Letters to the Editor - August 1999 - American Academy of Family Physicians

Letters to the Editor

Provocation-Neutralization in the Treatment of Food Allergy

TO THE EDITOR: I would like to thank Dr. Sicherer for his recent article on the evaluation and management of food "allergy."¹ The article's emphasis on life-threatening emergencies is timely in light of the recently publicized allergic reactions to foods such as peanut butter in Seattle-area schools.

However, I would take issue with the statement on page 419 of the article, which reads, "Unfortunately, unreliable information in the lay press and the use of unconventional and unproven methods, such as 'provocation-neutralization,' for diagnosing and treating behavior disorders can divert the patient's family from more useful treatments."¹

First, in my experience in family practice and environmental health, a distinct subset of patients does indeed have reproducible, physical changes in behavior, as well as asthma, headaches, arthritis, rhinitis and so on triggered by a particular food or additive. For such patients, the treatments that are usually helpful, such as conventional allergy care, psychotherapy and the use of medication, may, in fact, divert patients from the real issues. Provocation-neutralization really can be a helpful diagnostic and therapeutic technique to demonstrate sensitivity to foods and other agents. Sadly, those who criticize the technique have rarely seen it in operation.

Second, the expression "bona fide allergies" is misleading. The expression fails to recognize the existence of two distinct schools of thought in American allergy and clinical immunology: both a narrow and a broad definition of "allergy" exist. Unfortunately, many allergic reactions to foods, which happen to be non-IgE and even non-antibody, immune-mediated events, are ignored by many physicians to the patient's detriment.

Finally, Dr. Sicherer cited an article by Dr. Jewett, which was published in the New England Journal of Medicine, to support the above contention regarding provocation-neutralization.² This reference is decidedly weak for several reasons. It does not use the standard definition of "neutralizing dose." Also, several double-blind articles^3-6 showing data that support the effective use of provocation-neutralization had been published by 1990, but were not cited by Dr. Jewett or by the editor of New England Journal of Medicine.

Thank you for allowing another viewpoint about this important, albeit controversial subject.

PHILIP RANHEIM, M.D.
Allergy and Environmental Medicine
9407 4th St. NE
Bldg. A
Everett, WA 98205

REFERENCES

Sicherer SH. Manifestations of food allergy: evaluation and management. Am Fam Physician 1999; 59:415-24.

Jewett D, Fein G, Greenberg MH. A double-blind study of symptom provocation to determine food sensitivity. N Engl J Med 1990;323:429-33.

Scadding GK, Brostoff J. Low dose sublingual therapy in patients with allergic rhinitis due to house dust mite. Clin Allergy 1986;16:483-91.

Boris M, Schiff M, Weindorf S. Injection of low-dose antigen attenuates the response to subsequent bronchoprovocative challenge. Otolaryngol Head Neck Surg 1988;98:539-45.

King WP, Rubin WA, Fadal RG, Ward WA, Trevino RJ, Pierce WB, et al. Provocation-neutralization: a two-part study. Part I. The intracutaneous provocative food test: a multi-center comparison study. Otolaryngol Head Neck Surg 1988;99:263-71.

King WP, Fadal RG, Ward WA, Trevino RJ, Pierce WB, Stewart JA, et al. Provocation-neutralization: a two-part study. Part II. Subcutaneous neutralization therapy: a multi-center study. Otolaryngol Head Neck Surg 1988;99:272-7.

IN REPLY: I would like to thank Dr. Ranheim for his comments on my article.

I am not aware of "narrow" and "broad" definitions of allergy.¹ A food allergy is a specific immunologic response to a food protein that may or may not be mediated by a specific IgE antibody. Indeed, a number of well-described, nonIgE-mediated food allergy reactions exist, mediated, for example, by T-cell elaboration of cytokines such as tumor necrosis factor alpha, as detailed in my article. Additionally, many disorders or symptoms that are caused by food or food products are not mediated by the immune system (intolerance, reactions to toxins or pharmacologic agents in foods), but have a defined pathophysiologic basis and are also described in my article.

A number of diagnostic and treatment modalities for food allergy are considered controversial and unproven.^2,3 These include provocation-neutralization, IgG4 antibody testing, cytotoxic testing, electrodermal diagnosis, applied kinesiology, the "reaginic" pulse test and body chemical analysis. Generally, these tests are used to diagnose a wide variety of complaints that do not necessarily share a common pathophysiology. These tests and treatments also lack a rational basis in immunology. Restrictive diets that are based on results of these or any tests carry the risk of nutritional deficits and social and emotional stresses, so it is important to be sure that dietary changes are being advised on solid ground.

Dr. Ranheim has found provocation-neutralization to be a helpful diagnostic and therapeutic technique for his patients, as did the seven experienced clinical ecologists who participated in Dr. Jewett's study,⁴ before their techniques were shown to be unreliable in a carefully executed double-blind, placebo-controlled study. I am not aware of any subsequent studies that were so carefully controlled showing benefit to provocation-neutralization (in fact, no effect has been re-confirmed⁵), although the technique is still practiced and may not be a benign modality, especially if misused.⁶

When a question concerning true reactivity to a food arises, even in the face of positive tests for food-specific IgE antibody, the only way to determine a cause and effect relationship is through physician-supervised, double-blind, placebo-controlled oral food challenges. This diagnostic method is considered the "gold standard" since physician and patient bias is removed. I suggest that any diagnostic or therapeutic modality be held to this standard and studied systematically.

SCOTT H. SICHERER, M.D.
Mount Sinai School of Medicine
Jaffe Food Allergy Institute
Box 1198
One Gustave L. Levy Pl.
New York, NY 10029

REFERENCES

Bruijnzeel-Koomen C, Ortolani C, Aas K, Bindslev-Jensen C, Bjorksten B, Moneret-Vautrin D, et al. Adverse reactions to food. Allergy 1995;50:623-35.

Bernstein IL, Storms WW. Practice parameters for allergy diagnostic testing. Joint Task Force on Practice Parameters for the Diagnosis and Treatment of Asthma. The American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1995;75(6 Pt 2):543-625.

Jenkins M, Vickers A. Unreliability of IgE/IgG4 antibody testing as a diagnostic tool in food intolerance. Clin Exp Allergy 1998;28:1526-9.

Jewett D, Fein G, Greenberg MH. A double-blind study of symptom provocation to determine food sensitivity. N Engl J Med 1990;323:429-33.

Fox RA, Sabo BM, Williams TP, Joffres MR. Intradermal testing for food and chemical sensitivities: a double-blind controlled study. J Allergy Clin Immunol 1999;103(5 Pt 1):907-11.

Teuber SS, Vogt PJ. An unproven technique with potentially fatal outcome: provocation/neutralization in a patient with systemic mastocytosis. Ann Allergy Asthma Immunol 1999;82:61-5.

The Family Physician as a Hospitalist

TO THE EDITOR: We are writing to present our approach to structuring a hospitalist system with the hope that it may benefit other family physicians who see these changes on the horizon.

Although the hospitalist movement is still small, it has been heavily publicized in medical journals and keenly watched by an increasing number of health care providers. Hospital administrators, who have an eye on cost-effectiveness of care, length of hospital stay, patient satisfaction and competition for contracts, are very interested in the concept. Payors, particularly health maintenance organizations, see the hospitalist movement as an opportunity to increase efficiency, assure accessibility of physicians and address issues of timeliness.

At the same time, family physicians are seeing increased demands with more complex inpatient care and packed outpatient schedules. Physicians want to ensure that their patients receive good continuity and quality of care; however, many physicians are reluctant to give up the long-established relationships with their patients and the expertise of inpatient medicine by "abandoning" the care of these patients to other health care providers.

Physicians who work in the outpatient clinic of our hospital have wrestled with some of these issues. In response, we developed a set of goals that includes continuity and cost-effectiveness of both inpatient and outpatient care; availability and timeliness of care; coordination of care; relative manpower resources; and quality issues (communication, competency, patient satisfaction and documentation). We also included any physicians who were interested in using the system and, as long as the issue of quality was adequately satisfied, did not require participation.

Our system combines the manpower of several smaller clinics with physicians who rotate through an inpatient service. Admissions are accepted throughout the day, while admissions at night continue to be handled by the patient's primary care clinic. Because we emphasize primary care, the whole spectrum of inpatient admissions is covered, from nursery to hospice care. Thus far, our inpatient service has been well accepted by the physicians, patients and hospital staff, and we are now developing a system to ensure continuous monitoring.

Early observations indicate that length of stay has decreased, care is timely and physicians are more accessible. Such benefits have elicited many positive responses from patients and their families. Our family physicians and the receiving inpatient service colleagues stress that they work as a team, and at discharge, patients are sent directly back to "their" primary care physician. This system appears to be working; some physicians suggest that it is more important for the inpatients to have continuity of care than to have the more piecemeal cross-coverage that often exists with call groups.

Communication between the inpatient physician and the patient's primary care physician is the most significant concern. This communication occurs routinely at the times of admission and discharge; however, more effort is needed to convey significant or unanticipated changes in the patient's status or challenges in communicating with the patient's family.

We believe that the hospitalist movement is an extension of the general crisis in health care in the United States. And, like all crises, it promotes discussion that hopefully will lead to new opportunities for improving patient care.

JIM GUYN, M.D.
TOM GUYN, M.D.
Clinical Services
North Memorial Health Care
3300 Oakdale Ave. North
Robbinsdale, MN 55422-2900

Corrections*

The January 1, 1999 "Clinical Quiz" contained questions that were incorrect or poorly worded. The answer to Question 16, pertaining to the article "Snowboarding Injuries" (page 131), is incorrect as published. The correct answer is B. Question 17, pertaining to the article "Surgical Options in the Management of Groin Hernias" (page 143), is misleading in that the text of the article does not provide information on the percentage of inguinal hernias that are indirect. It is correct to say that more than 90 percent of groin hernias are inguinal. The correct answer to this question is B.

Question 12 in the January 15, 1999, "Clinical Quiz" (page 267), pertaining to the article "Ordering and Understanding the Exercise Stress Test" (page 401), has two correct answers as written. Although the question should have had only one correct answer, both options "C" and "E" are correct.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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