Investigating Novel Food Sensitization: A Real-Life Prevalence Study of Cricket, Locust, and Mealworm IgE-Reactivity in Naïve allergic Individuals

BACKGROUND AND OBJECTIVE

With the global population on the rise, edible insects are considered a potential solution to food security, although concerns about risks such as anaphylaxis exist.

METHODS

2,014 participants underwent testing with the Allergy Explorer-ALEX-2 including extracts of three novel foods: Acheta Domesticus (Ad), Locusta migratoria (Lm), and Tenebrio molitor (Tm). The IgE-mediated sensitization status was investigated in participants who had never knowingly consumed these insects. Data was recorded using an electronic database.

RESULTS

195 individuals (9.7% of all participants) were sensitized to insects. Tropomyosin was co-recognized by 34%, and 18.5% were positive for arginine kinases. Reactivity to Sarcoplasmic-CB, Troponin-C, Paramyosin, or Myosin-light-chain was found in less than 5% of the population, whereas 108 individuals (55.4%) did not show any reactivity to invertebrate panallergens. Additionally, 33 individuals (16.9%) exhibited monosensitization exclusively to insects. Multivariate analysis revealed an inverse association between arachnid reactivity and sensitization to insect allergens, while Mollusca, Blattoidea, and tropomyosin reactivity displayed a direct relationship. Furthermore, Myosin-light-chain reactivity correlated with Ad and Lm, and Troponin-C with Ad and Tm sensitization.

CONCLUSION

Edible insect extract IgE sensitization was observed in individuals without prior exposure to such foods. Mites showed a low likelihood of being primary sensitizers due to their inverse association with insect reactivity. Conversely, the direct association of insect sensitization with mollusk and cockroach extract reactivity suggests their potential as primary sensitizers in these participants. Tropomyosin consistently exhibited a positive association with reactivity to all studied insects, supporting its role as a primary sensitizer.

IgE-mediated reactivity to non-specific lipid transfer protein (nsLTP): clinical implications and management ‒ consensus document of the Association of Italian Territorial and Hospital Allergists and Immunologists (AAIITO)

Summary

The primary cause of adult-onset food allergy in Mediterranean countries is IgE-mediated reactivity to non-specific Lipid Transfer Protein (nsLTP), with a prevalence of 9.5% in Italy. nsLTP is heat- and pepsin-stable due to its 3D structure, causing severe allergic reactions, even anaphylaxis. It's conserved across plants and a "panallergen" due to homologous forms in various vegetable foods. Found in Rosaceae fruits' skin, it's categorized into nsLTP1 (9 kDa) and nsLTP2 (7 kDa), representing 93% and 7% of the molecules described to date, respectively. Pru p 3 (nsLTP1) from peach is a primary sensitizer, binding more epitopes than other homologs. Cross-reactivity varies in sensitized patients, influenced by IgE levels. Clinical manifestations range from none to various symptoms. Managing patients sensitized to nsLTP without clinical allergy is a challenge. Sensitization hierarchy usually starts with peach, then expands through Prunoideae, Rosaceae, and other foods. Clinical symptoms don't always expand across LTPs. Patients can tolerate some nsLTP-containing foods and consuming them may maintain tolerance. The absence of guidelines led to the Associazione Allergologi Immunologi Italiani Territoriali e Ospedalieri (AAIITO) creating a consensus-based document. Strategies involve avoidance, self-injectable adrenaline, verification through in vivo and in vitro testing, considering cofactors, and peeling fruits. In localized reactions, abstinence is recommended if specific IgE is high. Concurrent pollinosis may complicates diagnosis, but may help management since symptoms are often less severe. Asymptomatic patients are advised to continue normal diets while considering cofactors and total IgE levels. Management strategies should be case-specific, based on expert Consensus Document.

Clinical severity of LTP syndrome is associated with an expanded IgE repertoire, FDEIA, FDHIH, and LTP mono reactivity

Summary

Background. LTP allergy is often a challenge for clinicians. We evaluated a multiplex diagnostic approach with diverse cofactors to stratify LTP syndrome risk. Methods. Of the 1,831 participants screened with 'Allergy Explorer-ALEX-2', 426 had reactions to at least one LTP. Data was gathered and recorded via an electronic database. Results. Reactivity to peach Pru p 3 was found in 77% of individuals with LTP allergy. Higher levels of specific IgE and concurrent sensitization to more than 5 molecules (50% of all LTP-sensitised participants, 62% of symptomatic cases) were significantly associated with an increased risk of severe reactions (p = 0.001). Several cofactors, either alone or in combination, also influenced patients' clinical outcomes. Some cofactors increased the risk of severe reactions, such as mono reactivity to LTP in 44.6% of cases (p = 0.001), FDEIA in 10.8% of patients (p = 0.001), and FDNIH in 11.5% (p = 0.005). On the other hand, reactivity to PR10 (24.2%; p = 0.001), profilin hypersensitivity (10.3%; p = 0.001), and/or atopic dermatitis (16.7%; p = 0.001) had a mitigating effect on symptom severity. Conclusions. Clinical severity of LTP syndrome is associated with an expanded IgE repertoire in terms of the number of LTP components recognized and increased IgE levels in individual molecules. Ara h 9, Cor a 8, and Mal d 3 showed the strongest association with clinical severity. In addition, several cofactors may either exacerbate (FDEIA, FDHIH, and LTP monoreactivity) or ameliorate (atopic dermatitis and co-sensitization to profilin and/or PR10) individual patient outcomes. These factors may be utilized for the daily clinical management of LTP syndrome.

Severe asthma: follow-up after one year from the Italian Registry on Severe Asthma (IRSA)

Summary

Background. Asthma affects millions of people worldwide, with a subgroup suffering from severe asthma (SA). Biologics have revolutionized SA treatment, but challenges remain in managing different patient traits. This study analyzed data from the Italian Registry on Severe Asthma (IRSA) to investigate changes in SA characteristics and effectiveness of treatments after one year of follow-up, and to identify factors associated with response to treatments in a real-world setting. Methods. Data on SA patients with one year of follow-up were extracted from IRSA. Asthma control, exacerbations, lung function, and treatments, were assessed at follow-up and analyzed against baseline characteristics. Results. After one year of follow-up, notable improvements were observed in all the outcomes of SA of the included patients (n = 570). The effectiveness of biologic therapies was particularly evident, as they contributed significantly to these positive outcomes. Additionally, certain factors were found to be associated with improvement, namely T2 phenotype, baseline eosinophil count (BEC), and area of residence. On the other hand, comorbidities (obesity, gastro-esophageal reflux disease) and poor lung function were risk factors. Notably, poor-responders to biologics exhibited lower level of education, BEC, and exacerbations, and higher frequency of atopy and ACT score ≥ 20. Conclusions. The findings demonstrate the effectiveness of biologics in asthma management, when implemented as part of a planned follow-up strategy aimed at optimizing and fine-tuning the therapy. Moreover, the study highlights the importance of considering key traits such as the T2 phenotype, BEC, education, and comorbidities when tailoring SA treatment. Overall, this study contributes to enhancing our understanding of SA management and guiding the development of personalized treatment approaches for patients with SA.

Adherence to inhaled corticosteroids and long-acting β2-agonists in asthma: A MASK-air study

INTRODUCTION

Adherence to controller medication is a major problem in asthma management, being difficult to assess and tackle. mHealth apps can be used to assess adherence. We aimed to assess the adherence to inhaled corticosteroids+long-acting β2-agonists (ICS+LABA) in users of the MASK-air® app, comparing the adherence to ICS+formoterol (ICS+F) with that to ICS+other LABA.

MATERIALS AND METHODS

We analysed complete weeks of MASK-air® data (2015-2022; 27 countries) from patients with self-reported asthma and ICS+LABA use. We compared patients reporting ICS+F versus ICS+other LABA on adherence levels, symptoms and symptom-medication scores. We built regression models to assess whether adherence to ICS+LABA was associated with asthma control or short-acting beta-agonist (SABA) use. Sensitivity analyses were performed considering the weeks with no more than one missing day.

RESULTS

In 2598 ICS+LABA users, 621 (23.9%) reported 4824 complete weeks and 866 (33.3%) reported weeks with at most one missing day. Higher adherence (use of medication ≥80% of weekly days) was observed for ICS+other LABA (75.1%) when compared to ICS+F (59.3%), despite both groups displaying similar asthma control and work productivity. The ICS+other LABA group was associated with more days of SABA use than the ICS+F group (median=71.4% versus 57.1% days). Each additional weekly day of ICS+F use was associated with a 4.1% less risk in weekly SABA use (95%CI=-6.5;-1.6%;p=0.001). For ICS+other LABA, the percentage was 8.2 (95%CI=-11.6;-5.0%;p<0.001).

CONCLUSIONS

In asthma patients adherent to the MASK-air app, adherence to ICS+LABA was high. ICS+F users reported lower adherence but also a lower SABA use and a similar level of control.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Why lipid transfer protein allergy is not a pollen-food syndrome: novel data and literature review

Summary

Background.Based on the cross-reactivity between pollen lipid transfer proteins (LTPs) and the peach LTP, Pru p 3, it has been suggested that the pollen might initiate the LTP sensitization process. Objective. To establish whether LTP allergy can be considered as a pollen-food syndrome. Methods. The literature was reviewed and new data of component-resolved diagnosis from Italy obtained by both ISAC immunoassay and ImmunoCAP on large populations of LTP hypersensitive patients were provided and analyzed. Results. Among Pru p 3 reactors, patients positive for Art v 3 and Pla a 3 largely exceeded those sensitized to the respective major pollen allergens, Art v 1 and Pla a 1/Pla a 2. Pru p 3 reactivity remained stable around 80-90% at all ages, whereas Art v 3 and Ole e 7 recognition was missing in younger patients. Pru p 3 IgE exceeded IgE specific for pollen LTP at all ages. Inhibition studies carried out on LTP reactors showed that commercial extracts of mugwort and plane pollen were unable to inhibit significantly Pru p 3 IgE reactivity. In follow-up studies, baseline Pru p 3 IgE levels exceeded Art v 3 IgE levels in 84% of those sensitized to both allergens, and all patients positive to only one LTP allergen at baseline were sensitized to Pru p 3. Further, most of the patients who did not show any LTP reactivity at baseline became exclusive Pru p 3 reactors. On ImmunoCAP singleplex Pru p 3 IgE levels exceeded Art v 3 IgE levels in 89% of cases (p less than 0.0001). Most literature data were in keeping with these new observations. Conclusions. The evidence for LTP syndrome being a pollen-food syndrome is presently very thin. Our data do not rule out the possible sensitization to the protein, via the airways or the skin.

Treatment of allergic rhinitis during and outside the pollen season using mobile technology. A MASK study

Background

The analysis of mobile health (mHealth) data has generated innovative insights into improving allergic rhinitis control, but additive information is needed. A cross-sectional real-world observational study was undertaken in 17 European countries during and outside the estimated pollen season. The aim was to collect novel information including the phenotypic characteristics of the users.

Methods

The Allergy Diary–MASK-air–mobile phone app, freely available via Google Play and App, was used to collect the data of daily visual analogue scales (VASs) for overall allergic symptoms and medication use. Fluticasone Furoate (FF), Mometasone Furoate (MF), Azelastine Fluticasone Proprionate combination (MPAzeFlu) and eight oral H1-antihistamines were studied. Phenotypic characteristics were recorded at entry. The ARIA severity score was derived from entry data. This was an a priori planned analysis.

Results

9037 users filled in 70,286 days of VAS in 2016, 2017 and 2018. The ARIA severity score was lower outside than during the pollen season. Severity was similar for all treatment groups during the pollen season, and lower in the MPAzeFlu group outside the pollen season. Days with MPAzeFlu had lower VAS levels and a higher frequency of monotherapy than the other treatments during the season. Outside the season, days with MPAzeFlu also had a higher frequency of monotherapy. The number of reported days was significantly higher with MPAzeFlu during and outside the season than with MF, FF or oral H1-antihistamines.

Conclusions

This study shows that the overall efficacy of treatments is similar during and outside the pollen season and indicates that medications are similarly effective during the year.

Comparison of the performance of Skin Prick and ISAC Tests in the diagnosis of allergy

Summary

The recent European Union and Italian regulations in the matter of in vivo test could strongly impact on current diagnostic approach, increasing the usage of in vitro tests in daily clinical practice. We evaluated 506 patients with both skin prick test and a microarray system (ImmunoCAP ISAC 112). The overall evaluation between ImmunoCAP^® ISAC vs SPT showed a moderate agreement (k=0.509, 95% C.I. 0.480-0.540, SE: 0.016) considering both aeroallergens and food allergens. When we considered the concordant results (double-positive plus double-negatives), the agreement ranged from 69% to 80% for pollen allergens, between 74% and 76% for dust mites, and between 74% and 93% for animal epithelia. In the case of food allergens, the accordance was pretty lower, accounting values ranging from 67% to 86%. ISAC testing identified from 22% to 26% more cases than SPTs in peach and nuts hyper-sensitivity. In 2.8% of the control group, the ISAC-test failed to detect an allergy sensitization caused by dust mite, shrimp, Anisakis, or seed storage proteins. Multiplex testing is more than a promising tool for more precise and comprehensive profiling of allergic patients and can be considered as a second-line approach, after the anamnesis, in the diagnosis of allergic diseases.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Evaluation of two commercial peach extracts for skin prick testing in the diagnosis of hypersensitivity to lipid transfer protein. A multicenter study

Summary

The clinical usefulness of two commercial peach extracts for SPT (by Lofarma SpA and ALK-Abellò, respectively) was compared in a multicenter study carried out in Italy. Peach allergic patients were tested with the two extracts in parallel and underwent the detection of IgE specific for all three peach allergens currently available (Pru p1, Pru p3, and Pru p4, respectively). The two extracts were almost identical in terms of sensitivity and specificity, being able to detect virtually all patients sensitized to stable peach allergens (lipid transfer protein (LTP) and, presumably, peamaclein) but scoring negative in patients exclusively sensitive to labile allergens (either PR-10 and/or profilin). Thus, the two extracts represent an excellent tool to carry out a preliminary component-resolved diagnosis of peach allergy at the first patient visit.

Recommendations for the Use of Tryptase in the Diagnosis of Anaphylaxis and Clonal Mastcell Disorders

Summary

Tryptase is a serin-protease produced and released by mast cells after IgE-mediated or non-IgE mediated stimuli. We here review the various aspects related to the molecular characteristics of the enzyme and its biological effects, the genetic basis of its production and the release kinetics. Recommendations for the clinical use of tryptase measurement developed by a task force of Società Italiana di Patologia Clinica e Medicina di Laboratorio and Associazione Allergologi Immunologi Italiani Territoriali e Ospedalieri are given on the best procedure for a correct definition of the reference values in relation to the inter-individual variability and to the correct determination of tryptase in blood and other biological liquids, in the diagnosis of anaphylaxis (from drugs, food, insect sting, or idiophatic), death from anaphylaxis (post mortem assessment) and cutaneous or clonal mastcell disorders.

Galactose-α-1,3-galactose syndrome: an Italian survey

Summary

Background. The term of α-Gal syndrome, which includes the delayed allergy to red meat and the allergic reactions following the administration of cetuximab, is associated to the presence of specific IgE to α-Gal. In Italy, only anecdotal cases were reported so far. The Association of Italian Allergists (AAITO) carried out a survey with the aim of evaluating presence, characteristics, clinical features, and distribution of the syndrome in Italy. Methods. A web structured questionnaire was made available on the website of AAIITO from July 2016 to January 2017. It included 31 multiple-choice questions concerning different items, including the site of physicians, the number of patients diagnosed as having cetuximab allergy and/or delayed red meat allergy, recall of tick bites, symptoms, time to reactions, elicitor foods, reactions with foods other than meat, and in-vivo and in-vitro tests used for the diagnosis. Results. Seventy-nine physicians completed the questionnaire. Nine cases of allergy to cetuximab and 40 cases of delayed red meat allergy were recorded across Italy. 22.5% of patients with cetuximab allergy and 62.5% of those with delayed red meat allergy recalled a tick bite. 75% of patients with delayed red meat allergy experienced symptoms after eating beef (butcher's cut in 72.5%). Urticaria was the most frequent clinical manifestation (65% of cases). In 60.6% of cases symptoms appeared 2 - 4 hours after meat ingestion, while in 7.9% symptoms appeared after > 4 hours. The most used diagnostic methods were the intradermal test for cetuximab allergy (88.9%) and the detection of IgE to α-Gal (55.5%) for red meat allergy. Most case reports came from Northern Italy. Conclusions. α-Gal syndrome is present in Italy and beef is the most frequent offending food. In most cases symptoms were not severe.

Honey extracts inhibit PTP1B, upregulate insulin receptor expression, and enhance glucose uptake in human HepG2 cells

Honey is a food known for its medical properties. In this work, we have studied the impact of different types of honey on insulin signalling pathway. We found that honey extracts inhibit the enzyme PTP1B, one of the main negative regulators of insulin receptor signalling. HPLC-MS analysis allowed us to confirm the presence of several natural PTP1B inhibitors in the honey extracts analysed. Statistical analysis methods show a correlation between specific ¹H-NMR resonance frequencies/HPLC peaks and the inhibitory power of the samples. This finding will allow the prediction of the biological properties of honey samples applying relative simple analytical methods. Finally, we demonstrated that the treatment of HepG2 cells with honey extracts enhances the expression of insulin receptor, and stimulates glucose uptake. For the first time, our results demonstrate that bioactive components of honey could improve glycaemic control by both inhibiting PTP1B and stimulating the expression of insulin receptor in liver cells.

Guidance to 2018 good practice: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma

Aims

Mobile Airways Sentinel NetworK (MASK) belongs to the Fondation Partenariale MACVIA-LR of Montpellier, France and aims to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle, whatever their gender or socio-economic status, in order to reduce health and social inequities incurred by the disease and to improve the digital transformation of health and care. The ultimate goal is to change the management strategy in chronic diseases.

Methods

MASK implements ICT technologies for individualized and predictive medicine to develop novel care pathways by a multi-disciplinary group centred around the patients.

Stakeholders

Include patients, health care professionals (pharmacists and physicians), authorities, patient’s associations, private and public sectors.

Results

MASK is deployed in 23 countries and 17 languages. 26,000 users have registered.

EU grants (2018)

MASK is participating in EU projects (POLLAR: impact of air POLLution in Asthma and Rhinitis, EIT Health, DigitalHealthEurope, Euriphi and Vigour).

Lessons learnt

(i) Adherence to treatment is the major problem of allergic disease, (ii) Self-management strategies should be considerably expanded (behavioural), (iii) Change management is essential in allergic diseases, (iv) Education strategies should be reconsidered using a patient-centred approach and (v) Lessons learnt for allergic diseases can be expanded to chronic diseases.

MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary.

An atlas of IgE sensitization patterns in different Italian areas. A multicenter, cross-sectional study

Summary

Background. The development of recombinant technology supported the allergy diagnostic work-up in the daily clinical practice, representing a useful tool for epidemiological studies. Methods. An atlas of the IgE sensitization profiles found throughout Italy was prepared from a nationwide, multicenter, cross-sectional study. Results. 6052 unselected consecutive individuals, belonging to North-West [NW], North-East [NE], Centre [C], South [S], and Islands subset [Is] were evaluated by means of the ImmunoCAP ISAC test. The top-ranked sensitizations found were Cup a 1 in [C] (58.1%) and [S] (53.6%), Phl p 1 in the North (from 46.1% to 49%), and Cyn d 1 in [Is] (44.2%). High frequency of house dust mite group 2 molecules sensitization was found in [C] (36.9%) and [S] Italy (40.8%), whilst low level of reactivity was recorded in [NW] (20%). Pellitory hypersensitivity was mainly found in [C], [S], and [Is], whilst ragweed Amb a 1 sensitivity was particularly found in [NW] Italy. IgE recognition of PR-10, Profilin, and nsLTP was mutually exclusive in 69.1% of cases, PR-10 reactivity mostly occurring in [NE], Profilin in [NW], and nsLTP molecules recognition mainly recorded in [C] and [S]. Conclusions. Divergent IgE sensitization patterns were found along Italy, possibly linked to the distinct geographical locations, indicating multiplex system IgE analysis as a reliable approach for epidemiological evaluation even in small geographical areas.

News on Climate Change, Air Pollution, and Allergic Triggers of Asthma

The rising frequency of obstructive respiratory diseases during recent years, in particular allergic asthma, can be partially explained by changes in the environment, with the increasing presence in the atmosphere of chemical triggers (particulate matter and gaseous components such as nitrogen dioxide and ozone) and biologic triggers (aeroallergens). In allergic individuals, aeroallergens stimulate airway sensitization and thus induce symptoms of bronchial asthma. Over the last 50 years, the earth's temperature has risen markedly, likely because of growing concentrations of anthropogenic greenhouse gas. Major atmospheric and climatic changes, including global warming induced by human activity, have a considerable impact on the biosphere and on the human environment. Urbanization and high levels of vehicle emissions induce symptoms of bronchial obstruction (in particular bronchial asthma), more so in people living in urban areas compared than in those who live in rural areas. Measures need to be taken to mitigate the future impact of climate change and global warming. However, while global emissions continue to rise, we must learn to adapt to climate variability.

Pla a 2 and Pla a 3 reactivities identify plane tree-allergic patients with respiratory symptoms or food allergy

Nine hundred and thirty-nine rPla a 1, nPla a 2, and rPla a 3 ImmunoCAP ISAC reactors were studied. nPla a 2^pos MUXF3^pos but Pla a 1/2^neg subjects were excluded from the study because they were cross-reactive carbohydrate determinant reactors. Among the 764 remaining participants, 71.9% were Pla a 3^pos , 54.1% Pla a 2^pos , and 10.9% Pla a 1^pos . Among Pla a 3 reactors, 89.6% were Pru p 3^pos and 86.8% Jug 3^pos , but the strongest IgE recognition relationship was observed between Pla a 3 and Jug r 3. Distinctive clinical subsets could be documented among plane tree-allergic patients. Pla a 3 reactors had both local and systemic food-induced reactions, but lower past respiratory symptoms occurrence. Pla a 2 reactivity was associated with respiratory symptoms but inversely related to systemic reactions to food. Cosensitization to Pla a 2 and Pla a 3 was associated with a lower past incidence of severe food-induced reactions.

Parietaria pollination duration: myth or fact?

Background. Even though the Parietaria pollen season may be rather long, it is commonly thought that Parietaria pollen is a perennial allergen present along the whole year. Objective. This study aimed at investigating the duration of Parietaria pollen season during a 10-year period in Italy, analysing also the annual pollen quantity and the differences among geographical areas. Methods. Pollen count was assessed daily for 10 years. Globally, ten Italian centers measured Parietaria pollen count. Start date, peak date, end date, duration (days), peak value, and seasonal pollen index were evaluated in each center. Results. Ten-year Parietaria pollen count demonstrates that the pollen season usually lasted for 6-7 months in Italy. There are important differences among centres, mainly attributable to geoclimatic factors. Conclusion. This study demonstrates that Parietaria pollen season lasts about 6-7 months with two peaks (mainly in spring and lower in autumn) in Italy with important geographical variations. This information may have clinical relevance in managing patients allergic to Parietaria.

Thunderstorm-related asthma: what happens and why

The fifth report issued by the Intergovernmental Panel on Climate Change forecasts that greenhouse gases will increase the global temperature as well as the frequency of extreme weather phenomena. An increasing body of evidence shows the occurrence of severe asthma epidemics during thunderstorms in the pollen season, in various geographical zones. The main hypotheses explaining association between thunderstorms and asthma claim that thunderstorms can concentrate pollen grains at ground level which may then release allergenic particles of respirable size in the atmosphere after their rupture by osmotic shock. During the first 20-30 min of a thunderstorm, patients suffering from pollen allergies may inhale a high concentration of the allergenic material that is dispersed into the atmosphere, which in turn can induce asthmatic reactions, often severe. Subjects without asthma symptoms, but affected by seasonal rhinitis can also experience an asthma attack. All subjects affected by pollen allergy should be alerted to the danger of being outdoors during a thunderstorm in the pollen season, as such events may be an important cause of severe exacerbations. In light of these observations, it is useful to predict thunderstorms and thus minimize thunderstorm-related events.

Lipid transfer protein sensitization: reactivity profiles and clinical risk assessment in an Italian cohort

BACKGROUND

Nonspecific lipid transfer proteins (nsLTPs) represent a major cause of systemic food allergic reactions in the Mediterranean area. This study investigate hierarchical patterns and cluster relationships of IgE sensitization to different nsLTPs, and the relationship to clinical allergy in a large Italian cohort.

METHODS

A total of 568 nsLTP-positive subjects after IgE ImmunoCAP-ISAC microarray analysis with Ara h 9, Art v 3, Cor a 8, Jug r 3, Pla a 3, Pru p 3 and Tri a 14 allergens were studied. IgE inhibition experiments were carried out with mugwort and plane tree pollen extracts.

RESULTS

Eighty-two per cent of nsLTP-positive participants (94% if <6 years old) were Pru p 3(pos) , and 71% were Jug r 3(pos) . Participants who reacted to >5 nsLTPs reported a higher incidence of food-induced systemic reactions. Only Art v 3 and Pla a 3 (mugwort and plane tree nsLTPs, respectively) were associated with respiratory symptoms, and a correlation was observed between sensitization to pollen and plant food nsLTPs, particularly between Pla a 3 and tree nut/peanut nsLTPs. Co-sensitization to Par j 2 and PR-10 or profilin pan-allergens was associated with a lower prior prevalence of severe food-induced reactions. In inhibition assays, plane and mugwort pollen extracts inhibited 50-100% of IgE binding to food nsLTPs in microarrays.

CONCLUSIONS

Testing IgE reactivity to a panel of nsLTP allergens unveils important associations between nsLTP sensitization profiles and clinical presentation and allows the identification of novel cluster patterns indicating likely cross-reactivities and highlighting potential allergens for nsLTP immunotherapy.

Monitoring of occupational and environmental aeroallergens-- EAACI Position Paper. Concerted action of the EAACI IG Occupational Allergy and Aerobiology & Air Pollution

Exposure to high molecular weight sensitizers of biological origin is an important risk factor for the development of asthma and rhinitis. Most of the causal allergens have been defined based on their reactivity with IgE antibodies, and in many cases, the molecular structure and function of the allergens have been established. Significant information on allergen levels that cause sensitization and allergic symptoms for several major environmental and occupational allergens has been reported. Monitoring of high molecular weight allergens and allergen carrier particles is an important part of the management of allergic respiratory diseases and requires standardized allergen assessment methods for occupational and environmental (indoor and outdoor) allergen exposure. The aim of this EAACI task force was to review the essential points for monitoring environmental and occupational allergen exposure including sampling strategies and methods, processing of dust samples, allergen analysis, and quantification. The paper includes a summary of different methods for sampling and allergen quantification, as well as their pros and cons for various exposure settings. Recommendations are being made for different exposure scenarios.

Detection of 20 kDa and 32 kDa IgE-binding proteins as the major allergens in Italian sesame seed allergic patients

BACKGROUND

Sesame seed allergy, a potentially very severe food allergy, seems on the rise worldwide but is still uncommon in Italy. The aim of the present study was to investigate the allergenic profile of Italian sesame seed-allergic patients.

METHODS

Patients with genuine sesame seed allergy diagnosed over one year in a large number of allergy centers scattered through Italy were considered for the study. Their IgE reactivity to sesame seed allergens was characterized by immunoblot analysis.

RESULTS

Eleven sesame seed allergic patients were detected and studied. 10/10 patients showed IgE reactivity against a sesame allergen at about 20 kDa, and 7/10 showed an extremely strong reactivity at about 32 kDa. The same 7 sera reacted also against a 28 kDa allergen, although such reactivity was significantly weaker in 6/7 cases. Eight patients showed IgE reactivity at about 48 kDa, and 5 sera reacted against higher m.w. proteins at about 67 kDa. Two sera showed IgE reactivity at about 43 kDa as well. Only one serum appeared to react to 2S-albumin.

CONCLUSIONS

Italian sesame seed-allergic patients react mostly against allergens other than those described so far as major ones. A large number of recombinant sesame allergens will be needed for a comprehensive component- resolved diagnosis of allergy to this food.

Common ragweed: a threat to environmental health in Europe

Common or short ragweed (Ambrosia artemisiifolia L.) is an annual herb belonging to the Asteraceae family that was described by Carl Linnaeus in the 18th century. It is a noxious invasive species that is an important weed in agriculture and a source of highly allergenic pollen. The importance placed on A. artemisiifolia is reflected by the number of international projects that have now been launched by the European Commission and the increasing number of publications being produced on this topic. This review paper examines existing knowledge about ragweed ecology, distribution and flowering phenology and the environmental health risk that this noxious plant poses in Europe. The paper also examines control measures used in the fight against it and state of the art methods for modelling atmospheric concentrations of this important aeroallergen. Common ragweed is an environmental health threat, not only in its native North America but also in many parts of the world where it has been introduced. In Europe, where the plant has now become naturalised and frequently forms part of the flora, the threat posed by ragweed has been identified and steps are being taken to reduce further geographical expansion and limit increases in population densities of the plant in order to protect the allergic population. This is particularly important when one considers possible range shifts, changes in flowering phenology and increases in the amount of pollen and allergenic potency that could be brought about by changes in climate.

Towards a global vision of molecular allergology: a map of exposure to airborne molecular allergens

Allergy diagnostics have changed in the last 10-15 y, moving from the use of extracts for in vivo and in vitro diagnosis to the Component Resolved Diagnosis, based on purified or recombinant allergens. As expected, aerobiology developed similarly, and measurement of allergens in both outdoor and indoor air is now feasible. With the aim of promoting a global view of molecular allergy, we have drawn a map of exposure to molecular aeroallergens in Italy on the bases of geo-climatic regions, maps of pollen distribution, and published data on the molecular profile of sensitization in Italian patients. Given the latitudinal extension of Italy, the profile of exposure to some allergens, such as those of the "Birch Group" and weeds, varies greatly from North to South, while the distribution of exposure to grass allergens is more homogeneous. This map can contribute to a global molecular vision of allergy, helping clinicians to view exposure to pollen in a new way. The exposure profile of the area where patients live can also indicate the correct choice of molecular diagnostics and, therefore, of the appropriate allergen immunotherapy.

Airborne olive pollen counts are not representative of exposure to the major olive allergen Ole e 1

Pollen is routinely monitored, but it is unknown whether pollen counts represent allergen exposure. We therefore simultaneously determined olive pollen and Ole e 1 in ambient air in Córdoba, Spain, and Évora, Portugal, using Hirst-type traps for pollen and high-volume cascade impactors for allergen. Pollen from different days released 12-fold different amounts of Ole e 1 per pollen (both locations P < 0.001). Average allergen release from pollen (pollen potency) was much higher in Córdoba (3.9 pg Ole e 1/pollen) than in Évora (0.8 pg Ole e 1/pollen, P = 0.004). Indeed, yearly olive pollen counts in Córdoba were 2.4 times higher than in Évora, but Ole e 1 concentrations were 7.6 times higher. When modeling the origin of the pollen, >40% of Ole e 1 exposure in Évora was explained by high-potency pollen originating from the south of Spain. Thus, olive pollen can vary substantially in allergen release, even though they are morphologically identical.

A relapse of near-fatal thunderstorm-asthma in pregnancy

Thunderstorm-related asthma is a dramatic example of the allergenic potential of pollen antigens. Pollen allergic patients who encounter the allergenic cloud of pollen during a thunderstorm are at higher risk of having an asthma attack. Relapse is also possible and we describe here the first case of relapse of near fatal thunderstorm-asthma occurred in a 36 years old, 20 weeks pregnant woman affected by seasonal asthma and sensitized to allergens released by Parietariapollen. Patients suffering from pollen allergy should be alerted of the danger of being outdoors during a thunderstorm in the pollen season and if they experienced an episode of severe thunderstorm-related asthma could be at risk of a relapse during a heavy precipitation event.

Identification and assay of carbohydrates in olive drupes by cesium attachment electrospray tandem mass spectrometry (ESI-MS/MS)

Identification and assay of sugars in olive drupes during their ripening phase is evaluated by tandem mass spectrometry. Recent achievements have shown that the quality of an extra virgin olive oil can be directly correlated to the ripening degree of the drupes that is likely linked to their saccharides content. An innovation in this peculiar food chain is now proposed that considers a high throughput assessment of the carbohydrate content by a recently introduced protocol based on the gas-phase chemistry of sugar-cesium adducts by ESI-MS/MS.

Exploring element accumulation patterns of a metal excluder plant naturally colonizing a highly contaminated soil

This work investigates the element distribution in Silene paradoxa growing on the mine dump of Fenice Capanne (Tuscany, Italy). The accumulation of As, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb and Zn in root apoplast and symplast and in shoot was assessed and compared to the levels of the same metals in the respective rizosphere soils, analyzing both the total and the phytoavailable fractions. Levels of As, Cu, Fe, Pb and Zn, were above toxicity thresholds in both soil and shoot samples. Inter- and intra-element correlations were analyzed in plant and soil using different statistical methods. Soil total and phytoavailable metal concentration were shown not to be dominant in determining metal accumulation by the plant, since no significant positive correlation was found between metal concentration in soils and plants. Moreover, results indicated that S. paradoxa was able to cope with the studied multi-metal contaminated soil excluding the elements from its tissues and preferentially accumulating them into the root compartment, thus suggesting this species as possible good candidate for phytostabilization purposes.

Social networks: a new source of psychological stress or a way to enhance self-esteem? Negative and positive implications in bronchial asthma

The Internet and, in particular, social networks are an increasingly important part of daily life for both adolescents and adults who maintain a virtual relationship with others sharing interests and goals. Very often, they disclose more about themselves online than they do in person. However, cyberbullying and cyberostracism can be problematic for adolescents and sensitive individuals, who might be negatively affected by social networks. Some studies have shown an increased risk of depression, whereas others suggest beneficial effects through enhanced communication, social connection, and self-esteem. Bronchial asthma is an increasingly frequent disease in the industrialized world, and psychological implications play a role in increasing or in reducing its severity. One year after the case report of an asthma exacerbation that may have been triggered by Facebook, it seems reasonable to analyze the effects of social networks on bronchial asthma.

Has allergenic pollen an impact on non-allergic diseases?

Recent observations suggest that pollen do not only interacts with the human immune system to elicit an allergic response in susceptible individuals. It would have a much broader impact on human health. This applies more especially, yet not exclusively, to three groups of diseases: non-allergic respiratory conditions, cardio- and cerebrovascular accidents, and psychiatric disorders including suicide and suicide attempt. At present, the reasons for these unexpected connections are only hypothetical, and require further exploration in larger samples, but there is perhaps a multitude of them. One must therefore favour a holistic approach of pollen and its impact on human health.

Sensitization to horse allergens in Italy: a multicentre study in urban atopic subjects without occupational exposure

BACKGROUND

Horses play a significant role in people's leisure time in Italy and other countries, but few data are available on IgE-mediated sensitization to horse allergens in patients without occupational exposure. We assessed, in a multicentric survey, the prevalence of horse sensitization in atopic subjects and its clinical characteristics.

METHODS

Allergists from the whole Italian territory were required to collect the results of skin prick tests from at least 100 consecutive subjects. Those patients with a positive skin test to horse dander underwent a detailed interview concerning clinical history, pet ownership and possible exposure.

RESULTS

Data from 3,235 outpatients were collected and 2,097 had at least 1 skin positivity. Among them, 113 (5.38%) were sensitized to horse dander (9 monosensitized). Thirty patients reported direct horse contact (4 owners and 26 for riding or occasional contact), 23 patients were sometimes in contact with horse owners and 60 subjects denied any direct or indirect exposure. Among 9 horse monosensitized patients, 6 had intermittent and mild rhinitis and 3 persistent moderate/severe rhinitis plus asthma. Three of them were horse owners or riders and the remaining had no contact with the animal.

CONCLUSIONS

Our data evidence that the rate of sensitization to horse dander is not negligible and probably underestimated. In susceptible, not occupationally exposed individuals, horse contact, but also indirect or no apparent exposure, may induce sensitization. We recommend inclusion of horse allergen in the routine panel for the diagnosis of respiratory allergy.

Projections of the effects of climate change on allergic asthma: the contribution of aerobiology

Climate change is unequivocal and represents a possible threat for patients affected by allergic conditions. It has already had an impact on living organisms, including plants and fungi with current scenarios projecting further effects by the end of the century. Over the last three decades, studies have shown changes in production, dispersion and allergen content of pollen and spores, which may be region- and species-specific. In addition, these changes may have been influenced by urban air pollutants interacting directly with pollen. Data suggest an increasing effect of aeroallergens on allergic patients over this period, which may also imply a greater likelihood of the development of an allergic respiratory disease in sensitized subjects and exacerbation of symptomatic patients. There are a number of limitations that make predictions uncertain, and further and specifically designed studies are needed to clarify current effects and future scenarios. We recommend: More stress on pollen/spore exposure in the diagnosis and treatment guidelines of respiratory and allergic diseases; collection of aerobiological data in a structured way at the European level; creation, promotion and support of multidisciplinary research teams in this area; lobbying the European Union and other funders to finance this research.

Urban air pollution and climate change as environmental risk factors of respiratory allergy: an update

The incidence of allergic respiratory diseases and bronchial asthma appears to be increasing worldwide, and people living in urban areas more frequently experience these conditions than those living in rural areas. One of the several causes of the rise in morbidity associated with allergic respiratory diseases is the increased presence of outdoor air pollutants resulting from more intense energy consumption and exhaust emissions from cars and other vehicles. Urban air pollution is now a serious public health hazard. Laboratory studies confirm epidemiologic evidence that air pollution adversely affects lung function in asthmatics. Damage to airway mucous membranes and impaired mucociliary clearance caused by air pollution may facilitate access of inhaled allergens to the cells of the immune system, thus promoting sensitization of the airway. Consequently, a more severe immunoglobulin (Ig) E-mediated response to aeroallergens and airway inflammation could account for increasing prevalence of allergic respiratory diseases in polluted urban areas. The most abundant components of urban air pollution in urban areas with high levels of vehicle traffic are airborne particulate matter, nitrogen dioxide, and ozone. In addition, the earth's temperature is increasing, mainly as a result of anthropogenic factors (e.g., fossil fuel combustion and greenhouse gas emissions from energy supply, transport, industry, and agriculture), and climate change alters the concentration and distribution of air pollutants and interferes with the seasonal presence of allergenic pollens in the atmosphere by prolonging these periods.

Effects of climate change on environmental factors in respiratory allergic diseases

A body of evidence suggests that major changes involving the atmosphere and the climate, including global warming induced by human activity, have an impact on the biosphere and the human environment. Studies on the effects of climate change on respiratory allergy are still lacking and current knowledge is provided by epidemiological and experimental studies on the relationship between asthma and environmental factors, such as meteorological variables, airborne allergens and air pollution. However, there is also considerable evidence that subjects affected by asthma are at an increased risk of developing obstructive airway exacerbations with exposure to gaseous and particulate components of air pollution. It is not easy to evaluate the impact of climate change and air pollution on the prevalence of asthma in general and on the timing of asthma exacerbations. However, the global rise in asthma prevalence and severity suggests that air pollution and climate changes could be contributing. Pollen allergy is frequently used to study the interrelationship between air pollution, rhinitis and bronchial asthma. Epidemiological studies have demonstrated that urbanization, high levels of vehicle emissions and westernized lifestyle are correlated to an increase in the frequency of pollen-induced respiratory allergy, prevalent in people who live in urban areas compared with those who live in rural areas. Meteorological factors (temperature, wind speed, humidity, etc.) along with their climatological regimes (warm or cold anomalies and dry or wet periods, etc.), can affect both biological and chemical components of this interaction. In addition, by inducing airway inflammation, air pollution overcomes the mucosal barrier priming allergen-induced responses. In conclusion, climate change might induce negative effects on respiratory allergic diseases. In particular, the increased length and severity of the pollen season, the higher occurrence of heavy precipitation events and the increasing frequency of urban air pollution episodes suggest that environmental risk factors will have a stronger effect in the following decades.