system. Results: 16 children-first group with mild form of AD, in which SCORAD index amounted to 35.5-65.5 score,14 one-second group with moderate form-SCORAD index was 65.5-78.5 score. In 52% of observed children has been diagnosed IgE-depended allergy, in 20%-an increase of specific IgG4 antibodies level towards cow's milk albumin, but in 28% a mixed variant. Hence is follows, that for the purpose of diet-therapy, the children with AD have been taking specialized hypo-allergic formulas, which is made on basis of hydrolyzed cow's milk protein. The medicinal effectiveness of formula has been evaluated according to SCORAD index.
The results of research show, that in both groups have been noted a decreased of subjective showings in particular of itch and sleep disorder. In children who taking a hypo-allergic formula, are noted a good indicator of body's weight and surplus of length, which points in favour of good endurance of formula. In 82% of diseased after 1-3 weeks from the beginning of diet-therapy, is noted a clinical improvements-decreased of skin's inflammatory process has been proved according to subjective (itch, insomnia) and objective (erythema, dryness, humidity, excoriation) showings, which are fairly shown under SCORAD index. Conclusion: A convincing and reliable results of a conducted research give a opportunity to make a conclusion, that to use a formula of diettherapy in children with AD is expedient in specialized arsenal of children's nutrition. Introduction: The aim of this study is to evaluate the degradation over time of B Cell Activating Factor (BAFF) and Platelet-Activating Factor (PAF) in collected dried blood, evaluating the differences between two kinds of sample collectors: Whatman 903 Neonatal card (CARD) and Copan Nylon Swab (SWAB).

Methods:
A dried blood spot is a common, moderately-invasive method for collecting patient blood from finger pricks. The blood samples are collected from 18 individuals. The collection of the samples is carried out in triplicate for both devices. Samples were stored at room temperature in the dark until serum extraction and analysis. Samples are assayed by Enzyme-Linked Immuno-Sorbent-Assay (ELISA) for BAFF (R&D Systems) and PAF (Elabscience). Serum extraction and ELISA assay were carried out 2 days (T2), 7 days (T7), 14 days (T14), 21 days (T21) and 28 days (T28) after collection. Results were presented as mean ± SEM. Results: PAF values were stable over the time up to 21 days both for CARD and SWAB. At 28 days there was a reduction of up to 54.3 ± 6.76% for SWAB and up to 36.6 ± 5.5% for CARD (p < 0.001).
As regards BAFF, values were stable until T21 while at T28 there was a decrease of up to 77.1 ± 6.3% for SWAB and up to 63.7 ± 4.5% for CARD (p < 0.001). According to Finkelman, there is a pathway of activation of immune system mediated by IgG, FcγRs, macrophages, and PAF. BAFF is a member of the tumor necrosis factor superfamily and an important regulator of peripheral B cell survival, maturation and immunoglobulin class-switch recombination. Many studies suggest that BAFF might modulate immune inflammation and could probably be one of the cornerstones of this IgG pathway of immune reaction. BAFF and PAF have both already been linked in non-atopic subjects to food reactions, supporting the possibility that these inflammatory molecules could be involved in non-IgE-mediated allergic reactions.

Conclusion:
The data presented in this study should be considered for both clinical and research applications. The higher degradation of PAF compared to BAFF could be attributed to the different chemical nature of these two inflammatory molecules, lipid and protein respectively. The degradation over time of BAFF and PAF also depends on the type of technological support used for the collection of the specimen. Samples should be analysed as soon as possible and no later than 21 days from the time of collection to ensure greater stability of the values.
Introduction: Literature reviews showed that FA clinical manifestations on the skin of various degrees of severity related to foods ingestion can arise as a result of a number of disorders and only some of which can be defined as allergic.
The aim of the research was to identify diagnostic approaches to the differentiating food allergies from food intolerances in children.
Methods: Skin elements were identified in complex with anamnesis data and results of the laboratory data. Hypersensitivity to food was detected by the skin tests (patch and prick), levels of the specific IgE and/or oral challenge test. Gut permeability was identified with 6-h lactulose urinary excretion. Results: 56 patients (age 1-36 months old) with food allergy with typical allergic symptoms related to food intake were included into the study in the outpatient department. Major part of the parents (67%) couldn't clearly identify the causative product. Only 15 children (26%) had positive specific IgE to milk and/or egg. Skin tests were positive in 10 of the patients (17.8%). Oral challenge test with milk and/or egg was positive only in 7 children (12.5%). Skin lesions vary from urticaria to papulation. Commonly non-immune reactions were nonspecific, not itching and not intense. Nevertheless of the type of the food intolerance mechanism skin dryness was presented in the major part of the patients. Moreover lactulose was detected in urine in 76.7% of cases both in group with immune and nonimmune reactions. There was no association of the lactulose level with type of the skin lesions. But intestinal permeability correlated with skin dryness (p < 0.05).

Conclusion:
The study revealed that gut permeability in children with skin manifestations of food allergy often overlapping with symptoms found in nonimmune disorders such as disorders of absorption. Skin dryness can be its' phenotypical marker. Gut permeability is the purpose for additional dietary corrections in children with FA. Introduction: The aim of this study is to evaluate the percentage change of the diagnostic-therapeutic choice in complex polysensitized patients affected by food allergy, after using CRD compared to a first level survey (medical history and skin tests), along with an economic analysis of the patient's overall management according to the two different approaches (assessment of higher costs and savings).

Methods:
In this multicenter study in real life, 187 patients polysensitized to skin tests and with clinical symptoms related to an IgE mediated food allergy were recruited. Each patient was submitted to skin prick tests (SPT) with a standard panel of food allergens and to a blood sample in order to detect specific IgE against food recombinant molecules (CRD), which were chosen according to medical history and positivity to SPT, by ImmunoCAP method (Thermo Fisher Scientific ® , Uppsala, Sweden) or, when not available, by Microarray ISAC 112 allergens system (Thermo Fisher Scientific ® , Uppsala, Sweden). Then the first diagnostic-therapeutic hypothesis, based only on medical history and skin tests, was recorded for each patient and, after that, the second diagnostic-therapeutic choice (final) was made, the one which would be implemented considering the CRD outcome. Therefore, an evaluation of the change of the diagnostic-therapeutic choice was carried out, in percentage, between the first hypothesis and the final choice, analyzing statistically the results by the agreement coefficient (k index) and the Chi square test. Finally, a detailed analysis was conducted on the economic impact of a molecular approach to the overall management of the allergic patient in order to evaluate whether the increase in the diagnostic costs would be compensated and eventually exceeded by savings coming from the increasing diagnostic-therapeutic appropriateness. Results: A change in the prescription of self-injected adrenaline has been observed in about 50% of patients (k index 0.56) and an overall saving of financial resources along with a higher diagnostic-therapeutic appropriateness has been pointed out too. Conclusion: In this study there is only moderate agreement concerning prescription of self-injected adrenaline before and after performing CRD: as a result, it is highlighted the usefulness of CRD, at least in complex polysensitized patients, in indicating risk assessment and therefore the correct therapy of food allergy, thus resulting in a costsaving approach. Introduction: The gluten intolerance is associated with celiac disease and Allergy to gluten, the criteria for the differential diagnosis of which is still insufficiently developed. The aim of this study is the development of a diagnostic algorithm for gluten intolerance in children for the purpose of adequate diet therapy application to prevent development of complications and severe forms of the disease. Methods: Under supervision there were 42 children with chronic diarrhea and symptoms of impaired intestinal absorption. The diagnostic algorithm consisted of the following stages. The first stage-the detection of the risk groups for gluten enteropathy. These include: (1) immediate relatives of patients with celiac disease; (2) close relatives with allergic diseases; (3) children with gastrointestinal symptoms resistant to standard therapy; (4) children, lagging in physical development and with symptoms of impaired intestinal absorption; (5) patients with dermatitis herpetiformis and diseases that can be associated with celiac disease. At the second stage children included in the risk group were subjected to screening diagnostics. We used the BIOCARD TM Celiac Test (Finland), which allows to determine antibodies to tissue transglutaminase (IgA). Patients with a confirmed diagnosis of celiac disease and positive (BIOCARD TM Celiac Test) test was not included in further examination. The third stage of gluten intolerance diagnostics was in-depth examination of children with gastrointestinal and skin manifestations of Allergy, including anamnesis and clinical symptoms, determination of total IgE, IgG, IgA, IgM and specific IgG and IgE antibodies in the blood serum.

PP013
Results: Three groups of patients were identified. The first group consisted of 23 children with positive allergen-specific IgE antibodies to gluten and wheat and to cow's milk protein in serum. In 10 children from the second group IgE and IgG antibodies to gluten and wheat serum were identified at the same time. They had gastrointestinal symptoms within a few hours after eating a certain amount of foods containing gluten (individual for each child). The third group of patients included 9 children with IgG antibodies to gluten and wheat serum. Clinically they mainly had skin rashes.

Conclusion:
The staged diagnostic algorithm for gluten intolerance in children allows to determine the mechanism of gluten intolerance and to prescribe required elimination diet and treatment aimed at prevention of serious complications. Results: Of all the tests, 89(48%) were performed due to plant food allergy suspicion and in 58(65%) diagnosis was confirmed: profilin mediated allergy (n = 17); LTP allergy syndrome (n = 20); both profilin and LTP (n = 2); birch-plant food syndrome (n = 4), latex-fruit (n = 4); and to specific foods (peanut n = 3; walnut n = 1; banana n = 1; kiwi n = 4; wheat n = 1; blackberry n = 1 Acceptance test: Both taste and volume got acceptable results in the test. The mean value for taste was 5.6 out of 9 and for acceptable volume 7.9 out of 9. Triangle test: Out of 38 subjects, 16 pointed out the odd sample in the test i.e. p < 0.05 and the challenge drink and the control drink were thus not possible to identify in a blinded test.

Conclusions:
This study has shown that it is possible to develop a blinded recipe for use of DBPCFC using an "adult portion" of wheat protein. The recipe has acceptable portion size, few ingredients, contains ordinary staple foods and has low cost. Further recipes for other allergenic foods will be developed using the same model. Results: Within the studied population prevalence of PFS was 5.4%. Their average age was 10+/−3, 60% between 6 and 10 years, 35% from 11 to 14 years and only 5% between 15 and 18 years; 45% were women and 55% men. Apple (55%), peach (50%) and banana (50%), were the foods most commonly implicated. Rosaceae family was responsible in 75% of the cases, followed by Musaceae with 50%, Lauraceae with 45% and Cucurbitaceae and Fabaceae with 40%. All but one patient had allergic rhinitis, 50% had asthma, 35% atopic dermatitis, 25% had all three and 10% had other type of food allergy. In the subset of patients with PPT to fresh foods, 90% had a positive result and 10% had a negative one, these patients underwent open OFC which turned out positive. Sensitization to Quercus robur and Alnus glutinosa were the most frequents (40%), followed by Fraxinus excelsior (35%) and Betula verrucosa (30%). There is little knowledge about FPS in Mexico and there are no previous studies in pediatric population. We found that FPS affects males and females equally, being more frequent between 6-10 years. When compared with international literature, the prevalence is similar and we also found apple and peach as the most frequent foods implicated. Although, we also found banana as a frequent food responsible for FPS, similar to what is reported in the Mexican study performed in adults. Contrary to studies performed worldwide, we found birch sensitization in only 30% in FPS, being more frequent other Alnus glutinosa and Quercus robur.
Conclusions: It appears to be a significant difference in sensitization patterns to aeroallergens in Mexican pediatric population with FPS. Foods implicated seem to be similar to national and international reports. More studies are required to known the real characteristics of FPS in Mexico.

Introduction:
The association between food allergy and celiac disease (CD) and Non celiac Gluten sensitivity (NCGS) is still to be clarified. Gluten-related disorders have gradually emerged as an epidemiologically relevant phenomenon with a global prevalence that is estimated around 5%, drawing the attention of the scientific community. Epidemiological studies estimate a worldwide prevalence of CD of approximately 1:100 individuals, with a considerable proportion of patients remaining undiagnosed and untreated. According to a study performed by the National Health and Nutrition Examination Survey in the United States, the prevalence of self-prescribed GFD in an unselected population of subjects aged 6 years or older was 0.5%. Epidemiological studies report a prevalence of WA in American population of around 0.4% untill 0.6%. The diagnosis of WA is classically based on skin prick tests (SPT), in vitro specific Immunoglobulin E (sIgE) assays and functional assays. SPTs and sIgE in vitro assays are the first-level diagnostics for WA. However, they are affected by a low predictive value. In particular, their low sensitivity can be explained by the fact that the commercial test reagents are mixtures of water/salt-soluble wheat proteins that lack allergens from the insoluble gluten fraction. Case report: In our unit of celiac disease and related conditions to gluten we visited in one year about 400 patients. Of these 113 they were not celiac but were investigated for suspected non-celiac gluten sensitivity. After in vitro tests for the exclusion of celiac disease, the same patients underwent allergologic workup consists of: skin prick tests for foods including wheat (Alk-abello), LTP (lipid transfer protein) (peach Alk abello), alpha amylase, wheat flour, barley, corn, rice, grass pollen and histamine. Also all they performed patch tests for suspected allergy to nickel, if they reported reactions after a few hours of ingestion of gluten. Molecular-based allergy (MA) diagnostics could overcome some limitations of sIgE in vitro assays using wheat flour extracts. We have used omega-5 gliadin (Tri a 19) and nsLTP (Tri a 14), gliadin, wheat, gluten that are available in the ImmunoCAP ™ assay, whereas the alpha-amylase/trypsin inhibitor (Tri a aA/TI) is available only in the microarray ISAC ™ assay. The sIgE to omega-5 gliadin assay is highly reliable and now widely used to identify the patients with WDEIA. Conclusion: Of a total of 104 patients with a history of immediate reactions and not immediate after ingesting gluten, we found wheat protein sensitization in 14 patients (13%). In addition of 300 celiac patients we also found 5 patients with allergy to wheat or wheat protein (1.5%) different percentage than that reported in the literature.

Consent to publish:
Authors confirm that the individual(s) described have authorized them to publish the findings related with these cases. Introduction: To investigate the prevalence of food allergies and to identify the most common causes of the allergies in the population of preschool children from the city of Batumi.

Methods:
The study was conducted with children population, in Batumi. The random sampling was applied in the study to ensure representative sample and the cross section method of epidemiological survey was used. At the first stage of the survey 840 children aged from 6 months to 7 years, were questioned. Data were collected through the face-to-face and phone interviews. At the second stage of the survey, the subjects of study were the part of the population, who revealed the clinical signs of food allergy for the last 12 months. The causal factors were revealed on the basis of answers to the questionnaire, anamnesis data, specific IgE measurements and skin prick tests. The risk factors were studied on the basis of case control studies. Results: Skin manifestation (76%) of food allergy was significantly (p < 0.05) higher than the rate of gastrointestinal symptoms (24%) in the studied population. The most common causes of food allergies in the study population were different food addi-tives (29.2%), fish (22.6%), eggs (22.3%), milk (18.6%), honey (13.7%;) and nut (4.3%). Such factors as inheritance from mother (OR 13.69; 95% CI 7.08-27.04), excess weight of newborn (OR 1.08; 95% CI 0.30-3.82) and bottle feeding (OR 5.29; 95% CI 3.30-8.51) are associated with higher risks of food allergies. IgE mediated reactions to the food allergens were identified in 98% of the patients. The prevalence of parentally reported allergy was 15.8%, while proven allergy cases were 6.1% positive on the basis of IgE/STP. Thus, the allergy presence is significantly overestimated by parent (p < 0.01). This problem can be explained by lack of information and education about food allergy in parents. Allergy to nut is significantly higher in children between 3 and 5 years than in children of younger age, while allergy to milk and eggs was same in all ages. Conclusions: In the childhood, allergic skin manifestation of food allergy is high. According to the data on obtained in the study, management of the risk factors as well as education of parents and caregivers play significant role in the focused and effective prevention of disease. Methods: A chart review study of 3979 patients undergoing the food challenge was conducted at tertiary Allergy Centre. We identified all patients for whom adrenaline was administered for food-induced anaphylaxis between 2008 and 2016 year and analyzed demographic characteristics such as age, gender, type of food given in the challenge, time after first exposure to first symptoms, treatment required, skin prick test, specific lgE and allergic co-morbidities. Results: 32 patients had anaphylaxis for which adrenaline administration was required. Of the patients who developed these severe symptoms, 22 (68.75%) males and 10 (31.25%) females, median age was 4.9 years. Six (18.75%) of these reactions occurred to cow's milk of which 4 (66,6%) were to baked milk and 2 (33,4%) to fresh milk. Ten (31.25%) children reaction to nuts, 1 (3.13%) to soya, 3 (9.38%) to egg, 4 (12.5%) to sesame, 4 (12.5%) children to wheat. Children, who were allergic to nuts reacted sooner after exposure than that recorded for other foods.
Conclusions: This audit reveals that anaphylaxis during OFC's in a bust tertiary Allergy Centre seldom results in the need for adrenaline administration for the treatment of allergic reactions. However, all foods are capable of producing anaphylaxis in this setting of which milk was the commonest cause. Reactions can occur soon after allergen exposure, especially when the challenge is undertaken to nuts. It is difficult to predict who is most at risk for severe allergic reactions; all children in this audit had allergic co-morbidities and food allergy was the most frequent one. Children who have both asthma and a food allergy are at greater risk for anaphylaxis. Severe reactions requiring treatment with adrenaline was common, but few children required multiple doses of adrenaline. OFC's, which serve as the gold standard diagnostic modality are generally safe but severe reactions do rarely occur for which adrenaline treatment is required. To notice, a large proportion (50%, n = 102) of our study population was sensitized to almond; although small number reported reaction. Regarding peanut, 48.5% (n = 99) of the total population were sensitized with slightly more than one third of that group (36.7% of the peanut sensitized children) reporting immediate type of reaction. Conclusions: Almond and peanut have a considerably high sensitization rate among children visiting our Unit with reaction to nuts, however true reactors were only few. Peanut reactions are less frequent than these to tree nuts, however cannot be overlooked.

PP028
The Introduction: The aim of the study was an attempt to assess the frequency of the use of probiotics in the group of subjects in the light of the Epidemiology of Allergic Diseases in Poland project.

Methods:
The study group consisted of 4.783 subjects aged 6-7 years, 13-14 years and adults (20-44 years) from the eight largest Polish urban centres. The method that was used was the ECRHS II and ISSAC survey questionnaire as well as additional studies including those concerned with the problems related to the range of probiotics' uses.

Results:
The probiotics used were very popular in the group of subjects with diagnosed allergic diseases and were not only combined with antibiotic therapy but also supplemented with kefir and yogurt. The protective action could be observed especially at the age above 14 years. The preventive effect was not observed at the age of early childhood.

Conclusions:
Probiotics have relatively often used in the population under study and a health-improving effects was mainly observed at the age over 14 years old. Introduction: In 2015, the 11% of the total population in Madrid was foreign, being the Latin American origin the most frequent followed by Asia, East Europe and in fourth place by other EU countries. In our working area, the foreign population average was even higher: 19%. Racial disparities in food sensitization have been described. The aim of this work was to study the clinical characteristics of food allergy in children of immigrants from Latin American countries born in Spain. Methods: In our study population 474 children reported allergy to food (cow's milk and hen's egg allergy not included) between 2012 and 2016. We analyze all the children from Latin American origin who were born in Spain evaluated in our center. Clinical history, skin tests and quantitation of specific IgE antibodies were performed as well as oral food challenges. Results: A group of 29 children were included with an age range of 1-14 y.o., (Mean 7). Most of them were male (69%).Familiar atopy history: Rhinoconjunctivitis/Asthma was the most frequent entity (66%) followed by Atopic Dermatitis (16%). Most of the patients reported a personal history of Rhinoconjunctivitis/Asthma (51%) caused by pollen in 59% of cases; and AD (48%). Concerning food allergy, Latex-fruit group was the most frequent (25%), being Melon the most common, followed by Banana and Kiwi. Treenuts were the second family involved (21%), being Walnut the most common, followed by Peanut. Fruits belonging to the Rosaceae family were also involved (19%), being Peach the most frequent followed by Cherry. Shellfish (17%) was the forth family, Prawn was the most common, and Fish (11%) the fifth family, Hake was the most common. Finally, Legumes (7%) were the sixth group involved in allergy episodes, being Bean the most frequent. Describing Clinical Manifestations, Urticaria/Angioedema was the most frequent entity (59%), OAS the second (35%) followed by Anaphylaxis (4%).

Conclusions:
In this study, Rhinoconjunctivitis/Asthma was the most frequently reported entity of personal history of atopy, whereas in Spanish children Atopic Dermatitis is the most common. Latex-fruit group was the most frequently involved food in allergy episodes in The inhalant allergens were negative in the remaining patients. Food allergens and specific IgE for food were negative. Skin tests (milk, egg, soy, wheat, peanuts, hake, shellfish) were positive for wheat in just one patient, all the others were negative. It was empirically established a restrictive diet in 2 patients, since there was no clinical improvement with drug therapy alone (fluticasone 500 μg bid). The exclusion of cow's milk, beef, egg and soy in a patient's diet and cow's milk, soy and egg on another patient's diet resulted in a significant clinical and histological improvement. Conclusions: EE pathogenesis seems to be related to atopy and its control should include a dietary component as an adjunct to the pharmacological therapy instituted. Although skin tests may be negative, dietary restriction of certain foods can improve symptoms and histology on these patients. Introduction: Numerous discussions related to the justification for the use of certain formulas in infants with asymptomatic sensitization. The problem is that a balanced and rational nutrition in realization of metabolic programming is necessary for proper growth and development of the child, on the other hand -there is a risk of transition latent sensitization in clinical manifestations of food allergy. Our aim was to study goat milk formula effectiveness in healthy infants with asymptomatic sensitization.

Methods:
The study included 110 healthy children aged between 2 and 8 months of age who were bottle-fed. The duration of observation was 6-8 months. Prior to transfer to artificial feeding all children were breast-fed. Children received casein dominant formula based on whole goat milk. ELISA. used to identified allergen-specific IgE antibodies to the protein of cow milk, casein, ß-lactoglobulin, α-lactalbumin and goat milk protein in coprofiltrates. Results: Frequency of latent sensitization to cow milk protein and its fractions, as well as to a protein of goat milk in healthy children was maximal at 2-3 months of age. Observation of the children who received casein based formula showed positive dynamics, which is expressed in reducing allergen-specific IgE antibodies to cow's milk and its fractions, as well as the goat's milk to 7-8 months of life. Conclusion: Using goat milk casein based formula was effective in artificial feeding in children with asymptomatic sensitization. Introduction: Food-specific IgE (sIgE) determines the sensitization to food but oral food challenges are necessary to determine the clinical relevance of a food allergy in most cases. Therefore the identification of other biomarkers could be of great interest. Previously, chemokine levels have been correlated with the severity of eczema and the sensitization status to food allergens. The aim of this study was to analyze if chemokine levels could predict a positive or negative outcome of a food challenge with hen's egg. Methods: 37 children sensitized to hen's egg were included in the study. They underwent an oral food challenge with hen's egg to proof its clinical relevance. Serum chemokines (CCL17 and CCL20) as well as total and sIgE were measured using an ELISA kit (R&D Systems) and the ImmunoCAP250 System ® (Phadia) respectively. For statistical analysis the Mann-Whitney-U-test and the Spearman rank correlation were computed. Regarding the chemokine levels of CCL20 there was no significant difference seen. Our previous studies have shown a strong correlation between serum levels of CCL17 and the severity of eczema in food-sensitized infants. In this study the serum levels of CCL17 could be significantly correlated to the level of hen's egg-specific IgE and were significantly elevated in children with clinically relevant hen's egg sensitization in comparison to clinically tolerant ones. Conclusions: CCL17 might not only be a biomarker for severe eczema but also for clinically relevant hen's egg allergy. However larger studies are necessary to prove these findings. Furthermore, determination of CCL17 will not be able to replace oral food challenge tests. order of the challenges with verum or placebo food are randomized. It is currently unknown whether there is a significant difference when initiating the DBPCFC with a placebo challenge or with an active food challenge.

PP035 The influence of the order of food challenge days on DBPCFC outcomes in children
The study aims to explore whether there is a significant difference when initiating the DBPCFC with a placebo challenge or with an active challenge DBPCFC in children Methods: In this study, a total of 1680 patients who underwent DBP-CFC were analyzed. Differences between test day reaction frequencies were assessed with the Mcnemar test. Subjective and objective reactions were considered together and separately. Events occurring on placebo days were also assessed separately.
Results: There was no significant difference between the frequency of reactions on test day 1 and day 2 (p-value = 0.160). This was also the case for subjective and objective reactions considered separately (p = 0.640 and 0.193, respectively). When considering only placebo challenges, 58 patients experienced events on the first day and 47 patients on the second day. This difference was significant (p = 0.000). Conclusions: Patients tend to experience spurious events more often during the first challenge day than the second challenge day, perhaps because of pre-conceived notions about the test and greater anxiety. However, this has no significant impact on the overall diagnostic accuracy of the test, even in patients where the diagnosis is made on the basis of subjective reactions.

Introduction:
The primary aim of this study is to evaluate the percentage of anaphylactic reactions treated with epinephrine during a food challenge test and to identify associated factors for the administration of epinephrine. Methods: Children who underwent a food challenge test with peanut, hazelnut, cow's milk, hen's egg or cashew nut in the period 2005 to 2015 at the department of Allergology Erasmus Medical Center Rotterdam in the clinical setting or in a research setting (IDEAL-study, collaboration of three tertiary care centers for food allergy, trial number NTR3572) were evaluated. The children with reactions meeting the criteria for anaphylaxis according to the EAACI Guidelines for Food Allergy and Anaphylaxis and/or who were treated with epinephrine were included. Possible factors associated with the administration of epinephrine such as age, gender, symptoms consistent with asthma, history of an allergic reaction to the tested allergen and the type of symptoms during the anaphylactic reaction were investigated with logistic regression analysis. Results: A total of 92 children (40 boys, 44%) with a median age of 7 years (range 1-17 years) who met the criteria for anaphylaxis (n = 85) or who were treated with epinephrine (n = 7) were included in this study. Thirty-three children (39%) with anaphylaxis were treated with epinephrine. Factors significantly associated with epinephrine treatment were younger age (p = 0.001) and lower airway symptoms (p = 0.001). Gastro-intestinal symptoms and a history of an allergic reaction to the tested allergen were significantly associated with the lack of epinephrine treatment (p < 0.001 and p = 0.043, respectively). The most severe allergic type of reaction during a food challenge test is anaphylaxis, for which the recommended treatment is epinephrine. However, only about half of the children with anaphylaxis received epinephrine during the food challenge tests in our study. Treatment of anaphylaxis during food challenge test does not correspond to the indication for such treatment as delineated in the EAACI Guidelines. Further analysis is warranted to ascertain the cause of this discrepancy. Conclusions: Anaphylaxis occurring during challenge tests seems to be undertreated with epinephrine. Introduction: Nowadays allergies are among the most common of medical disorders. It is estimated that more than one in every five people suffer from some form of allergy in the world. Allergic pathology in children is usually manifested by food allergy (FA). This problem starts in infancy and is most likely to arise when atopic diseases run in the family. Food allergens are major components of sensitization structure in children under one year. Our purpose wat to select high-adapted nutrition mixtures for infants with allergic manifestations. Methods: 116 artificially fed infants with the signs of allergic constitutional dermatitis and children's eczema. Programme contemplated estimating efficiency of the nutrition mixture. "NAN Lactose free" was administered as main nutrition for 78 and "NAN Soy"-for 38 infants. If they proved ineffective "Acidophilic NAN" and "Alfare" were given. Adequacy of nutrition was determined by the dynamics of skin status and simultaneous analysis of the character of sleep, presence of gastro-intestinal changes, microbiological profile of feces, and specific allergodiagnosis in vitro. Results: Soy-bean nutrition proved effective in 56%. "NAN Soy" combined with "Acidophilic NAN" led to stabilization of intestinal motility Clin Transl Allergy 2017, 7(Suppl 1):10 in 80% of infants with a good tolerance to this mixture. Application of "NAN Lactose free" caused positive dynamics in 63%. The rest (37%) were transferred successfully to a combined nutrition "NAN Soy" + "Acidophilic NAN". In case "NAN Soy" and "NAN Lactose free" (33%) were ineffective, mixture "Alfare" or its combination with "Acidophilic NAN" were tested. Positive dynamics of FA course was observed in all infants. Conclusions: Thus, at the absence of breast milk, infants with FA manifestations are expedient to feed with the following mixtures:

Analysis of dietary programmes for infants with allergy signs
• with complete protein hydrolysis (Alfare); • acidophilic (Acidophilic NAN); • alactic (NAN Lactose free); • soy-bean (NAN Soy). Introduction: Our aim was to investigate the anti-allergic and immunomodulatory effects of Lactobacillus reuteri in a murine model of food allergy. Methods: BALB/c mice were sensitized with ovalbumin (OVA) plus alum and subsequently challenged with OVA by gavage to induce food allergy. The mice were daily administered with L. reuteri (1 x 10 9 CFU/mouse) and/or MRS broth (as vehicle) throughout the entire period of experiment. Allergic diarrhea was monitored after each OVA challenge, and the mice were sacrificed post the last OVA challenge to collect serum samples, spleen and duodenal tissues for immunological and histopathological analysis. Results: L. reuteri administration attenuated the occurrence of diarrhea, intestinal mast cell activation, and serum IgE production. Furthermore, both the production of IFN-γ and IL-4 by splenocytes was suppressed by L. reuteri. Concordantly, a decreased expression of IL-4, IFN-γ, GATA3 and T-bet were observed in the duodenum. However, the expression of IL-10, TGF-β and Foxp3 was augmented. These findings demonstrate that oral administration with L. reuteri attenuated allergic responses and down-regulated both T helper (Th)1 and Th2 immune responses, which was closely associated with the enhanced reactivity of regulatory T cells. Conclusions: L. reuteri may be used as a functional probiotic for managing intestinal disorders associated with exaggerated immune responses, especially food allergy.

Conclusions:
• Most schools have policies in place relating to managing allergy in schools. • More guidance surrounding storage of AAI and checking expiry date may prevent out of date AAIs as well as AAIs being locked away, which in an emergency could prove problematic. • Schools appear to be influencing AAI prescription practices by specifying numbers of AAIs they require. • Ongoing partnership between the allergy clinic, LAs and school nurses are required to further improve the infrastructure for managing allergy in schools. Introduction: The children's allergy service in Leicester has worked with local school nurses to produce educational material on the recognition and treatment of allergic reactions. School nurses deliver this package to school staff. The aim of this survey was to ascertain whether staff felt they were able to manage children presenting with an allergic reaction. Methods: 377 schools under the jurisdiction of two local education authorities were sent a link to an online questionnaire. The schools were requested to circulate the questionnaire to all members of staff to complete.

Results:
• Training for the management of allergic reactions was provided by a LEA school nurse (75.1%), first aid training provider (16.7%) and other including no training (8.2%) • 75.4% of school staff had received training in recognition and management of allergic reactions within the last 12 months, 14.2% within 12-24 months and 10.4% >24 months. • 91.1% felt confident in the recognition of an allergic reaction, while 89.3% felt confident in being able to manage an allergic reaction, including the use of an AAI. • 30.4% and 22.9% respectively felt they needed more training on recognition of an allergic reaction and administration of an AAI.
Nearly all members of staff completing the survey had received training within the last 2 years and feel confident in the recognition and management of allergic reactions. Significant numbers of staff feel further training would be beneficial.

Introduction:
A negative oral food challenge (OFC) should normally be followed by its reintroduction in the diet. However, this fails in a subset of children. Aims: (1) To analyse the rate of occurrence and the reasons for failure of reintroduction of the implicated food after negative OFC in children; (2) To determine the proportion of food avoidance in children who did not undergo OFC. Methods: A retrospective study of children with an OFC scheduled between January 2012 and December 2015 was performed. Clinical records were reviewed and the food consumption status (FCS) was obtained using a short structured phone or paper enquiry answered by the caregivers. Results: Data of 127 children (59% male; median age [interquartile range, IQR] 5 [7] years); 64% atopic (48% allergic rhinitis; 38% asthma and 27% atopic eczema); was collected. A total of 235 OFC were scheduled during this period and only 186 were performed and 137 were negative. The major foods tested were with cow's milk (29%), hen's egg (26%), fish (14%) and crustaceans (11%). Data on FCS was obtained in 97.3% of the total 235 OFC scheduled during the study period. The mean time (±std) between the OFC and the assessment of FCS was 13 ± 6.9 months. Food avoidance was maintained in 26.3% of the 137 negative OFC. Food rejection was the main reason (44%), followed by the fear of reaction by caregivers (35%). Food avoidance was related with the suspected food group (p < 0.01). Further comparison of children's FCS revealed no significant differences with respect to gender (p = 0.651), age (p = 0.07), clinical manifestation of the index reaction (p = 0.627) or the presence of allergic comorbidities (p = 0.133). Eviction of the suspected food was maintained in 61.2% of the 49 OFC scheduled that were not performed, in contrast to the 37.1% when an OFC was performed, independently of its result; p < 0.001. Conclusions: Avoidance of the offending food is still the mainstay of management and so, children with suspected food allergy often present with a long-lasting elimination diet. Despite a negative challenge outcome and advice to re-introduce the food in the diet, 26.3% of the children were still avoiding the implicated food. Almost two thirds (61.2%) of the patients who did not undergo OFC maintained avoidance of the suspected food. These data highlight the importance of performing an OFC in preventing unnecessary restrictive diets as well as alert to the need of assessing food consumption after a negative OFC. Introduction: Risk is a function of hazard and exposure. For food products, allergens are a well-known hazard and exposure scenarios are calculated based on the concentration of unintended allergen in combination with the amount of food consumed. At the moment, food consumption data from the general population are used for calculating exposure scenarios in food allergen risk assessments. A reasonable assumption is that if a food product is chosen to be consumed, the population distributions of amounts of a food product consumed at one eating occasion are comparable between the allergic population and the general population. A second assumption is that the frequency of consumption for certain product categories may differ between the allergic and general populations. However, structured data are lacking to underpin these assumptions and research initiatives are needed to fill in the current data gaps. Methods: Based on the US National Health and Nutrition Examination Survey, a statistical comparison was made between the food consumption distribution at a single eating occasion of allergic and non-allergic individuals. Two allergic identifiers were studied, serum IgE to the specific food (NHANES 2005(NHANES -2006) and self-indicated food allergy (NHANES 2009(NHANES -2010 Introduction: Our aim was to determine eliciting doses (EDs) in walnut allergic adults and to compare with previously established threshold data in peanut and tree nuts. Methods: Prospectively, adult subjects with a suspected walnut allergy were included and underwent a low-dose double-blind, placebo-controlled food challenge (DBPCFC). Individual no observed and lowest observed adverse effect levels (NOAELs/LOAELs) were determined and Log-Normal, Log-Logistic and Weibull models were fit to the data. Estimated eliciting dose (ED) values were calculated for the ED5, ED10 and ED50, the dose respectively predicted to provoke an allergic reaction in 5, 10 and 50% of the walnut allergic population. Results: Fifty-seven subjects were challenged and 33 subjects were confirmed to be walnut allergic. Objective symptoms occurred in 20 of the positive challenges (61%), varying from angioedema of the lip to severe dyspnea. The lowest cumulative LOAEL for objective symptoms was 0.31 mg of walnut protein, leading to repeated coughing in one subject. Data from 13 subjects with only subjective symptoms were right censored. The cumulative eliciting doses in the three distribution models ranged from 3.1 to 4.1 mg for the ED05, from 10.6 to 14.6 mg walnut protein for the ED10 and from 590 to 625 mg of walnut protein for the ED50. Conclusions: Population EDs for walnut are slightly higher compared to those previously found in peanut and hazelnut allergy. Additionally, previous ED estimates for cashew from a limited number subjects (31) was also higher when compared to hazelnut (202 subjects), indicating that threshold levels for hazelnut could be used as a conservative estimate for risk assessment of other tree nuts where little or no food challenge data is available. Introduction: Unexpected allergic reactions to food are frequently occurring, with even severe and fatal reactions. Our aim was to analyze the type of food products and possible presence and levels of allergens involved in unexpected reactions in daily life of patients. Methods: A prospective cohort study in adults with a doctor diagnosed food allergy. Patients reporting an unexpected allergic reaction were asked to provide information on the food product, the label and estimated consumed amount, and a sample to determine the possible culprit allergenic substances and their concentrations. This was combined with individual patient food allergies and products were analysed using ELISA or qPCR for different allergens. Results were analyzed and compared with the Reference Doses as established by Taylor et al (Food and Chemical Toxicology 63, 2014, 9-17). Results: Patients experiencing an unexpected allergic reaction reported a very diverse range of food products. A significant part of the unexpected reactions, 78% (118 out of 151), was attributed to a specific product by the patients. In 22% the reaction was caused by a composite meal. A total of 53 food samples were received and analyzed for 28 different allergens, ranging from 1 to 15 allergens per product, and on average 5-6 measurements per product. In 40% of the products 1 to 4 allergens were detected per product, other allergens analyzed were not present or under the limit of detection. In 60% of the received samples no unexpected allergenic substance was detected. Levels ranged from 0.2 ppm up to 5000 ppm allergen protein/kg food product. The levels of peanut, hazelnut, sesame, cow's milk and hen's egg were all above action levels determined using the Reference Doses. Walnut, pecan nut, cashew nut and celeriac were Clin Transl Allergy 2017, 7(Suppl 1):10 also detected. The severity of the reactions for the 21 products ranged from mild to moderate (Muller score 0-3). In part of the unexpected reactions it was difficult to attribute to a specific food product or allergen. Reasons could be that meals consisted of multiple products, allergens might not be present or are not equally distributed in the food, or the wrong product was provided by patients.

PP050 Unexpected allergens and food products causing allergic reactions in daily life
Conclusions: Levels of unexpected allergen and estimated doses taken by patients did not exceed the Reference Doses for precautionary labeling as described in Taylor  Introduction: Hen's egg (HE) allergy is one of the commonest food allergies in young children with a natural history to resolve, although recent evidence suggests a greater prevalence and more persistent nature. Treatment strategies of allergen avoidance anticipating that the child will grow out of the allergy are being replaced by interventions like oral immunotherapy (OI). The recipes used in HE OI are however in forms of egg not commonly ingested and are therefore considered experimental and not suitable for widespread clinical application.

Methods:
We developed a recipe of baked egg biscuits for use in HE OI and implemented a home-based slow up-dosing programme. Five recipe stages were provided to create enough doses to allow gradual increases in allergen exposure. Eligible subjects were recruited at routine allergy clinic visits. Persisting HE allergy was confirmed mostly by recent contact symptoms or, if not, by a positive baked egg challenge. As allergic symptoms are frequent in OI, families had ready access to dietetic advice on dosing and symptom treatment. Results: Fifteen subjects (9 boys) age from 6 to 17 years (median 11 years 2 months) were treated. Eight achieved full tolerance (equivalent to one egg), 5 became partially tolerant allowing them to include dietary traces and 2 failed. Allergic symptoms during OI were mild with oral pruritus, abdominal pain, nausea and vomiting and urticaria or eczema flares, successfully treated with antihistamines.

Conclusions:
We have demonstrated the efficacy and safety of a HE OI programme using an easy-to-make baked egg recipe. As the biscuit form of egg presentation is widely ingested, we propose the recipe to enable HE OI be more widely clinical available. Introduction: Allerg-e-Lab is a semantic web service initiative for the documentation and exchange of information related to food allergies. The data dictionary-controlled medical vocabulary is essential to identify and characterise the semantic relationship of variables and is key to interpreting data. This study will analyse and compare existing standard terminologies used to describe oral food challenges, and develop a structured approach to collating meta data required for modelling dose distributions from clinical data from double blind placebo controlled food challenges. Methods: Data harmonization -integrating data into the Allerg-e-Lab is a five step process which is being based on the DataSHaPER approach (quality, quantity, and harmony) used for bio clinical studies. The data annotation tools (software and user interface) are being used to annotate data, attaching metadata, and referring to terms from a controlled vocabulary for importing EuroPrevall and iFAAM study data sets into the Allerg-e-Lab platform. Results: The initial focus for developing the EuroPrevall-iFAAM data dictionary has been to develop a controlled medical vocabulary which describes the protocols and clinical symptoms recorded during food challenges undertaken in the EuroPrevall-iFAAM studies. Differences in protocols and definitions between the two projects will be described, and their application to developing data sets to allow comparison in the development of dose distributions based on pooled data described.

Conclusions:
The EuroPrevall-iFAAM data dictionary will be implemented within the Allerg-e-lab environment and used to investigate the effect of age on threshold dose distributions for peanut, egg and milk from the EuroPrevall and iFAAM projects. Results: 75 cases were included in the study. Only 5 had not introduced any form of egg; 4 of these due to refusal by the child. Almost 50% deviated from provided instructions. 41 (54.7%) reported a reaction during home challenge. 35 (46.7%) had immediate reactions with n = 17 given an anti-histamine, and 1 patient seen by a GP. 6 reported worsening eczema. Only 1 subject had a severe reaction. 60% of patients introduced egg in forms less baked than cake or muffin, such as pancake, egg pasta, egg noodle and hardboiled egg. 54.7% stated that finding time to bake goods was a barrier to introduction. More regular ingestion of egg was associated with greater success. The number of egg products in the diet was directly associated with increased peace of mind socialising, reduced worry and increased meal options. Home introduction of egg containing products at an earlier age may be important. The process is associated with allergic reactions, primarily mild. Increased egg introduction appears to improve aspects of QoL. Simplifying challenges to include bought produce needs to be considered. Conclusions: Home introduction of egg containing food in a step by step manner is achievable and allows for provision of options for children, more appealing to parents than cake. , and tree nuts (16.1%); 9 patients were allergic to foods from more than one group. Reactions were immediate in 20 (95.2%) cases and 12 (57.1%) presented as anaphylaxis. Two (9.5%) patients confessed to be not fully avoiding foods from the sensitizing group and one had recurrent allergic reactions (oral allergy syndrome); 7 (33.3%) patients admitted not always carrying their emergency medication and 1 had already needed it. Eleven (52.4%) patients stated that they had changed their vacation plans due to FA. Five (23.8%) referred to never or rarely reading food labels and 4 (19.0%) patients had a food allergic reaction following accidental exposure. Five (23.8%) referred to have increased monthly expenses due to FA and another 10 (47.6%) felt somehow impaired by their FA. Interestingly, all patients mentioned to be more confident with the diagnosis and management after an Allergist's evaluation. Food allergy continues on the rise. The negative practical and psychological impairment associated with FA in both adults and allergic-children caregivers has been recently assessed. A negative impact on daily life was also evident in our patients and this needs to be addressed in order to improve disease management in all aspects. In this group, half of them admitted to changing vacation plans; almost one quarter had increased expenses because of their FA; almost one-fifth had a reaction following accidental exposure and almost half admitted feeling somehow impaired by their FA. All of the patients stated feeling more confident after consultation with a specialist.

Conclusions:
The scope of an Allergist should also include helping patients cope with FA and reduce its interference in daily life.  Our aim was to develop and validate a real-time, multilingual, onlinebased reporting system to capture real-world circumstances and determinants of food-allergic incidents across Europe.

Methods:
The Allergic REACTions (AlleREACT) is an international community-based intervention using a prospective multi-site design. Adults, adolescents and parents of children with food allergies in the UK, Ireland, Germany, Spain, France, Belgium and Poland will report food allergic incidents using a validated online reporting tool between April-December 2016.

Results: Following experts' consultations and Patient Organisations'
(POs) workshops, a short version of a previously validated reporting tool 'Allergic Reactions in the Community' (AlleRiC) was adapted for international use. The new measure has already been tested online and piloted in the English language by adults and parents of children with food allergies (N = 37). Translation and back-translation have been completed in German, Spanish, French and Polish and the system has now been launched. The resulting tool "AlleREACT'" is a comprehensive (42 items), user-friendly and takes only 10 min to complete.

Conclusions:
AlleREACT builds on e-Health and community-based research frameworks. It will provide novel findings in areas not previously researched in depth, and promote understanding of food allergic incidence with implications for risk assessment and risk management across Europe. It is intended that the tool will be used by patient groups and individuals within the community and managed by POs from participating countries.  (Table 3). Information about current milk consumption and side effects to milk were collected from 63 patients between January to April 2016 with a questionnaire, phone calls, or from medical records (Table 4). Results: At the 1-year follow up visit, 51 (76%) patients consumed milk daily (Fig. 6) and 23 (45%) of them reported side effects to the milk. The side effects were mostly mild and they required no medication  or only antihistamine. One patient had an anaphylactic reaction during the OIT build-up phase. After the reaction, the patient continued OIT and is now consuming 5 dl milk a day without reporting any side effects. At the 7-11 years follow-up, 48 (72%) patients consumed milk daily (Fig. 6) and 18 (38%) of them reported side effects to milk during the last 12 months. Side effects were mostly mild requiring no medication, or only antihistamine, but two patients reported using adrenalin to allergic reaction after consuming milk. Information about side effects was not available for 6 (13%) patients. Five patients, who were previously consuming milk, had discontinued its consumption because of the symptoms. However, two of them recently had a negative oral food challenge (OFC) to milk. Five patients who previously failed in milk OIT, and were on a milk-avoidance diet, consumed milk at the long-term follow up. They had started using small amounts of cheese daily by escalating doses or had a negative OFC to milk or had started milk OIT again. Our results suggest that performing a longterm follow-up after milk OIT is important, irrespective of the outcome of the OIT. Conclusions: After milk OIT, the milk consumption can change over time and allergic reactions may appear even after 7 years or more of daily milk consumption.  Introduction: Children and adolescents with food allergy are the group most at risk of serious and fatal reactions from accidental ingestion of an allergen. Ways in which they cope with their food allergy could explain this increased risk. A systematic review was conducted of published papers looking at coping strategies used by children and adolescents with food allergy to explore current knowledge and identify gaps for future research. Methods: Electronic searches were conducted using the following databases: MEDLINE, PsycINFO, SCOPUS, Science Direct, Web of Science. Papers including data from participants aged 8-16 years old with a food allergy or hypersensitivity were retrieved and analysed. Thematic analysis was used to synthesise the findings. Results: Twelve studies were selected from 4672 papers after a review of abstracts and full texts. These papers underwent data extraction, quality appraisal and thematic analysis. Six key themes were identified: (1) Coping with risk (2) Using auto-injectors (3) Education, knowledge and understanding (4) Social support (5) Taking responsibility and (6) Coping with emotions. Adaptive coping strategies were identified such as problem-solving and planning; maladaptive coping strategies such as mental or behavioural disengagement were also apparent. Education and knowledge regarding allergies and its treatment varied and influenced how well patients coped, as did attitudes towards the allergy. Social and peer support was important for coping but can be limited for children and adolescents with food allergy. Many felt that their needs were not fully understood, even at school, and some felt pressured by peers or social situations to ignore the risks. Coping with food allergy by children and adolescents is a complex multifaceted process and the type of strategy used is dependent on the individual's perception of risk, the situation or environment they are in, the influence and attitude of others, and the individual's age and gender. Participants in the review were mainly teenagers; therefore further research on how younger children cope with food allergy is needed. Conclusions: Ways of teaching adaptive coping strategies from point of diagnosis need to be investigated. The impact of social influences should be considered when supporting this population particularly as they get older, with age-appropriate strategies that facilitate confidence in being able to cope with and manage their food allergy. Introduction: This general population based RCT aims at answering two major hypotheses: First, systematic early introduction of solid foods decreases the incidence of food allergy and dietary restrictions by the age of one year. Second, stimulation with the symptom-eliciting food rather than avoidance will induce tolerance in babies with non-severe allergic symptoms. Methods: All new born babies living in the city of Oulu are recruited to the study (n = 1380) at their first health nurse visit (at or before 1 month of age) in the local primary care child health clinics. Families in the intervention group will get an instruction booklet including information on early systematic introduction of solid foods starting at the age of 4 months, with foodstuff from all major groups in diet by the age of 6 months (vegetables and fruits, wheat and other grains, meat, fish, egg, dairy products). Furthermore, the booklet includes information and instructions on food related symptoms and atopic eczema. Babies with mild symptoms are encouraged to continue the symptom-eliciting food. All families fill out monthly internet-based questionnaires on food diary, symptoms, diagnoses and health care visits until the age of 1 year. Dietary restrictions and food allergy diagnoses are verified at the age of one year. The primary outcome measures will be the incidence of diet restrictions, parentreported and doctor-verified food allergies and atopic eczema by the age of 1 year. The secondary outcomes will be the need for health services and the family experienced distress during the first year of life.

Results:
The study has started in March 2014. Currently, 1317 babies have been recruited and 645 children have completed the entire study by the end of April 2016. According to the preliminary data from questionnaires at the age of 6 months, 70.6% of 425 children in the intervention group and 74.1% of 444 children in the control group were still on breast-feeding (p = 0.256). Furthermore, 45.9% of children in the intervention group and 23.3% in the control group (p < 0.001) had 2 or more potentially allergenic food (wheat, egg, fish or fermented milk products) in their diet before the age of 6 months.

Conclusions:
The study protocol seems to be feasible at a population level and does not affect the rate of breastfeeding during the first 6 months of babies. INTO-study will provide invaluable data on earlyfeeding strategy in primary and secondary prevention of food allergy. Introduction: Egg and milk allergy is the main food allergy in the paediatric population in our country. In recent years, as an alternative to egg and milk avoidance a novel and promising treatment has appeared consisting in induction of oral tolerance. Allergenic food doses are increased progresively from a minimun amount of egg/milk. Doses are increased in the hospital and the same dosis are maintained at home. The procedure is not free of risk even when doses are taken at home. We aim to evaluate the adherence to desensitized food doses and patient safety at home. Methods: One-hundred and twenty patients treated by specific oral tolerance induction (SOTI) to milk or egg from two hospitals were invited to fill an anonymous survey via web. Similar recommendations were given to the patients under SOTI in these two hospitals and fulltime access to anallergist was available by e-mail or telephone. Survey asked about adherence to treatment, cofactors avoidance and confidence about treating reactions at home. Results: 109 patients answered the survey. 70% of the patients never forgot to take the dose. Whereas 82% never forgot to take premedication (antihistamines), 40% forgot to take asthma medication. Most of the patients always avoided cofactors (89% avoided fasting, 90% NSAIDs, 78% exercise) and 88% of the patients were correctly monitored after taking the doses always. However, regarding reactions at home, at least in one reaction, 53% of the patients did not know if the reaction suffered should be treated and 26% did not know the type of medication required for that reaction. Most of the patients showed good adherence to the treatment and correct cofactors avoidance however, patients do not feel confident when a reaction occurs. Conclusions: Patients need to be teached in managing reactions before starting a food SOTI.

Introduction:
This study investigated the effects of a new amino acidbased formula (AAF) with pre-and probiotics (synbiotics) in infants with suspected non-IgE mediated CMA. Methods: In a prospective, randomised, double-blind controlled study (registered as NTR3979), infants with suspected non-IgE mediated CMA were enrolled to receive either an AAF (control n = 36) or an AAF with synbiotics (oligofructose, long-chain inulin, Bifidobacterium breve M-16 V) (test n = 35) for 8 weeks. Faecal samples were collected at baseline and weeks 8, 12 and 26 after initiation of dietary management. Faecal samples from non-randomized healthy breastfed infants, which were age-matched with CMA infants at wk 8 of intervention, were collected as a reference group. Primary outcomes were bifidobacteria and the Eubacterium rectale/Clostridium coccoides group (ER/CC) as percentage of total faecal bacteria determined by fluorescent in situ hybridization. To monitor intestinal inflammation and immune status secondary and exploratory outcomes included faecal Calprotectin (FC) and Eosinophilic Cationic Protein (ECP) and faecal α1-antitrypsin (A1A). Results: Average age (±SD) of CMA infants (n = 71) was 6.00 ± 2.98 months at inclusion of the study and 7.84 ± 3.25 months in the reference group (n = 51). Of the CMA subjects, 90% presented predominantly GI symptoms and 10% dermatological symptoms; stratification was based on these manifestations. Sixty CMA infants completed the 8 weeks intervention (control n = 32; test n = 28). Using the intention-to-treat data set and ANCOVA technique, levels of bifidobacteria at 8 weeks were significantly higher in the test (35.6%) vs. control group (14.7%) (p < 0.001) and ER/CC was significantly lower in the test (12.1%) vs. control group (26.6%) (p < 0.001). Determined bacterial proportions in the test group were close to levels observed in the healthy reference group. Median FC and A1A were lower in week 8 compared to week 0, but were not significantly different between groups at week 8 (p = 0.815 and p = 0.717, respectively). Additional outcomes, including healthy reference data, will be presented. Conclusions: This study shows that an AAF with specific synbiotics significantly affects the gut microbiota composition of non-IgE CMA infants. Determined bacterial proportions in the test group were close to levels observed in the healthy reference group. Median levels of FC and A1A decreased in both study groups at week 8 of intervention. Introduction: Food allergy (FA) has a significant impact on the patient's quality of life, namely on travelling. We aimed to assess the ability of the commercial airlines to support passengers with FA. Methods: A worldwide commercial airlines on-line survey, including 841 companies, from 216 countries, addressing their preparation to support passengers with FA was performed. A total of 721 airlines were reached by 2 reminders (3 refuse to participate and contact failed with 117). Additionally, the Top 100 Airlines, according to the World Airlines Awards 2015, were contacted to reply to a simulated reservation for a passenger with FA addressing staff training, the availability of special meals for FA on board, and the possibility to travel with their own food and medication. The information available on the airline's website was also analysed. Statistical analysis included descriptive statistics. Results: 3 out of 721 companies completed the survey and reported to have trained staff to deal with emergencies and no restrictions for travelling costumers with FA concerning to food or medication carrying. From the remaining, 713 failed to reply and 5 reported not being able to provide requested information. Considering the simulated reservation, 22 out 100 replied. Six reporting to have the information on their website, 8 having special food allergy menus, 2 staff training for emergencies, 9 allowed passengers to carry their epinephrine injector; 11 allowed to bring food and 8 highlighted that cannot guarantee allergen-free flights, regarding the risk of cross-contact. Concerning the Top 100 website information, only 4% mention that the flight crew are trained, 67% have special FA menus, 40% recommend the carriage of medication and 26% refer it is possible to carry food on board. Conclusions: Most of the commercial airlines are not prepared or even warned about the impact of an in-flight allergic reaction. Our results aware for a priority on airline's education and training in FA order to increase the family's confidence to travel and afford the life safety on board. Introduction: Food allergy is a growing problem in the school aged children It is a common cause of anaphylaxis [1], with an estimation of 1 in 25 children at school affected [2]. Surveys indicate that 16 to 18% of children with food allergy experience a reaction in school [3,4]. In UAE, 8% of children suffer from food allergy [5]. The objectives of this study was to look for School readiness to treat anaphylaxis to food allergy, how are they managed, and to identify any scope for further improvement. Method: Data was collected retrospectively from schools in Sharjah, A validated questioner (on epinephrine administration) was distributed in English and Arabic to all Schools which was filled by the School clinic nurse /doctor for those children's who encountered life threatening reactions to food and required epinephrine administration during 2013-2014. 33 out of 80 schools in Sharjah completed the epinephrine administration form. An official approval from Ministry of Education, Sharjah was obtained for this study. Results: Eighty schools in emirate of Sharjah have been invited to participate in the survey 33 schools responded by filling up the questioner. The survey showed the following results: • Number of the schools that have Epi pen available: 3 schools (9%).
• Number of the schools that have emergency response activated team: 3 schools (9%). • Number of food allergy cases reported 14 cases; 2 cases were managed with Epi pen adminstration, and 12 cases were managed with antihistamines and transferred immediately to hospital as epi pens were not available. Clin Transl Allergy 2017, 7(Suppl 1):10 Time required for treatment of the two cases treated with Epi pen was within 3to 5 min, one given by the student and the other by the school doctor. Conclusions: Our survey showed that Anaphylactic reaction in schools are not uncommon. Management of such cases need clear policies to recognize and treat allergic reactions and anaphylaxis. Epi pen availability, food allergy action plans and school nurse training and education are vital to ensure the safety of such children. Introduction: This study was performed to identify the critical success factors (CSFs) of an anaphylaxis app to support patients in an emergency situation. Methods: CSFs were identified through a literature study, by analyzing existing anaphylaxis apps and by surveying a sample of patients who visited the website of the Dutch Anaphylaxis Network. An expert interview was used to further reflect upon the findings. Results: Five existing anaphylaxis apps were found, with different features, most were for the UK or US market, available for free or at low costs. The literature presents the following CSFs that influence the adoption of mobile technology for allergic patients: 1. being contextaware through scanning of physical items; 2. automating the retrieval of product-related allergy information; 3. helping to improve the patient's understanding of their condition in general; 4. ensuring medical validation of given advice; 5. being tailored to patient's medications and 6. providing advice in a patient-sensitive manner, based on age and level of experience. The survey yielded 276 responses, 80% was female, mean age of 40.96 (sd = 11.2) years and an average of 9.81 (sd = 7.5) years of experience with anaphylaxis. The desirability of an app to support anaphylaxis patients was rated with an average of 8.34 on a scale of 1 to 10 (sd = 1.8), while the probability of the respondents using such an app was rated with an 8.75 (s = 1.9). Most important features of an app according to the respondents was Clarity of information (6.68); Medical validation (6.62) and Emergency procedure information (6.48). Less important features were Interactivity of the app (4.50); Allergy knowledge quiz (3.33) and use of games (2.66). The expert mentioned that the app should be available at no cost to boost its use.

PP075 Supporting anaphylaxis patients through a mobile application
Conclusions: An app that includes medically validated and clear information on allergy symptoms and treatment procedures has great potential to fill a gap in the support of anaphylaxis patients. Relevance for daily practice. An app in Dutch language will be developed to support patients or caregivers in emergency situations. The app will be patient-tailored, so that a patient can import his own emergency medication and personal information. The main feature is a step-wise approach to cope with allergic reactions. Besides general information about the most important causes for anaphylaxis: food allergy or insect sting allergy will be given. The app will be built in cooperation with Allergy patient's organizations, the Dutch dermatologists' association and the University Medical Centre Utrecht, the Netherlands. Introduction: Nutritional deficiencies have been reported in foodallergic children. The aim of our study was to assess the actual food intakes and nutritional status of children with suspected or proven multiple food allergies when elimination diet was not supervised by continuing dietitian follow-up. Methods: 22 children (8 girls, 16 boys; mean age 5.0 ± 4.1 years) with proven (19 children) or suspected only (3 children) multiple food allergies were studied retrospectively. Twenty children presented with atopic dermatitis, eight with anaphylaxis, two with hives and four with gastrointestinal symptoms. Two children had additional conditions that influenced nutritional status (one cromosomopathia, one histamine intolerance). Nutritional intakes assessment was passed on exact questioning on actual food avoidance. Children's weight, height, laboratory data for nutritional parameters were assessed. Results: In 18 (82%) children additional questioning revealed their diet was extended from advised by physician. Fourteen children (64%) did not eat milk, egg and wheat and in addition numerous variable foods were also avoided in their diets-in nine of animal origin and in twelve of plant origin (most often peanuts and tree nuts). Two children did not consume egg and milk and excluded also some plant and/or animal foods, two children avoided numerus plant foods, one child did not eat cow milk and some plant foods and one child had no special food restrictions. In described group of 22 children the means for anthropometric measures were below the average for age (41.P for height and 35.P for weight). Three children were <−3% for relative height and two children were <−3% for relative weight. Lower serum levels of levels of albumin/iron/zinc/selenium/vitamin B12 were found in 5/8/11/10/1 children, respectively. Three children had osteoporosis and one had osteopenia. Eleven children (50%) had multiple nutritional deficits. Combined diet without cow milk, egg and wheat (14 children) was always associated with nutritional deficits. Conclusions: Multiple food elimination diet (e.g. without cow milk, egg and wheat) has negative impact on nutritional status of foodallergic children if not supervised continually by experienced physician and dietitian. Introduction: One of the most important implications of a multiplex assay such as ISAC assay should be its ability to distinguish between allergy and asymptomatic sensitisation due to cross reactivity which could ex. influence the decision for performing a food/latex challenge in children with multiple allergies. Methods: Test results of food and latex recombinants in 53 ISACs were retrospectively analysed and compared in allergic versus tolerant Clin Transl Allergy 2017, 7(Suppl 1):10 children. Allergy was confirmed by typical clinical history and determination of specific IgE/skin prick test, by provocation test or by very high values of specific IgE/skin prick tests. When analysing potential cow's milk/egg/soy/wheat/peanut/hazelnut/fruit/latex allergy 1/2 /8 /1 /14 /15 /3 /3 children were excluded because of unknown clinical allergic status (e.g. waiting/refusing provocation test). Results: 12 egg allergic children had significantly higher specific IgE to nGal d 1, nGal d 2 and nGal d 3 than 39 egg tolerant children (p < 0.0001). 12 cow's milk allergic children had significantly higher specific IgE to nBos d 4, nBos d 5 and nBos d 8 than 40 cow milk tolerant children (p < 0.0001). 16 peanut allergic children had higher specific IgE to rArah 1, n/rArah 2, n/r Arah 3, nArah 6, rArah 8 and rArah 9 than 23 peanut tolerant children (p from <0.0001 to < 0.05). 14 hazelnut allergic children had higher specific IgE to rCor a 8 and rCor a 9 than 25 hazelnut tolerant children (p = 0.006 and p = 0.0009, respectively) and significantly lower specific IgE rCor a 1 than hazelnut tolerant children (p < 0.0001). Three soy allergic children had significantly higher specific IgE to nGly m 5 and nGly m 6 than 42 soy tolerant children (p < 0.001 and p = 0.003, respectively). Two wheat allergic children differed from 50 wheat tolerant in rTri a 19, rTri a 14, tTri a aA_TI (p from < 0.001 to< 0.05). 6 children with anaphylaxis to different fruit had significant higher n/r Pru p 3 than 25 fruit tolerant children (p = 0.03). 18 children with OAS associated with fruit had significantly higher specific IgE to rPru p 1, rMal d 1 and rApi g 1 than 25 fruit tolerant children (p < 0.0001). Four children allergic to latex had significant higher specific IgE antibodies to rHev b 6.01 than 46 latex tolerant children (p = 0.005). Conclusions: ISAC differentiated allergic from tolerant children when analysing recombinants of cow's milk egg, peanut, hazelnut, soy, wheat, fruit or latex.

Introduction:
To describe the frequency and evolution of esophageal eosinophilic infiltration in patients with cow's milk protein allergy (CMPA) submitted to oral desensitization. Methods: A descriptive study involving pediatric patients with CMPA submitted to desensitization protocol from 2012 to 2016. This protocol included daily intakes of increasing diluted amounts of cow milk until 120-200 ml of non-diluted milk. The mean initial dilution was 10 −7 and the average time of progression from diluted milk to non-diluted milk was 3 months. Patients reported symptoms daily, and when persistent gastrointestinal symptoms occurred, endoscopy was performed. Abnormal findings (endoscopy and histology) suggestive of eosinophilic infiltration (eosinophils ≥15HPF) demanded appropriated treatment with proton-pump inhibitor (PPI) for 8 weeks. Swallowed topical corticosteroids (STC) was initiated if inadequate response. Results: 19 patients were enrolled (11 F: 8 M), mean age of 10,25 years at baseline. All patients had previous history of anaphylaxis and positive specific IgE to cow milk and casein. Nine patients (9/15) presented specific IgE levels to cow milk and casein higher than 100 kU/L. Five patients developed gastrointestinal symptoms during treatment, all of them receiving non-diluted milk being abdominal pain the most frequent complaint, followed by vomiting and dysphagia. All patients had abnormal macroscopic findings, and increased eosinophils (mean = 20 HPF Eo). Four patients (P1, P2, P3, P4) received PPI as initial therapy, and one patient lost follow up (P5). Endoscopy was repeated and eosinophils were normal in two patients and clinical symptoms disappeared (P1, P2) but symptoms returned in one (P1). Another patient had milk excluded (P3) and P4 is waiting second endoscopy. STC was necessary in two patients with distinct evolution (P1, P3). One patient kept milk ingestion and STC (P1) and the other persisted with endoscopic abnormalities despite milk exclusion and STC treatment (P3).

Conclusions:
Esophageal eosinophilic infiltration is a described complication in patients submitted to oral desensitization, but it seems more prevalent in patients with severe allergy and presents different outcomes. It is necessary continuous follow up of these patients for long periods to understand the disease and provide the best management. Introduction: Vitamin D is known for its role in the bone metabolism but it also has immune-modulatory properties. Most of the evidence points towards a causal relationship between low vitamin D levels and the development of asthma and allergies but the results are not conclusive. We studied the vitamin D levels of patients who presented to our hospital with anaphylaxis with or without asthma and compared it to previously published vitamin D levels in Saudi population. Methods: All patients given new Adrenaline auto injector prescriptions for anaphylaxis between the periods of 1/1/2010 and 31/12/2011 were included in this study. Their medical records were also screened for diagnosis of asthma.

PP084
Results: A total of 238 patients were identified. Data about Vitamin D level was available for 121 of those patients. 84 out of these 121 patients were also being treated for asthma. There was no evidence of any difference in vitamin D levels between those with or without asthma presenting with anaphylaxis. Vitamin D levels compared in patients with anaphylaxis to the general population revealed that while there was no significant difference in terms of vitamin D deficiency, patients who presented with anaphylaxis had a higher chance of either having a normal or higher than normal vitamin D level. Conclusions: When compared with the general population, patients with anaphylaxis have more chance to have normal vitamin D level. Vitamin D deficiency was not found to be a significant risk factor for anaphylaxis in our patients compared with the general Saudi population. We therefore developed an adjuvant-free mouse model of ASA, and compared pathways of anaphylaxis in this model vs. in an ASA model using adjuvants for sensitization. Methods: Mice were sensitized intra-peritoneally (i.p.) with ovalbumin (OVA) at weekly intervals for 6 weeks (adjuvant-free ASA model), or once i.p. with OVA together with Alum and Bordetella pertussis toxin (ASA model using adjuvants). Mice were then challenged i.p. with OVA two or three weeks later, respectively. Results: Wild-type (WT) mice developed immediate hypothermia in both models, but significant mortality was only observed in the ASA model using adjuvants for sensitization. Depletion of monocytes/macrophages with clodronate liposomes significantly reduced anaphylaxis in both models. Depletion of neutrophils using anti-Gr-1 antibodies reduced anaphylaxis in the ASA model using adjuvants, but had no effect in the adjuvant-free ASA model. By contrast, anaphylaxis developed in mast cell-deficient Kit W-sh/W-sh mice in the ASA model using adjuvants, while it was markedly reduced in both Kit W-sh/W-sh mice and Cpa3-Cre; Mcl-1 fl/fl mast cell-deficient mice in the adjuvant-free model. Finally, we found that combined treatment with the anti-histamine triprolidine and the platelet-activating factor (PAF) receptor antagonist CV-6209 almost entirely blocked anaphylaxis in the adjuvant-free ASA model. Conclusions: Our data demonstrate that components of both the "classical" and "alternative" pathways contribute to anaphylaxis in the adjuvant-free ASA model. Monocytes/macrophages contribute to anaphylaxis regardless of the presence or absence of adjuvant during the sensitization, but the use of adjuvant in effect masks any non-redundant contribution of mast cells while revealing a contribution of neutrophils. During the anaphylactic episode, 12 (57.1%) patients presented a de novo increase in peripheral relative and absolute neutrophil counts (mean ± SD: 85.8 ± 5.9% and 13.8 ± 7.1 × 10 −9 /L, respectively), 8 (66.7%) also with leucocytosis; 5 (23.8%) patients had a fall in blood neutrophils. Two (9.5%) fatal outcomes occurred (1 with neutrophilia). The limited sample size may be explained by the decision of including only hospitalized patients, fact that may justify the greater percentage of anaphylactic shock. Our analysis revealed clear reduced tryptasedosing rates and adrenaline underuse. Although it is the common understanding that anaphylaxis associates with blood neutropenia, an increase in systemic neutrophils has been previously described in nonhuman anaphylaxis models and changes in blood-leukocyte populations were pointed as possible markers for severe shock in mice.

Conclusions:
To the authors' knowledge this is the first study to describe the occurrence of systemic neutrophilia in humans in the context of anaphylaxis. Despite the limited sample size, our study is ongoing and the authors believe that this is a promising field of research in understanding the complexity of anaphylaxis. The training of teachers is important along with videos and protocols which explain simply how to recognize and treat an anaphylactic reaction.

Introduction:
The iFAAM project is investigating whether the passage of allergen into the circulation may contribute to determining the severity of an allergic reaction by comparing uptake in healthy individuals and individuals undergoing oral food challenge. A mass spectrometry based method to detect the presence of peanut allergens in serum samples is being developed which will allow confirmation of peanut allergens in serum identified by other methods such as immunoassay and mediator release. Methods: A set of heavy labelled tryptic peptide targets for detection of peanut allergens Ara h 1, Ara h 3 and Ara h 2, 6 and 7 have been used to develop a targeted mass spectrometry (MS) method using multiple reaction monitoring, for detection of peanut in serum. Using serial isotopic dilution (SID) series and blank serum spiked with a peanut protein extract, initial validation studies have been undertaken exploring the use of different depletion methods to remove the most abundant serum proteins. MS analysis has made use of different TOF and triple quadrupole platforms. Results: Undepleted serum samples had a marked matrix effect on SIDs, likely due to the presence of other serum peptides causing suppression effects on peanut peptide ionisation. These effects were less marked in depleted serum samples. Analysis of peanut spiked into blank serum and analysed after depletion showed differential matrix effects, with some peanut peptides having been lost during the

Introduction:
The objective was to understand and evaluate patient characteristics, concordance with post discharge care, health care resource utilization and repeated events among adults and children with an inpatient or Emergency Department (ED) claim for food or non-food induced anaphylaxis in the United States. Methods: For retrospective analysis the Truven Healthcare MarketScan ® Commercial and Medicare Supplemental and COB Databases was used to (1) identify the patient profiles with inpatient or ED claims for anaphylactic shock, stratified to food-based allergic reactions and to allergic reactions due to non-food or unknown causes; (2) examine the event characteristics and healthcare resource use (HCRU) related to the event and (3) assess Epinephrine Auto-Injector (EAI) prescriptions pre-and post-event and the HCRU associated with these prescriptions.

Results:
The study comprised 10,189 adults (age >18) and 3891 pediatric patients (age <18). Those patients treated in the ED present with acute respiratory failure (3.8%), hypotension (5.0%), and in rare cases cardiac arrest (0.3%). While in the ED, intervention included resuscitations (25.4%), intubation (1.6%), tracheostomy (2.0%), epinephrine administration (13.2%), and cardiopulmonary resuscitation (0.1%). 11.7% of patients seen in the ED were admitted to inpatient care and spent 2.7 days on average in the hospital. At the time of the index event 83.3% of patients did not have a prescription for an EAI filled. Only 12.1% of patients had the minimum of 1 EAI prescription refill. The mean number of days from last prescription to anaphylactic event was 2350 days. A significant portion of patients are transitioned to inpatient care from the ED resulting in greater healthcare utilization.
The data indicate that patients demonstrate suboptimal maintenance of EAI prescriptions placing them at risk for life threatening events and questioning the preparedness of patients and caregivers for the management of an anaphylactic event. Given the low active prescription level it appears patients are not proactively prepared for an anaphylactic event which may lead to costly ED visits and hospital admissions. Conclusions: Current educational programs and safety information delivered to patients and caregivers regarding the use of EAIs to treat anaphylaxis are not effective. Introduction: Oral immunotherapy using IFN-gamma has been done for more 10 years successfully. The dosage modulation of treatment including initial dose and incremental dose for the treatment is absolutely necessary in the clinical field. Dosage modulation is also the issue during the treatment. For these issues, the theoretical and clinical backup is also needed. The aims of this study are the built up the dosage modulation by dosage calibration during oral challenge test and during the treatment for the precise oral immunotherapy using IFN-gamma for anaphylactic food allergy. Also, the theoretical principle is also suggested. Methods: Patients who had anaphylactic food allergy for milk, eggs, soybean and wheat were selected. Basic allergic laboratory tests were done including allergen-specific IgE and skin prick tests. Oral food challenge tests were conducted. Especially, the minimal dose and clinical severity were checked during oral immunotherapy. The initial dose was determined by the minimal dose and incremental dose was determined by the clinical severity. During the treatment, the incremental doses were escalated according to the patient's responses to dosage. The duration and effectiveness of treatment is compared and evaluated between the classic methods and the advanced methods applying the concepts of calibration and modulation of dosage.

Results:
The trial of calibration is proper for oral immunotherapy using IFN-gamma for anaphylactic food allergy. By dosage calibration, the duration and the effectiveness of oral immunotherapy using IFN-gamma was much improve, significantly. By dosage increment, the incremental dose was escalated exponentially. The basic theory of oral immunotherapy using IFN-gamma is depending on the tolerogenic effects of IFN-gamma. The allergy provocation strength should be within the range of tolerogenic effects of IFN-gamma. During oral immunotherapy using IFN-gamma for anaphylactic food allergy, patients were getting tolerance for last therapeutic dose. The meaning of allergy provoking dose and strength did not follow the absolute dose. The allergy provoking dose seems to be the dose of difference between the therapeutic dose and tolerable dose.  (6), nonsteroidal anti-inflammatory drugs (15), acetaminophen (4), local anesthetics (1), proton pump inhibitors (1) and angiotensin 2 receptor antagonists (1). The suspected drug was confirmed in 6 cases and excluded in 3; 12 pts are still under investigation and 22 were lost to follow-up. Suspected foods were fresh fruits (13), seafood (11), fish (3), nuts (4), milk (2), seeds (4), spice (2), wheat (2) and honey (1)-suspected etiology was confirmed in 24 cases, excluded in 9 and under investigation in 3; 7 cases were lost to follow-up. In 3 pts with both etiologies suspected, only one of them was confirmed for each (food-2; drug-1). The hymenoptera suspected by clinical history was wasp but we confirmed sensitization to polistes. The investigation in ICM reaction was negative. Regarding the 8 pts with unknown etiology, 4 are being studied, 3 were lost to follow-up and 1 revealed food allergy (LTP sensitization). Overall, from the 92 pts that came to a first appointment after hospital discharge, 42 have a confirmed anaphylaxis's etiology; 32 pts were lost to follow-up.
Conclusions: Long-term management of patients who experienced anaphylaxis may be long and time-consuming but it's crucial to identify the etiologic agent in order to avoid the culprit and minimize the risk of further reactions. In our cohort more than half of the pts doesn't have a confirmed culprit allergen, mainly due to a high dropout rate. Introduction: Anaphylaxis to paracetamol is rare and the underlying mechanisms are poorly understood. We aimed to review the cases of anaphylaxis to paracetamol in our Drug Allergy Unit (DAU) in the last five years. Methods: The authors did a retrospective analysis of all cases of anaphylaxis to paracetamol studied in our DAU between January 2011 and December 2015. The data were analysed using SPSS, version 21. Results: Twelve adult patients with anaphylactic reaction to paracetamol were studied (67% males, aged 18-72y), 25% had allergic respiratory disease. All patients were medicated with oral paracetamol for pain relief. Six patients also had anaphylaxis to nonsteroidal anti-inflammatory drugs (NSAID's): acetylsalicylic acid (n = 4), ibuprofen (n = 3), naproxen (n = 1), nimesulide (n = 1) and diclofenac (n = 1). Nine patients had immediate reactions (75%), and 3 (25%) late reactions (onset 3-12 h). Eleven patients (92%) had mucocutaneous involvement, 11 respiratory manifestations, 3 (25%) cardiovascular and 1 (8%) gastrointestinal. None had anaphylactic shock. Only 8 (67%) patients were admitted to the emergency department (ED), none was treated with adrenaline nor had tryptase determined. Because the in vivo work up of these patients is very limited, they all underwent an oral challenge (OC) with an alternative drug (etoricoxib) and tolerance was confirmed.

Analysis of 150 anaphylaxis episodes
In the 6 cases of multiple-reactors, the authors postulate an underlying COX-1 inhibition mechanism since paracetamol is a weak inhibitor of COX-1.In the cases of single-reactors (SR) IgE-mediated mechanisms may be involved. A possible explanation for the late anaphylaxis (12 h) in a SR is COX-1 inhibition; alternatively, IgE involvement may be considered if this "late anaphylaxis" is in fact the late manifestation of a bifasic response. The in vitro study of this patient is in progress.

Conclusions:
Paracetamol is a widely used drug, available over-thecounter in most countries, but not entirely without risks. The allergy diagnosis work-up in cases of anaphylaxis to paracetamol is difficult and mostly based on a detailed clinical history. Skin tests are not standardized and positive results are doubtful. In vitro assays such as specific IgE and Basophil Activation Test have poor specificity and sensitivity. Moreover OC with the culprit drug are contraindicated in anaphylaxis.  Introduction: 20 to 30% of infants in Europe are diagnosed with an atopic (allergic) disease. The majority of first atopic responses are directed towards food proteins that are consumed during the first months of life. There is increasing evidence that certain milk-derived components have positive effects on infant health. Ongoing research in this area has identified immunomodulating ingredients (milkderived hydrolysates) which have potential to support the immune system in an allergy setting. Hydrolysing the proteins in infant formula is one approach in the management of allergenic responses in infants. These hydrolysed proteins which lack allergenic IgE binding sites can modulate T-cell differentiation away from a Th2 response and decrease inflammation. Our research focus is on identifying hydrolysates that can be added to infant formula to ameliorate cow's milk allergy. The aim of this study was to identify milk protein hydrolysates (peptides) with (anti-inflammatory/anti-allergy) properties using an in vitro approach. Methods: To that end, hydrolysates were screened for their immunomodulatory properties in 4 cellular models, human peripheral blood mononuclear cells (PBMC), human monocyte dendritic cells (DC), T helper 1 (Th1) polarised and Th2 polarised cells. Specifically, T cell proliferation was analysed, before and after the addition of hydrolysates using a CFSE assay by flow cytometry and cytokine levels, released in the culture supernatants were measured by ELISA. DC maturation and cytokine production were also examined by flow cytometry and ELISA. Naïve human CD4 + T cells were activated with plate-bound anti-CD3 and anti-CD28 and then cultured under Th1 or Th2 polarising conditions with or without hydrolysates for 4 days. Transcription factor expression was then assessed by flow cytometry. Results: A number of hydrolysates significantly decreased T cell proliferation driven by anti CD3/CD28 beads and several downregulated the maturation marker CD86 in DCs. Select hydrolysates increased the expression of T-bet and Gata-3, decreased production of the pro-inflammatory cytokines IFN-gamma and IL-6 and increased antiinflammatory IL-10. Conclusions: Thus far we have identified a number of hydrolysates which promote an anti-inflammatory /anti-allergy T cell and DC phenotype. Further work will examine these hydrolysates in an in-vivo humanised mouse model of allergy in order to confirm their protective impact.

Recurrent anaphylaxis in a patient with LTP syndrome
Acknowledgements: Funding code: TC2013-001.

PP104
Serum tryptase measurement is useful to assess clinical positivity of oral food challenge to hazelnut in children Nelly  Methods: In order to identify FAQLQ items that are reported most frequently and have the highest impact for peanut allergic patients, we used previous data from the development of the FAQLQs. We calculated frequency, percentage, mean importance and overall importance of individual FAQLQ items in peanut allergic patients and non-peanut allergic patients. In order to identify peanut-specific FAQLQ items that are sensitive to change, the data of the longitudinal validation of the FAQLQs (HRQL following a double blind placebo controlled food challenge) were used in a comparison of peanut allergic and non-peanut allergic patients and tested for significance (p < 0.05). Results: In general, peanut allergic patients reported a higher overall impact for each item than non-peanut allergic patients. There was 1 item in each FAQLQ that significantly changed following DBPCFC in the non-peanut allergic group compared to the peanut allergic children ("Don't get anything when someone is giving treats at school", −1.06 vs 0.04, p = 0.044), teenagers ("Being careful about touching certain foods", 0.82 vs −0.59, p = 0.016) and adults ("Able to eat fewer products", −1.00 vs 0.30, p = 0.011). Since peanut allergic patients reported higher overall impact scores and only one item differed between non peanut allergic patients and peanut allergic patients for each FAQLQ, this study did not result in peanut-specific FAQLQ instruments.
Conclusions: All parts of the FAQLQ-CF, -TF and -AF are considered to be relevant for peanut allergic patients. Introduction: Around 8% of children suffer from food allergy, worldwide. Children who become aware about the good food safety practices via practical experiences are more likely to perform long-term protective behaviours and may disseminate knowledge to families. Here we describe our workshops aimed to engage primary schools to join an educational experience about allergenic food. The activities were included in the "EXPO 2015 events" host by the municipality of Turin. Methods: We designed the "Allergen Hunt" Workshop as follows: • Welcome telling "The fairy tale about Sabrina" who discovers to be allergic to hazelnut and learns how to manage her allergy. • Presentation of the main allergenic foods.
• "Guess the allergen here inside"-children have to select the right allergen-card that can be hidden in some proposed foods. • "Special cookies"-children are divided in two groups: group A cooks hazelnut cookies (using play dough and green glitter powder as hazelnut flour) and group B cooks coconut cookies (using play dough and gold glitter powder as coconut flour); then few cooks of group A go to help group B and vice versa. • Dissemination of rules on behaviour to prevent cross-contaminations.
Results: From 11th to 15th May 2015, ten primary schools (216 children) joined our workshops: 29.6% of the first class (age: 6 y-o), 40.3% of the second (7 y-o), 18.5% of the third (8 y-o), and 11.6% of the fifth class (10 y-o). All of them knew the word "allergy" for environmental allergens, and many of them had already heard about milk, peach and hazelnut as food allergens. We presented the most frequent food allergens (milk, eggs, wheat, nuts, soybeans, crustaceans, molluscs, fish) among the ones reported by EU Regulation 1169/2011; we chose to add to the list peach, kiwifruit, and sesame seeds because they are usually eaten by children and may cross-reacted with environmental allergens. Younger children showed great interest in the "Special cookies" handling game. "Guess the allergen here inside" did unexpectedly excite older and younger children: most of them answered correctly and were aware about the presence of milk in ham and eggs in hamburgers. Conclusions: Children were interested in learning more about food allergens and in joining the practical experiences we proposed. Participants were often competent, sensitive to food allergy topic and interested to know the rules to manage food allergy and to reduce contamination during food handling and preparation. Introduction: Studies showed that teachers' competences for managing children at risk of anaphylaxis or children with food allergy in kindergartens and schools are poorly developed. The purpose of this study was to explore how short theoretical and practical intervention programme influence on pre-service teachers' knowledge about allergy and anaphylaxis. Methods: 62 post-graduate pre-service primary and lower secondary school teachers (all female; median age 24.5) participated in the study. 27.4% of pre-service teachers reported that they are allergic themselves. Participants were exposed to 90 min theoretical (about allergy and anaphylaxis) and practical (using adrenalin auto-injector) educational intervention. Participants answered the Teachers' Health Competences Development-Anaphylaxis Management Questionnaire (THCDAMQ) which comprised knowledge items about anaphylaxis (Max 7 points) and attitude items on managing children's anaphylaxis three times, before intervention, immediately after and 14 days after the intervention. Results: Pre-service teachers showed positive attitudes towards learning more about different children's health issues (91.9%). All of them expressed that child health topics were very important for each teacher and all wanted to increase their health competences. 90.3% thought that teacher is responsible for pupils' health issues during school time. 71% reported that they haven't been exposed to any activities that would promote their health competences development.

PP113 Psychological impact of open food challenges in adults
The results of the Friedman Test indicated that there was a statistically significant difference in THCDAMQ scores across the three time points (pre-intervention, post-intervention, 14-days follow-up χ 2 (2, N = 37) = 48.127, p ≤ .000). Inspection of the median values showed an increase in total scores on items that test post-graduate pre-service teachers' knowledge about anaphylaxis from pre-intervention (Md = 3; IQR 2-4.5) to post-intervention (Md = 6; IQR 6-6) and a follow-up (Md = 6; IQR 6-6) scores. Conclusions: Intervention anaphylaxis programme had positive effect on students' knowledge and attitudes towards school child allergy. Students retained their knowledge after intervention. Pre-service Clin Transl Allergy 2017, 7(Suppl 1):10 The FLG effect increased with the number of organ systems involved suggesting an effect on severity of the allergic response.

Conclusions:
Since FLG mutations cause a skin barrier defect, our results suggest a pathway for food allergy similar to that for eczemaassociated asthma, where transcutaneous sensitization through the impaired epidermal barrier is the initializing event leading to localized or systemic allergic responses that may affect distant organ systems. Co-occurrence of food allergy and eczema in early childhood is a common phenomenon. Using our large, well characterized food allergy cohort we demonstrated that FLG mutations confer risk for food allergy beyond their known association with eczema. They predispose to multi-organ involvement during allergic reactions, and should thus be considered when assessing anaphylaxis risk. Clin Transl Allergy 2017, 7(Suppl 1):10 symptoms/tolerant, oral allergy syndrome (OAS), and grade I-IV anaphylaxis (ANA). Subsequently sera from all subjects were investigated for sIgE using EUROLINE sIgE multiparameter tests (EUROIMMUN, Luebeck, Germany) with extracts and components of distinct tree nuts (hazelnut, walnut, macadamia nut, cashew nut, pecan nut, Brazil nut, and pistachio) and peanut. Results: SPT indicated sensitization to tree nut and/or peanut, and pollen in 68 subjects. 41% and 59% of these subjects presented with OAS and ANA, respectively. As determined by EUROLINE tests, subjects from both symptom groups were sensitized to PR-10 proteins from hazelnut (Cor a 1: OAS 89%; ANA 95%), almond (Pru du 1: OAS 36%; ANA 43%), and peanut (Ara h 8: OAS 18%; ANA 23%). The sensitization to storage proteins from tree nuts and peanut was almost exclusively shown in anaphylactic patients, 33% of which were positive for sIgE against storage proteins from more than one tree nut and/or peanut. Moreover, among anaphylactic patients, sIgE against Ara h 6 was most frequently (38%) detected.

Conclusions:
In this cohort, sensitization to storage proteins from tree nut and/or peanut was highly associated with ANA, indicating that the detection of sIgE against storage proteins can improve the assessment of clinical outcome in allergic patients. In contrast, anti-PR-10 IgE gave no indication on clinical outcome since the majority of subjects with tree nut and/or peanut allergy was sensitized to PR-10 protein due to cross-reactivity to birch pollen. Component based multiplex sIgE tests including storage proteins can aid in assessing the risk of ANA that provides additional value for the diagnosis of serious allergic reactions in tree nut and peanut allergy. Introduction: 2S albumins have been described as food allergens constituting important clinical diagnostic tools in food allergies. Despite their relatively low sequence similarity, there are studies focused to their potential role in cross-reactivity reactions, so they can be used as a tool for their prediction. The aim of this study is to identify ten 2S albumins from seeds and nuts, as well as to characterize its structural parameters and assay them for IgE reactivity with patients' sera. Methods: Isolation of 2S albumins from extracts using chromatographic methods. After identification by mass-spectrometry, molecular characterization was conducted by electrophoretic methods (1-and 2-dimensional electrophoresis); its secondary structure and thermal stability were studied by circular dichroism spectroscopy. Finally, immunoassays were performed to reveal their allergenic capacity, using allergic mustard-allergic patients' sera. Results: Proteins have been isolated and purified from extracts by means of two chromatographic steps, a gel filtration and a reverse phase in HPLC. They were identified as 2S albumins by mass-spectrometry of digested peptides (MALDI-TOF). They generally show a helicoidal secondary structure, stable at 85 °C and possess a wide range of pI and heterogeneous polypeptide size and composition.

Conclusions:
The fingerprint analysis confirmed the purified proteins as 2S albumins, storage proteins already characterized as allergens. Purified proteins shown similar characteristics than those described for this family of proteins. The molecular characterization revealed low molecular masses and acid and basic pI, some of them exhibit the typical two chains-pattern and others, such as the one from sunflower seed, are constituted by one polypetide chain. Circular dichroism studies reveal their high resistance to thermal treatment except the one from pistachio. The characterized 2S albumins will be used as clinical tools in Component-Resolved Diagnosis (CRD) in a big Spanish population of patients allergic to vegetable foods using the potent high-throughput screening technology with ADVIA-Centaurus, to elaborate a more accurate diagnosis and therefore a more effective treatment. This diagnosis is especially relevant having in account the severe symptoms caused by this allergenic family.

PP127
A systematic approach to identifying food allergens of public health importance Bushra Javed Introduction: Food safety authorities recognise food allergy as a significant public health concern and have defined a list of "priority foods" that must be labelled irrespective of their level of inclusion in a recipe. Allergen molecules of those priority foods are the actual hazard for sensitive individuals but data are often lacking regarding their capacity to cause an allergic reaction. A systematic approach is being taken to assess this for peanut and tree nut allergens. Methods: Legislation from across the world has been searched to compile a list of tree nuts that have to be labelled and from this a search stratgey developed. This was implemented in a pilot study and data used to develop a modified PECO approach to the full systematic review. In addition a set of gradings has been developed to allow data gathered to be critically appraised in a consitent manner. Results: A search strategy and search terms, based on allergen labelling requirements across the world for peanut and tree nuts, has been developed. This was implemented in a pilot study and the retrieved articles were systematically reviewed and an inclusion list generated. Articles included were subject to analysis uing grading crieteria spanning the quality of the patient population used to the quality of an allergen preparation used in a given study.
Conclusions: This framework along with scientific grading criteria provides the basis to conduct a systematic literature review to identify the quality of evidence supporting inclusion of particular tree nut species in allergen labelling lists and quality of evidence that certain protein molecules can be classified as an allergen. Such data will allow future development of curated sequence sets of verified allergen molecules which are needed for development of analytical methods for determining allergens in foods. Introduction: Allergy to milk is one the most prevalent allergies affecting around 3% of children. At present there is no effective treatment for milk allergy and therefore strict avoidance is recommended. This however can be difficult as milk is an ingredient in many foods. The development of diagnostics and therapeutics for milk allergy depends on accurate and reliable methods for standardisation. Our aim was to develop quantitative immunoassays that could be used to accurately measure specific milk allergens. Methods: Monoclonal antibody pairs recognising the major milk allergens Bos d 11 (β-casein) and Bos d 5 (β-lactoglobulin) in its native and denatured state and were obtained. Subsequently two-site ELISAs and Luminex xMAP assays were developed using highly purified, IgE validated allergens as standards. The assays were used to measure milk allergens in different types of foods (powdered milk, chocolate mousse, chocolate bar, and cookie) and in diagnostic/therapeutic preparations. They were also used to monitor potential milk contamination in products that claim to be 'milk free' . The Luminex assays for Bos d 5 and Bos d 11 were "multiplexed" to allow for simultaneous quantification of both allergens in a single sample. Results: All assays showed wide standard dynamic range. The Lower Limit of Detection (LLOD) for ELISA was 7.8 ng/ml for both native and denatured Bos d 5 and 15.6 ng/ml for Bos d 11. The Luminex assays proved to be even more sensitive with LLOD up to 40-fold lower compared to ELISA (0.2 ng/ml, 2.0 ng/ml and 2.4 ng/ml for native Bos d 5, denatured Bos d 5 and Bos d 11 respectively). Concentration of Bos d 5 in tested samples ranged from 12.3 mg/g in milk powder to 0.279 µg/g in a placebo "milk free" chocolate bar developed for research. Conclusions: These data demonstrate that these immunoassays are suitable for the quantification of specific milk allergens, in their native and denatured forms, as well as in food samples containing relatively low levels of milk allergen. Immunoassays for quantification of specific milk allergens have been developed. The assays can be used separately (as ELISA) or be "multiplexed" (Luminex assays) allowing simultaneous quantification of multiple allergens in a single sample. The immunoassays will allow standardization of milk protein levels in diagnostic and therapeutic extracts and detection of milk allergens in foods. Introduction: Hydrolysed wheat proteins have provoked IgE mediated symptoms after skin exposure or ingestion in subjects tolerant to wheat. Acid hydrolysed wheat protein in a facial soap has been described to break tolerance to wheat. We have previously investigated the sensitising capacity of wheat gluten (G), enzymatic hydrolysed (EHG) and acid hydrolysed gluten (AHG) in naïve Brown Norway rats (Kroghsbo et al. 2014). The aim was to study the influence of wheat tolerance on the sensitising capacity of G, EHG and AHG. Methods: Rats were bred for at least two generations on ordinary wheatcontaining rat chow. After weaning the rats were kept on chow and then moved to a gluten free diet. Blood was drawn before dosing day 0 and a week after termination of dosing. Oral study: Rats were dosed by gavage with 20 mg G, EHG or AHG daily for 35 days. I.p. study: Rats were dosed with G, EHG or AHG 320 µg protein day 0, 14 and 28. Sera were analysed for specific IgG1 and IgE to the respective protein by ELISAs. Cross-reactivity was measured by inhibition ELISA's and avidity by KSCN ELISA. Results: At baseline >50% of the rats had low IgG1 titre to G, but no detectable IgE to G. Oral dosing with G, EHG or AHG did not induce significant changes in the level of specific IgG1 and IgE to either the product used for dosing or to G. I.p. dosing resulted in a significant increase in IgG1 antibodies to the respective proteins and in IgE to G and AHG. The G dosed rats had IgG1 with the highest avidity. IgG1 from AHG immunised rats showed a higher avidity to G than to the AHG. The inhibition ELISA's showed a high level of similarity within and between the groups. Conclusions: In contrast to our study in naïve rats, oral dosing in wheat tolerant rats could not induce a specific immune response above baseline. In the i.p. dosed animals the high level of cross-reactivity indicates a response dominated by antibodies to epitopes that are similar on all three products. The lower avidity to AHG (containing novel epitopes) compared to G in AHG dosed animals suggests a role for affinity maturation in the wheat tolerant animals. Exposure by the oral route to EHG or AHG is very unlikely to break an already established tolerance to wheat and induce sensitisation. In the i.p. study prior affinity maturation to common epitopes on G and AHG makes it possible to induce a high avidity immune response to G by dosing with AHG. This may illustrate how AHG in a facial soap could break tolerance to wheat. Introduction: Food-dependent exercise induced anaphylaxis (FDEIA) is a distinct form of food allergy induced by physical exercise. The ingestion of specific food are usually tolerated if not followed by exercise. FDEIA patients generally have not experienced symptoms in response to warmth (such as a hot bath), or other condition that increases the core body temperature, and they have symptoms only in association with an ingestion of specific food(s). A variety of foods have been described as causal allergy inducing foods in FDEIA. Skin tests and in vitro serum food-specific IgE assays are currently used, but the results are frequently negative. A challenge test consisting of ingestion of assumed food followed by intense physical exercise is the only reliable method to diagnose the disease, but this is not always safe to perform. Monosodium glutamate is a common added ingredient to savoury foods, namely in Chinese food, and it has been previously linked to urticaria and angioedema. Case report: We present a case of a 16-year-old white boy that developed within a few minutes from onset of physical activity: periorbital edema, urticaria, generalized pruritus and cough. In the emergency department, he was hypotensive (79/50 mmHg). He was treated with intramuscular epinephrine, clemastine and methylprednisolone and symptoms resolved completely. 4 h before the onset of physical activity he eats Chinese food, including pasta, shrimp and pork meat, which were previously tolerated by him. He regularly exercises without any problem. There was no past personal history of anaphylaxis, angioedema, food allergy, atopic dermatitis, drug allergy or vaccine Introduction: Allergic reactions to peanut are on the rise in Western countries. In vitro diagnostic tests applying aqueous extracts or watersoluble single allergens are investigated as an alternative to costly and potential life-threatening oral food challenges (OFC). However, their diagnostic accuracy to predict the degree of clinical severity is still inferior to OFCs which might be based on the absence of lipophilic allergens such as oleosins. Recently, sensitization to oleosins has been associated with more severe allergic symptoms in allergy to sesame and hazelnut. Hence, we sought to investigate oleosins as possible new candidates for routine diagnostic measurements in peanut allergy. Methods: Oleosins from raw and in-shell roasted peanuts were isolated by flotation centrifugation and purified by preparative electrophoresis. Protein identification was carried out by N-terminal sequencing and mass spectrometry. Sensitization prevalence to oleosins from raw and in-shell roasted peanuts was investigated by western blot. The ability of oleosins to trigger type I hypersensitivity reactions was evaluated by basophil activation test (BAT). Results: A number of eight oleosins were isolated and identified from peanut. So far, these molecules showed IgE binding exclusively to sera from patients suffering from severe peanut allergy. Moreover, Clin Transl Allergy 2017, 7(Suppl 1):10 IgE binding to oleosins obtained from in-shell roasted peanuts was increased compared to raw ones. Both, oleosins from raw and in-shell roasted peanuts were able to stimulate basophils from peanut-allergic individuals having severe symptoms. Conclusions: Oleosins are important lipophilic allergens that are able to trigger allergic reactions but have been overlooked so far due to their low solubility in aqueous buffers. Sensitization to these proteins seems to be solely associated with severe allergic symptoms. Peanut oleosins are clinically relevant peanut allergens. As they are most likely associated with more severe allergic symptoms they might be new maker candidates for the clinical severity of peanut allergy. Furthermore, in-shell roasting increases the IgE binding potency of oleosins which is in line with previous results for other peanut allergens. 1 Clin Transl Allergy 2017, 7(Suppl 1):10 standardized wheat seeds extract in order to evaluate their sIgE reactivity against the protein spots. Their sIgE sensitization profiles were compared and protein spots of interest were identified by LC-MS/MS. Results: Specific sensitization profiles were identified for each phenotype group. For WDEIA, protein spots around 37 kDa (pH 6-9) and 37-50 kDa (pH 5-6) were identified. For AD, spots were observed around 50 kDa (pH 9), 10 kDa (pH 9) and 20 to 75 kDa (pH3). For PR, specific spots were situated around 90 kDa (pH 9). The LC-MS/MS analysis of these identified spots pointed out several potential interesting allergens: tri a 26, tri a bA, tri a 34, tri a tritin. Conclusion: Our study answers to the request of many allergists wishing to get an accurate diagnosis of wheat allergy in order to determinate the risk of cross-reaction, to adapt the diet and to limit the risk of anaphylactic choc. Nevertheless, it is necessary to consider the 2D immunoblot results with the medical history of each patient. Moreover, there are different clinical manifestations of wheat allergy depending on the involved allergen and the way of exposure: WDEIA, AD, PR or baker's asthma. The present project pointed out new wheat allergens that could be associated to a specific phenotype. The identification of further protein spots is still under investigation. At this stage, specific sensitization profiles were identified for the 3 phenotype groups (WDEIA, DA, PR). The protein spots of interest detected by sIgE concern one or more allergens. Some wheat allergens were identified by LC-MS/MS. At the end of the study, it will be possible to establish a link between a specific symptomatology and the responsible allergens newly identified. Introduction: Cow's milk (CM) protein allergy is the most prevalent food allergy in children. Patients with CM allergy usually do not tolerate goat's (GM) or sheep's (SM) milk, since there is a high cross-reactivity between all of them. There are few case reports of patients with allergy to GM tolerant to CM. Case report: A 14 years old girl with IgE-mediated CM allergy since 6 months of age, with CM eviction till 12 years old. At this age an oral food challenge (OFC) has been performed, being negative. She started a regular ingestion of CM proteins during the last two years. She was referred to our Immunoallergy department, one week after an episode of lip angioedema and generalized urticaria with intense pruritus after eating a meal containing goat cheese, parsley, tomato, onion, poached egg and pepper. Two weeks before she had already an episode of oral pruritus after eating a small portion of goat cheese. Skin prick tests (SPT) (Bial-Aristegui, Bilbao, Spain) to milk and CM proteins (casein, α-lactoalbumin, β-lactoglobulin), egg and egg's proteins, pepper and parsley, were negative. Prick by prick test (PPT) were positive to goat cheese (19 × 8 mm), GM (11 × 7 mm) and SM (7 × 9 mm). In order to validate these results, PPT with goat's cheese and milk and SM have been performed to 10 healthy adult controls. Specific IgE (Uni-CAP ® , Thermo Fisher Scientific, Uppsala, Sweden) was positive to GM (8.7 kU/L) and SM (9.3 kU/L) and negative for CM and proteins. Total IgE 241 kU/L. Two weeks after the episode, an OFC with CM was performed, being negative, and daily ingestion of CM proteins has been advised with good tolerance.

Conclusions:
The majority of patients with allergy to CM proteins do not tolerate GM or SM. We describe a rare case of an adolescent girl who started to react to goat's cheese after outgrown a CM allergy, probably due to sensitization to proteins without homology to CM proteins.

Consent to publish:
The authors confirm that the individual described has authorized them to publish the findings related with the case. Introduction: IgE antibodies to peanut storage protein Ara h 2 have high diagnostic accuracy in verifying or excluding symptomatic peanut allergy, and high levels are considered to predict serious allergic reactions. In our experience some adult patients with peanut allergy suffer disabling fear of peanuts, having been taught that they risk a severe allergic reaction upon airborne exposure of, or consumption of peanuts. Case report: 1. Female, 24 years old with asthma. The patient had been told to exclude peanuts from her diet and not to be in a room where peanuts are consumed. She had always carried an adrenaline autoinjector. Current level of Ara h2 was 9.3 kU/L. She had never experienced a severe allergic reaction and was eager to find out how she would react to accidental intake of peanuts. Following a strict protocol, she consumed one peanut and experienced instantly some mild oral symptoms. After 20 min she reacted with profuse vomiting and a stuffy nose. No adverse respiratory or circulatory reactions occurred and no adrenaline or other medication was given. The recovery was swift and the patient left the clinic after two hours. 2. Male, 20 years old with asthma. At the age of seven he reacted with oral symptoms, nausea and vomiting after eating peanuts. Hence he developed a fear of all nuts and had been prescribed an adrenaline auto-injector. Current level of Ara h2 was >100 kU/L. He wanted to know if his fear of nuts was relevant and if there still was a need to always bring the adrenaline auto-injector. According to a strict protocol he ate three peanuts. Initially he experienced transient mild symptoms from the throat, followed by abdominal pain and flushing 10 min later. After another 10 min he developed hives and profuse vomiting. Antihistamine and cortisone was given intravenously, and the patient recovered quickly. He left the clinic after being observed for four hours.

Conclusion:
Both patients expressed great relief to have undergone a peanut challenge. Knowing that eating small amounts of peanuts did not affect their ability to breathe or their circulatory functions has helped them replace the fear of what might happen into a relevant respect for peanuts. Oral challenge with peanuts in patients with peanut allergy could be justified in some patients, even with elevated levels of Ara h2, when it is important for the patient to know not only that he/she will react but also how.

Consent to publish:
Patients have consented to the publication of this abstract. Introduction: Pemetrexed is a folate antimetabolite, approved for treatment of mesothelioma and non-squamous non-small cell lung cancer. It's usually used in combination with platinum salts, gemcitabine or docetaxel. Pemetrexed presents a good safety profile, with Clin Transl Allergy 2017, 7(Suppl 1):10 myelosuppression being the most common dose-limiting toxicity. However, hypersensitivity reactions to pemetrexed have been described.

PP156 Pemetrexed anaphylaxis -An unusual suspect
Case report: We report the case of a 52 year old woman, with stage IV metastatic adenocarcinoma of the lung, on palliative chemotherapy (QT) with pemetrexed plus carboplatin; for nausea control she was also receiving fosaprepitant immediately before QT. On her first treatment with these drugs, 3 min after starting pemetrexed perfusion, the patient developed dyspnea, cyanosis of the extremities, generalized pruritic exanthema and hypersudoresis. QT was immediately stopped and the patient was treated with hydrocortisone and clemastine. However, her status rapidly progressed to anaphylactic shock, with loss of consciousness, sphincters control, bradypnea, bradycardia, non-measurable blood pressure) and tachycardia. She received IV adrenaline and aggressive fluid resuscitation, with rapid improvement and was discharged 24 h later, fully recovered. Serum tryptase during the episode was elevated at 67.5ug/L (normal range: <11.4ug/L). The patient was referred to our drug allergy unit for study. Skin prick tests performed 6 months later were positive to pemetrexed 25 mg/ml (7 mm; histamine 10 mg/ml = 5 mm) and negative to carboplatin 10 mg/ml and fosaprepitant 1 mg/ml; intradermal tests were also positive to pemetrexed (1/1000) and negative to carboplatin (1/1000-1/10) and fosaprepitant (1/1000-1/10). As the oncologist decided for an alternative treatment, a desensitization protocol to the culprit drug, pemetrexed, was not considered. Conclusion: Reports of hypersensitivity reactions to pemetrexed are very rare. This drug is almost exclusively used in combination with other chemotherapeutic agents, like platinum salts, which might underestimate pemetrexed as a cause of immediate hypersensitivity reactions. To our knowledge, this is the third report of documented anaphylaxis to pemetrexed, and the first to support the diagnosis of an IgE dependent mechanism through skin tests.
Consent to publish: Consent for publication was obtained. Introduction: Barnacles (Pollicipes pollicipes), a type of seafood found on sea coasts worldwide, are a delicacy consumed in Portugal, Spain, France and South America. Barnacle allergy is rare, with few published cases [1]. Case report: Case 1: A 4-year-old boy with allergic rhinitis, sensitized to pollens and house dust mites, reported 2 suspected food-related allergic reactions. In the first episode, he complained of pruritus and facial erythema immediately after eating barnacles and fish. The second episode occurred 6 months later and he presented with dyspnea, cough, urticaria and facial edema immediately after eating hake. He had a specific IgE to hake = 0.34 kU/L and positive skin prick-prick tests (SPPT) (raw hake: 7 mm; cooked hake: 5 mm; histamine: 4 mm) performed at another hospital. No further tests were conducted and he was instructed by his previous physician to avoid all fishes. A more detailed history at our out-patient clinic revealed that he continued to ingest and tolerate fish. Also, the parents were eating barnacles in the second episode and they could not guarantee the absence of cross contamination with the son's food. One year after the last episode, SPPT with barnacle were performed and they were positive (raw meat: 13 mm, cooked meat: 13 mm, histamine: 4 mm). Parents refused oral provocation test (OPT). Comment: This case illustrates the importance of hidden allergens, cross contamination and a detailed history in order to establish a correct diagnosis and unnecessary dietary restrictions. Case 2: A 9-year-old boy, with allergic rhinitis undergoing allergen immunotherapy with D. pteronyssinus, was referred to our Allergy Department for an episode of dyspnea, nausea, and vomiting, oral and nasal pruritus immediately after eating 4 barnacles. He was rushed to the ER and successfully treated with corticosteroids, antihistamines and nebulized salbutamol. Four months later, SPPT were positive to cooked barnacle (meat: 7 mm; histamine 10 mg/ml: 5 mm); OPT with barnacle was not performed. Conclusion: Barnacle allergy is a rare, but its allergenic potential is well established. Molecular allergens and cross-reactivity with mites have been described [1].

Statement of consent:
Consent for publication was obtained. Case report: We report the case of a 72-year-old woman, non-atopic, that developed manifestations of an anaphylactic shock, with generalized urticaria, stridor, dyspnoea, nausea, abdominal pain and severe hypotension in about 20 min after nurse treatment of a chronic vascular ulcer with Prontosan ® and petrolatum, at primary care; she was immediately medicated with hydrocortisone but no adrenaline and was transferred to the hospital emergency. The ulcer has been treated with the same antiseptic compound twice weekly before the described severe reaction although in the two previous treatments she presented with generalized urticaria, stridor and dyspnoea in 30 min after the ulcer care. Following the episode of anaphylactic shock, treatment did no longer include Prontosan ® , and no more reactions occurred after that. The patient was referred to an Allergist for evaluation. A skin prick test with the implicated antiseptic was performed inducing a 6 × 5 mm wheal at 15-minute reading (identical to histamine 10 mg/ml); however, at 30 min a significant wheal increase was observed, to 14 × 10 mm. The patient's daughter offered to be a control with a negative skin test result. At this point it was not possible to test each antiseptic component separately, but this will be the next step, along with an in vitro assay. Conclusion: To the authors' best knowledge this would be the forth case of anaphylaxis to a polyhexanide irrigation solution. No reports of severe immediate hypersensitivity reactions to topical betaine formulations were found in the literature.

Consent to publish:
The authors state they have obtained patient's informed oral consent for presentation and publication of the present clinical case. Introduction: Several studies suggest that tick bites are a cause of IgE antibody responses to alpha-gal in the United States, Europe, Asia and Australia. Delayed-onset reactions, especially anaphylaxis, have been reported to happen 3 to 6 h after ingestion of mammalian food products. Hereby we describe the first case of alpha gal allergy in Brazil in a male farmer, who presents with no other symptoms than urticaria. Clin Transl Allergy 2017, 7(Suppl 1):10 Case report: A 55 year-old cattle breeder from North of Brazil (Rondonia) with no previous allergies refer to presenting with a daily scattered and pruritic papules for five years. Symptoms used to show up mostly in the late afternoon and were closely related to the ingestion of meat (lamb, bovine, pork, chicken) during lunch time. When questioned about tick bites, he clearly described multiple lesions in his body secondary to his job with animals and farm. Specific serum IgE revealed: bovine meat: 38.80 kU/L; pork meat: 28.60 kU/L; cow's milk: 9.7 kU/L; serum bovine albumin: 1.51 kU/L; alpha gal: 70.7 kU/L; total IgE 888UI/mL. After orientation to restrict all meats, his symptoms have disappeared.

Conclusions:
Although most of reports about alpha-gal allergy involve anaphylaxis, this patient presented only with urticaria. The only route of sensitization was through tick bites, since he never had contact to cetuximab. Chronic urticaria in farmers or environment with ticks, which can be very often in Brazil, should be investigated for alpha gal allergy.
Consent to publish: Patient consented to the publication of this abstract. Clin Transl Allergy 2017, 7(Suppl 1):10 Case report: We report three anaphylaxis cases presented in our clinic during 2014-2016, all initially referred by the ED professionals as fish induced anaphylaxis. They all had none co-morbidities and no previous allergic reactions of any kind.
• 23 years old female patient developed generalised rush and urticaria, angioedema of the lips, difficulty with swallowing and breathing, abdominal cramps about 40 min after cod-fish ingestion. • 27 years old female patient developed angioedema of the lips, generalised urticaria, difficulty with breathing and swallowing about10 min after fish ingestion. • 24 years old female patient developed urticaria and angioedema, abdominal cramps, mild breathing difficulty about 20 min after fish ingestion. • Biochemical and full blood count resulted normal. Mast cell disorder was excluded (Table 5).

Conclusions:
• Scombroid food poisoning and fish allergy are often confused interchangeably and in vivo and in vitro allergy tests as well as a careful history are needed to make the right diagnosis. • The role of co-factors is important in eliciting anaphylaxis.
• De novo food allergy related to fish and shellfish in adults should always be investigated by the allergist.
Consent to publish: Written informed consent was obtained from the patient's parent or guardian for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Introduction: Sequence homology in IgE binding epitopes of proteins from different foods may cause cross-sensitivity and hereby also clinical cross-reactivity. A recent study investigating allergy towards pistachio nut and cashew nut found that 25/25 patients were doubleallergic to the nuts. The levels of specific IgE (sIgE) may increase with age and new allergies may occur towards previously tolerated foods. Sensitization, on the contrary, can be present though the patient is tolerant to the food item, why diagnosis relies on oral food challenges (OFCs). A study has shown that up to 13% of OFCs can be negative, with a clinical reaction upon re-exposure. This can be due to priming or maturation of the immune system. But the course of events leading to reactivity or cross-reactivity towards a previously tolerated food item is not fully clarified. Case report: A 1-year-8-months-old girl was referred to an allergy center after an allergic reaction to hazelnuts. She had sIgE (Thermo Fisher Scientific, Uppsala, Sweden) towards other tree nuts that she had never ingested, and kept a nut-free diet until subsequent OFCs (Fig. 8). After two negative pistachio-OFCs, one positive cashew-OFC and one negative walnut-OFC, a 20 fold increase in sIgE was observed towards all nuts challenged with including hazelnuts (later hazelnut-OFC was positive). Regular intake of the food tolerated in an OFC is normally recommended. But due to the increase in sIgE it was regarded unsafe. When re-challenged with pistachio nut, the patient reacted with grade-2-anaphylaxis (asthma, rhinitis and urticaria) to a dose much lower than the dose previously tolerated. Due to safety and ethical reasons the patient was not re-challenged with walnuts.

Conclusions:
The report suggests that allergy or cross-allergy towards pistachio nut may be induced by repeated exposure. It also stresses the importance of IgE testing close to the date before and shortly after an OFC. The natural course of allergic disease should be taken into consideration. But the timing of OFCs could be of importance to the challenge outcome.

Consent to publish:
A written consent for presentation and publication is obtained from the parents.

Table 5 See text for description
Epipen was prescribed to patient 2 and 3 in case of future potential anaphylaxis and a written anaphylaxis action plan Introduction: Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction, being a medical emergency. Trigger identification, patient education and establishing emergency action plans are essential steps in the management of this condition. However, in rare cases, patients deliberately expose themselves to the trigger to attempt self-harm. Case report: We report a case of a 39-year-old woman, with a history of multiple sclerosis, borderline personality disorder, depression (with 10 previous emergency department visits with suicidal thoughts) and documented hypersensitivity to nuts and fresh fruits (rosaceae). Following a fifth discharge from a Psychiatric Department, she stopped OFCs were terminated at appearance objective symptoms or after tolerating 10 grams (g) of nut (the first pistachio-OFC was stopped at 0.45 g, due to time-shortage). IgE (detection limit ≥0.35 kU/L) towards all listed nuts and components were measured on each blood sample. IgE is depicted on a logarithmic scale