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Rationale Environmental exposures have been associated with adverse outcomes in COPD. Approximately one third of individuals with COPD have allergic sensitization, but it is unknown whether exposure to allergens in the home are associated with outcomes. Objectives To determine the prevalence and associations of allergen sensitization with exposure to common indoor allergens with symptoms and exacerbation risk in COPD. Methods Allergen sensitization to five common indoor allergens was assessed in former smokers with COPD. Home settled dust was assessed for presence of corresponding allergens. Sensitization and exposure status were determined and associations evaluated in adjusted models with longitudinal outcomes including symptoms, lung function and exacerbations. Interactions were assessed between sensitization/exposure status and lung function. Measurements and Main Results One hundred eighty-three individuals studied were on average 67.3 years old (SD 8.22) with average FEV1 of 53.2 % (SD 17.6%). Seventy-seven percent of participants were exposed to at least one tested allergen, and 17% had sensitization with corresponding allergen exposure. After adjustment, sensitization with exposure was associated with lower lung function (β -8.29, 95% CI -14.80 to -1.77), higher SGRQ (β 6.71, 95% CI 0.17 to 13.25) and higher exacerbation risk (OR 2.31, 95% CI 1.11 to 4.79). Associations appeared to be more pronounced among individuals with lower lung function. Conclusions Allergen exposures are common in COPD and associated with adverse outcomes among those with concomitant allergen sensitization. This study establishes allergens as an important home exposure that potentially could be addressed with comprehensive home environmental modification strategies to improve COPD outcomes.

Egg white (EW) allergy model mice underwent 15-day oral immunotherapy (OIT) using diets with different corn-oil content and 1% EW. After OIT, mortality following an oral food challenge in OIT groups was approximately 90%. However, in previous studies, mortality was 0%. This phenomenon is to be associated with increased corn-oil intake during allergy sensitization and allergen exposure for 2 weeks.

Pollen allergies are responsible for a considerable global public health burden, and understanding exposure is critical to addressing the health impacts. Atmospheric pollen counts are routinely used as a predictor of risk; however, immune responses are triggered by specific proteins known as allergens, which occur both within and on the surface of the pollen grain. The ratio between atmospheric pollen counts and allergen concentrations (‘pollen potency’) has been shown to be inconsistent, with potentially important implications for pollen monitoring practice. Despite this, there has been no previous synthesis of the literature and our understanding of the factors that influence pollen potency remains poor. We conducted a scoping review with the aim of deriving a current understanding of: (a) the factors that influence pollen potency; (b) its variation through time, between taxa and by location; and (c) the implications for pollen monitoring practice. Our synthesis found that pollen potency is highly variable within and between seasons, and between locations; however, much of this variability remains unexplained and has not been deeply investigated. We found no predictable pollen potency patterns relating to taxon, geography or time, and inconclusive evidence regarding possible driving factors. With respect to human health, the studies in our synthesis generally reported larger associations between atmospheric allergen loads and allergy symptoms than whole pollen counts. This suggests that pollen potency influences public health risk; however, the evidence base remains limited. Further research is needed to better understand both pollen potency variability and its implications for health.

BACKGROUND Sensitization to house dust mite (HDM) is a leading cause of allergic rhinitis and asthma. Despite more than 30 HDM-derived allergens having been identified to date, specific therapeutic approaches do not yet take into account the local sensitization profiles of patients. This study aimed to identify patterns of HDM sensitization in HDM-allergic adults living in distinct geographic areas, to inform the development of targeted diagnostic and therapeutic tools. METHODS Serum samples from 685 HDM-allergic subjects from Canada, Europe, South Africa, and the USA were tested for levels of IgE specific for 17 micro-arrayed HDM allergens by ImmunoCAP Immuno Solid-phase Allergen Chip (ISAC) technology. RESULTS The results confirmed significant geographical variability in sensitization patterns and levels of IgE. In all areas, the major sensitizers were the group 1 and group 2 allergens and Der p 23. Der p 23 was a frequent sensitizer: 64% of the subjects had IgE specific for Der p 23, and 2.3% were monosensitized to it. In South Africa, Der p 23 was the dominant HDM allergen (86% prevalence) and Der p 7 achieved major allergen status (56%). IgE sensitization to HDM was influenced by asthmatic status, levels of allergen exposure, age, race-ethnicity and smoking status, but not by BMI. CONCLUSION Sensitization profiles to HDM allergens differ considerably among distinct geographic areas, with Der p 7 and Der p 23 being major sensitizers in South Africa. Such heterogeneity should be taken into account in the diagnosis and treatment of HDM-allergic patients.

Background: Sublingual immunotherapy (SLIT) had good effectiveness for children with allergic rhinitis (AR). However, no studies explored the effect of persistent allergen exposure on SLIT treatment. Coronavirus disease 2019 (COVID-19) restricts outdoor activities of children significantly. We aimed to evaluate the effectiveness of SLIT during this special period. Methods: A total of 335 AR children who sensitize to house dust mite (HDM) undergoing SLIT were recruited in this study. The clinical effectiveness and safety were evaluated at different time points using symptom and medication scores. The serum total IgE and specific IgE (sIgE) at different time points were detected by using the Unicap system. Results: The total nasal symptoms score (TNSS) and total medication score (TMS) during the epidemic of COVID-19 increased significantly compared with the same period last year (p < 0.05), despite that they were still significantly lower than baseline levels (p < 0.05). The occurrence of adverse reactions at different time points had no significant differences. We also found that the family of the good response group had more frequent bedding cleaning. Both the tIgE and sIgE levels had no significant changes during SLIT treatment. Conclusion: Our results suggest that continuous HDM exposure reduced the effectiveness of SLIT, whereas effective reduction of HDM levels by frequent bed cleaning will be helpful during the SLIT treatment.

International audience; This review analyzes the state and recent progress in the field of information support for pollen allergy sufferers. For decades, information available for the patients and allergologists consisted of pollen counts, which are vital but insufficient. New technology paves the way to substantial increase in amount and diversity of the data. This paper reviews old and newly suggested methods to predict pollen and air pollutant concentrations in the air and proposes an allergy risk concept, which combines the pollen and pollution information and transforms it into a qualitative risk index. This new index is available in an app (Mobile Airways Sentinel NetworK-air) that was developed in the frame of the European Union grant Impact of Air POLLution on sleep, Asthma and Rhinitis (a project of European Institute of Innovation and Technology-Health). On-going transformation of the pollen allergy information support is based on new technological solutions for pollen and air quality monitoring and predictions. The new information-technology and artificial-intelligence-based solutions help to convert this information into easy-to-use services for both medical practitioners and allergy sufferers.

Background: Wheezing is a highly frequent symptom in paediatric populations. An etiologic diagnostic is complex and becomes more difficult with younger children. For asthma, allergen exposure plays a fundamental role in sensitization, and subsequent acute and chronic symptoms Skin prick test (SPT) allows detection of sensitization safely and efficiently in all age-groups. Aim and objectives: To assess the prevalence of sensitization to aeroallergens in a pediatric population with recurrent wheezing episodes using SPT. Methodology: Cross-sectional observation study to study the type of allergic sensitivity in a pediatric population in Hyderabad. Results: Children with recurrent (4 or more episodes of wheezing in the past year) ages between 2yrs to 10 yrs. The total number of the patients included in the study was 100 patients, 50 (50%) male and 50 (50%) with Mean Age = 6.15 years. Out of the 50 male cases, 35 (70%) had positive SPT to at least one of the aeroallergens and 15 (30%) were negative for all aeroallergens tested. Out of the 50 female cases, 32(64%) had a positive SPT to at least one of the aeroallergens and 18(36%) were negative for all aeroallergens. Out of 100 children, 67 (67%) had positive SPT to at least one of the aeroallergens. 26 (70.2%) of patients with positive tests were in the age group 5-7 years and 26 (78.78%) were in the age group of 8-10 Yrs. Only 15 (48.3%) were found in the age group 2-4 years. The highest prevalence of positive skin reaction was recorded for mite allergens among them Dermatophytosis pteronyssinus (80.5%), D. Farinae (80.5%), Bloomia (56.4%), among Fungi group, Aspergillus fumigates (11.9%) Alternaria alternate (10.4%), Cladosporium herbarum (2.9%) Cat, cockroach and pigeon showed positive in (19.4%) (14.9%) and (4.4%) of cases respectively. Allergy to indoor allergens was significantly higher than outdoor allergens (P-value

Introduction The relationship between allergen exposure to animals in pregnancy and the development of allergic symptoms is not clear. Aim To evaluate the association between prenatal and postnatal exposure to pet ownership and development of atopic dermatitis, food allergy and wheezing in children at the age of 1 and 2. Material and methods The mother-child pairs included in this study were part of the Polish Mother and Child Cohort. Mothers in each trimester of pregnancy and 1 year after childbirth have completed a questionnaire on animal exposure. Children's health status was assessed at around one year and two years of age. Results Keeping a dog at home before and during pregnancy (every trimester) decreased the risk of food allergy in the first year of life. On the other hand, keeping any animal other than a dog (cat, hamster, guinea pig, rabbit) before pregnancy and during each trimester separately increased the risk of food allergy in the first year of life of children. Keeping a guinea pig in the first trimester of pregnancy increased the risk of wheezing in the first year of life. The analysis did not show any significant associations between keeping animals at home before and during pregnancy and the occurrence of atopic dermatitis in the second year of life. Conclusions Keeping a dog at home before and during pregnancy decreased the risk of food allergy in 1-year-old children. This effect was eliminated in case of having a cat, hamster, guinea pig, or rabbit.

Storage mites (SM) may induce allergic respiratory symptoms in sensitized individuals, in both rural and urban settings. The relationship among specific IgE reactions to determined groups of SM allergens in the coincident asthma pheno-endotypes has not yet been investigated. We aimed to study a Precision Allergy Molecular Diagnosis (PAMD@) model to depict the SM molecular profile in individuals presenting with Type-2 inflammation, in two different (moderate and severe) asthma phenotypes. A customized PAMD@ panel, including SM allergens and their concurrent protein allergenic characterization was investigated. Mite group 2 allergens were most frequently recognized, including Lep d 2 (83.45%), followed by Gly d 2 (69.17%) and Tyr p 2 (47,37%), in 133/164 asthmatic subjects. Blo t 5 and Blo t 21 exhibited significant higher titres in both asthma groups. Although relevant mite group 2 allergens cross-reactivity is suggested, individualized sensitization patterns were relevantly identified. The present PAMD@ panel confirmed the dominance of mite group 2 allergens in moderate-to-severe T2 asthmatics. A broadly heterogeneous molecular repertoire of SM allergens was found in all subjects, regardless of their asthma severity. Blomia tropicalis deserves special attention in certain territories, as diagnostic and/or therapeutic approaches merely based on Pyroglyphidae mites may be insufficient.

There continues to be an erroneous belief that allergens (especially food allergens) are more resistant to gastrointestinal digestion than non-allergens. Government regulations based on this erroneous belief may result in technology developers altering the amino acid sequences of digestively stable native proteins to create digestively unstable modified versions for expression in genetically engineered crops. However, an investigation where a known stable allergen was modified to make it more digestible eliminated the protein’s ability to tolerize against allergy in a mouse model, which is consistent with the dual allergen exposure hypothesis. Thus, the false belief that digestive stability increases the allergenic risk of novel food proteins (e.g., such as expressed in genetically engineered crops) could, in some cases, lead to introduction of digestively unstable modified protein versions with greater sensitization risk. However, it is noteworthy that developers have historically been very effective at preventing allergens from being introduced into crops based on the other components of the weight-of-evidence assessment of allergenic risk such that no newly expressed protein in any commercialized genetically engineered crop has ever been documented to cause allergy in anyone.

PURPOSE OF REVIEW We evaluated the time-course of clinical and immunologic changes that occur during and after cessation of sublingual and subcutaneous allergen immunotherapy for inhalant allergies. RECENT FINDINGS Increases in production of inhibitory cytokines, such as IL-10 and allergen-specific IgE and IgG4 antibodies are induced within weeks of starting immunotherapy for both seasonal and perennial allergens. In general, 2-4 months' immunotherapy is needed for onset of efficacy whereas maximal clinical effect is achieved within 1-2 years of treatment. Therefore, assuming optimal patient selection, good compliance and at least moderate allergen exposure, if immunotherapy is ineffective at 2 years, it is reasonable to discontinue the treatment. For long-term clinical efficacy, at least 3 years of either subcutaneous or sublingual immunotherapy is required and this results in clinical and immunologic tolerance -- persistence of clinical benefits and suppression of type 2 immunity for years after discontinuation of treatment. SUMMARY Both sublingual and subcutaneous immunotherapy are effective and well tolerated for respiratory allergy. Clinical and immunological changes occur at early stages of treatment. Long-term evaluations support recommendations in international guidelines that both routes of administration should be continued for a minimum of 3 years to achieve disease modification and long-term tolerance.

Objectives Most studies on indoor allergen exposure used vacuumed surface samples for quantification. One alternative is electrostatic dust collectors (EDCs), which sample previously airborne settled dust. The aim of this study was to compare allergen quantification using two different sampling methods, with respect to repeatability, and to determine how well the results agree with one another. Methods Four times a year, measurements were made from samples that were either collected from the vacuuming of surfaces, or from EDCs, from 20 German day-care centers totaling 167 rooms. Overall, 504 vacuumed samples collected from smooth floors, 435 samples from carpets, 291 samples from upholstered furniture and beds, and 605 EDC samples were analyzed using six fluorescence enzyme immunoassays recognizing Fel d 1, Can f 1, Mus m 1, domestic mite (DM), Dermatophagoides pteronyssinus (Dp), and Tyrophagus putrescentiae (Tp) antigens. Variances and correlations among the repeat measurements over the course of the year within each sample type, and the correlations between surface samples and the corresponding EDC samples were calculated. Results Repeat measurements over the year correlated significantly with one another. However, only Fel d 1, Can f 1, and DM in the EDC samples; DM, Dp, Tp, and Fel d 1 in the upholstered furniture samples; and DM in the carpet samples show representative results of single measurements according to their variance ratios (within-room/between-room variance Conclusions Both vacuumed dust from upholstered furniture and EDC samples were suitable for repeatable quantification of several allergens in day-care centers within a year. However, there was little agreement among the different collection methods, especially for Mus m 1 and certain mite antigens. Therefore, the method and location used for collection may greatly influence allergen exposure assessment and study results.

Allergen immunotherapy (AIT) is a proven therapeutic option for the treatment of allergic rhinitis and/or asthma. Many guidelines or national practice guidelines have been produced but the evidence- based method varies, many are complex and none propose care pathways. This paper reviews care pathways for AIT using strict criteria and provides simple recommendations that can be used by all stakeholders including health professionals. The decision to prescribe AIT for the patient should be individualized and based on the relevance of the allergens, the persistence of symptoms despite appropriate medications according to guidelines as well as on the availability of good-quality and efficacious extracts. Allergen extracts cannot be regarded as generics. Immunotherapy is selected by specialists for stratified patients. There are no currently available validated biomarkers that can predict AIT success. In adolescents and adults, AIT should be reserved for patients with moderate/severe rhinitis or for those with moderate asthma who, despite appropriate pharmacotherapy and adherence, continue to exhibit exacerbations that appear to be related to allergen exposure, except in some specific cases. Immunotherapy may be even more advantageous in patients with multimorbidity. In children, AIT may prevent asthma onset in patients with rhinitis. mHealth tools are promising for the stratification and follow up of patients.

A Difficult-to-Treat Asthma Bronchiale Is Not Necessarily a Severe Asthma Abstract. New biologicals offer the opportunity for treatment of 'difficult-to-treat' asthma. Before prescribing these medications, each 'difficult-to-treat' asthma bronchiale has to be checked for factors aggravating asthma control (e.g. insufficient inhalation technique and adherence, persistent allergen exposure) and asthma-related comorbidities (e.g. rhinosinusitis, gastro-esophageal reflux disease or obstructive sleep apnea) rendering the asthma 'controlled'. Asthma phenotyping s essential for the understanding of different treatment modalities.

Introduction: Amongst allergic asthmatics, high allergen exposure increases asthma severity. However, there is no consensus on the role of mite allergen avoidance in the management of asthma, and various guidelines differ in their recommendations.Areas covered: Several systematic reviews/meta-analyses on mite avoidance in the management of asthma have been published, and their findings have been used for a call to provide a recommendation in British guidelines that dust-mite control measures should not be recommended. However, there are several problems with such analysis (such as combining studies in adults and children), and we question whether these are appropriate tools to evaluate available evidence about mite allergen avoidance, and whether it is correct to rely disproportionately on the results of meta-analyses/systematic reviews to inform clinical practice in this area. Recent evidence in children suggests that mite–impermeable bed encasings reduce emergency hospital attendance with severe asthma exacerbations.Expert opinion: The practical questions include how to achieve a sufficient real-life reduction allergen exposure, and how to identify patients who will benefit from effective intervention. The intervention should start early in the natural history of asthma, and consideration for choosing patients should include using the titre of allergen-specific IgE antibodies or the size of skin test wheal as an indicator.

Mouse allergen is endemic in the inner cities of the United States, with research predominantly in the Northeastern United States. A recent practice parameter notes the effect of mouse exposure in asthma in inner cities. However, studies are emerging that find a role of mouse allergen in non-inner cities as well. Mouse sensitization is associated with mouse allergen exposure and has been linked with adverse asthma outcomes including increased asthma symptoms, poorer lung function, and increased risk of exacerbations. There are commercially available extracts for testing for mouse sensitization although they are not standardized. Pest management studies have had varying results, but with decreased allergen exposure, there is a trend toward improved asthma outcomes. Physicians should be aware of the potential for rodent exposure and sensitization and consider screening for mouse allergy in asthmatic children, especially if they are located in the inner city, have poorly controlled asthma, or have a history of mouse infestation in their location. Evidence is emerging that this allergen should be considered in non-inner-city asthmatics as well. Finally, advocacy efforts are necessary to ensure that removal of this allergen is accomplished, when possible, in the environments of asthmatic children sensitized to mouse.

Objective: Sublingual immunotherapy has been considered to be a painless and effective therapeutic treatment of patients with allergic rhinitis. Its mechanism of action has been elucidated, but there are still controversies among many reports between clinical efficacy and laboratory data. Therefore, its mechanism of action needs to be investigated further by using promising animal models such as rodents and monkeys. Materials and Methods: Bearing this in mind, in our present study, we successfully constructed an effective murine model for sublingual immunotherapy (SLIT) in allergic rhinitis in which mice were sublingually administered ovalbumin (OVA), followed by intraperitoneal (ip) sensitization and intranasal (i.n.) challenge of OVA. Results: To summarize our experimental data, nasal symptoms such as sneezing and nasal rubbing of sublingually treated mice were significantly attenuated in accordance with lower specific IgE antibodies in sera. Histological analysis of eosinophil recruitment in nasal mucosae reveals less allergic inflammation in sublingually treated mice. Interleukin-10 (IL-10) production and IL-10–specific mRNA gene expression of cultured submandibular lymph node (SMLN) cells with OVA, obtained from sublingually treated mice, were significantly higher than those of mice without sublingual treatment. Conclusion: These results demonstrate that sublingually introduced antigens can actually attenuate nasal symptoms in a murine allergic rhinitis model upon allergen exposures. Furthermore, our immunological data might indicate an important role of IL-10 producing T cells in SMLN to control nasal allergic reaction.

Background: Eosinophilic esophagitis is a newly recognized condition driven by allergen exposure. The management of eosinophilic esophagitis can be a challenge for the practicing allergist. Objective: Provide the allergist with the skills needed to effectively manage eosinophilic esophagitis. Methods: A literature review of the important aspects of evaluation and management. Results: More effective care of patients with eosinophilic esophagitis. Conclusion: This review provided the allergist who sees patients with eosinophilic esophagitis some additional tools to help avoid the pitfalls and use the pearls in disease management.

Asthma is highly prevalent and causes significant morbidity in children. The development of asthma depends on complex relationships between genetic predisposition and environmental modifiers of immune function. The biological and physical environmental factors include aeroallergens, microbiome, endotoxin, genetics, and pollutants. The psychosocial environment encompasses stress, neighborhood safety, housing, and discrimination. They all have been speculated to influence asthma control and the risk of developing asthma. Control of the factors that contribute to or aggravate symptoms, interventions to eliminate allergen exposure, guidelines-based pharmacologic therapy, and education of children and their caregivers are of paramount importance.

Exposure to airborne allergens is an important risk factor for sensitization, allergic rhinitis and asthma. The aim of this study is to verify whether the use of an air filtration device, called “air purifier” (AP) is able to reduce indoor allergen exposure. In three rooms of one household with pets (a cat and a dog), inhalable dust was sampled with transportable pumps for 1–2 h during typical household chores on 15 days—either in the morning without the AP or in the afternoon using an AP. In addition to sampling inhalable dust both with a stationary and a personally carried pump with Teflon filters, nasal filters were used. Inhalable dust on the Teflon filters was quantified gravimetrically, and allergen content was measured on all filters (n = 90) using fluorescence enzyme immunoassays for domestic mites (DM), the cat allergen Fel d 1, and the dog allergen Can f 1. The use of the AP significantly reduced inhalable dust in both personal and stationary samples by 40 or 20%, respectively. In most cases, allergen exposure was also reduced; the median allergen concentrations in the air were up to 60% lower with the AP than without. Allergen exposure varied greatly, and with the exception of Can f 1 sampled with the personally carried pump, and DM allergens in the nasal samples, there was no significant difference with or without an AP. Typical household chores can result in high levels of exposure to indoor dust and allergens. The use of an AP however can reduce the inhalable dust concentrations, but the effect on allergen exposure was in most cases not large enough to achieve statistical significance.

Environmental exposures interplay with human host factors to promote the development and progression of allergic diseases. The worldwide prevalence of allergic disease is rising as a result of complex gene-environment interactions that shape the immune system and host response. Research shows an association between the rise of allergic diseases and increasingly modern Westernized lifestyles, which are characterized by increased urbanization, time spent indoors, and antibiotic usage. These environmental changes result in increased exposure to air and traffic pollution, fungi, infectious agents, tobacco smoke, and other early-life and lifelong risk factors for the development and exacerbation of asthma and allergic diseases. It is increasingly recognized that the timing, load, and route of allergen exposure affect allergic disease phenotypes and development. Still, our ability to prevent allergic diseases is hindered by gaps in understanding of the underlying mechanisms and interaction of environmental, viral, and allergen exposures with immune pathways that impact disease development. This Review highlights epidemiologic and mechanistic evidence linking environmental exposures to the development and exacerbation of allergic airway responses.

Background Levocetirizine, active R (-) enantiomer of cetirizine, is an orally active and selective H1 receptor antagonist used medically as an anti-allergic. Allergic rhinitis is a symptomatic disorder of the nose induced by inflammation mediated by immunoglobulin E (IgE) in the membrane lining the nose after allergen exposure. Objectives The purpose of the present study was to prepare rapidly disintegrating tablets of levocetirizine after its complexation with β-cyclodextrin (β-CD). Material and methods Levocetirizine-β-CD complex tablets were prepared by direct compression technique using 3 synthetic superdisintegrants in different proportions. Development of the formulation in the present study was mainly based on the concentration of superdisintegrants and the properties of the drug. Nine batches of tablets were formulated and evaluated for various parameters: drug content, weight variation, water absorption ratio, wetting time, in vitro disintegration, hardness, friability, thickness uniformity, and in vitro dissolution. Results A Fourier-transform infrared spectroscopy (FTIR) study showed that there were no significant interactions between the drug and the excipients. The prepared tablets were good in appearance and showed acceptable results for hardness and friability. The in vitro disintegrating time of the formulated tablet batches was found to be 15-35 s percentage and the drug content of tablets in all formulations was found to be between 90-102%, which complied with the limits established in the United States Pharmacopeia. Conclusions Complexation of levocetirizine with β-CD significantly improves the solubility of the drug. The disintegration time of the tablets was decreased with an increase in superdisintegrant amount. The tablets (batch CPX5) had a minimum disintegration time of 20 s and 99.99% of the drug was released within 10 min.

House dust mites inhabit bed mattresses contaminating them with allergens. A strong temperature/moisture gradient exists in mattresses when it is used by humans daily. Here, we studied migration patterns of the mite Dermatophagoides farinae in continuous and time-discontinuous temperature gradients consisting of five sectors with 19–23, 23–28, 28–32, 32–36 and 36–41 °C, containing dye-labeled diets as an indicator of mite presence and feeding. The mites migrated through the sectors and fed on the labeled diets or stayed unfed. The numbers of mites with the same coloration in their guts and the numbers of unfed mites in the sectors were recorded. Unfed mites provided information on short-term temperature preferences. Apart from a control trial, two experiments were performed: (i) a constant 19–41 °C gradient for 24 h, and (ii) alternating cycles of the same temperature gradient (19–41 °C, 8 h) and room temperature (16 h) for 5 days to model the typical daily occupancy of bed by humans. In both experiments, fed mites preferred a sector with 32–36 °C, suggesting that in mattresses, house dust mites prefer to stay as close as possible to the resting human, thus maximizing allergen exposure. However, the number of unfed mites decreased with increased temperatures in the gradient. Experiment (ii) showed that the fed mites remained at the same optimal distance from the heat source, suggesting that they stay at the upper surface of the regularly used mattress, even when human was temporarily absent during the day. Unfed mites apparently hide deeper in mattresses as suggested by their avoidance of increased temperatures.

A food allergy is a potentially life-threatening disease with a genetic and environmental background. As its prevalence has increased significantly in recent years, the need for its effective prevention has been emphasized. The role of diet modifications and nutrients in food allergy reduction has been extensively studied. Much less is known about the role of other environmental factors, which can influence the incidence of this disease. Changes in neonates gut microbiome by delivery mode, animal contact, inhalant allergens, oral and then cutaneous allergen exposure, air pollution, smoking, infections and vaccinations can be the potential modifiers of food allergy development. There is some data about their role as the risk or preventive factors, but yet the results are not entirely consistent. In this paper we present the current knowledge about their possible role in primary prevention of food allergies. We discuss the mechanisms of action, difficulties in designing accurate studies about food allergy and the potential biases in interpreting the connection between environmental factors and food allergy prevention. A better understanding of the role of environmental factors in food allergies development may help in implementing practical solutions for food allergy primary prevention in the future.

Pollen and fungal spores are associated with seasonal and perennial allergies. However, most scientific literature thus far suggests that pollen allergy is more clinically relevant than fungal allergy. Several environmental and biological factors and the difficulty in producing reliable fungal extracts account for this. Biodiversity, taxonomy, and meteorology are responsible for the types and levels of pollen and fungal spores, their fragments, and the presence of free airborne allergens. Therefore, it is difficult to accurately measure both pollen and fungal allergen exposure. In addition, understanding the enzymatic nature of fungal and some pollen allergens, the presence of allergenic and nonallergenic substances that may modulate the allergic immune response, and allergen cross-reactivity are all necessary to appropriately evaluate both sensitivity and exposure. The raw materials and manufacturing processes used to prepare pollen versus fungal extracts differ, further increasing the complexity to properly determine allergic sensitivity and degrees of exposure. The pollen extracts used for diagnosis and treatment are relatively consistent, and some have been standardized. However, obtaining clinically relevant fungal extracts is more difficult. Doing so will allow for the proper selection of such extracts to more appropriately diagnose and treat both pollen- and fungal-induced allergic diseases.

Purpose of review To familiarize the reader with the most recent insights in the use of Omalizumab (monoclonal anti-immunoglobulin E) monotherapy in the treatment of patients with severe food allergy. Recent findings The current data from early stage clinical trials show that Omalizumab may be safe and effective by itself in providing desensitization to one or several foods without requiring allergen exposure. Summary In the near future, advances in knowledge will guide the adoption and implementation of any new therapy for food allergy and allow the development of a personalized treatment tailored on the specific patient's profile.

Allergen-specific immunotherapy (AIT) is the only disease-modifying treatment option for allergic rhinitis (AR) patients with persistent moderate-severe AR for whom traditional pharmacotherapies are ineffective. The nasal allergen challenge (NAC) and allergen exposure chamber (AEC) are two translational models of AR that can be used to investigate the properties, safety, and efficacy of AIT.Peer-reviewed, human-centered articles utilizing AEC or NAC models to investigate AIT between 2010 and 2020 were curated from PubMed, EMBASE, and OVID Medline databases. AECs have been used to evaluate traditional subcutaneous and sublingual administrations of AIT, including cross-protective effects and different dosing regimens. More recently, the effectiveness of novel AIT formulations has been evaluated. NACs are another model used to study AIT, including using novel intralymphatic routes of administration. It is an especially powerful and versatile tool to determine if basic science and animal model findings are clinically translatable.The AEC and NAC models both produce clinically relevant and reproducible results. AECs are more effective for studying many participants but are limited because they require a specialized facility. As more AIT therapies and new formulations are developed over time, the versatility of the NAC will be especially useful.

Item does not contain fulltext BACKGROUND: Environmental exposures are involved in the pathogenesis of the allergic phenotype and in determining which individual triggers a person becomes sensitized to. Atopic dermatitis (AD) may modulate these effects through increased penetration through the skin modifying the immune system and AD may be triggered or intensified by environmental exposures. These exposures and immune-modulating factors may differ in urban and rural environments. OBJECTIVES: To compare house dust composition in urban and rural settings and correlate them with AD outcomes. METHODS: Dust samples were collected from the beds of 156 children aged 6 months to 3 years. 42% of participants had atopic dermatitis. Samples were analyzed for bacterial endotoxin, fungal (β-1,3-glucan) levels, and house dust mite, cockroach, dog, cat, mouse, and peanut allergen. Exposures were compared in urban and rural environments and in participants with and without AD. RESULTS: Endotoxin but not fungal β-glucan exposure is higher in the environment of healthy controls than children with AD in both urban and rural settings. House dust mite allergen exposure is high in urban and rural settings with Dermatophagoides detected in 100% of samples. Cat and dog allergen exposure mirrors pet ownership patterns which differ slightly between groups and environments. Mouse allergen exposure is higher in urban homes. CONCLUSION: Environmental endotoxin may be protective against AD in both urban and rural settings. There are marked differences in allergen exposure in urban and rural settings, but these are unlikely to be important protective or risk factors.

Recent evidence has highlighted the critical role of memory cells in maintaining lifelong food allergies, thereby identifying these cells as therapeutic targets. IgG+ memory B cells replenish pools of IgE-secreting cells upon allergen exposure, which contract thereafter due to the short lifespan of tightly regulated IgE-expressing cells. Advances in the detection and highly dimensional analysis of allergen-specific B and T cells from allergic patients have provided insight on their phenotype and function. The newly identified Th2A and Tfh13 populations represent a leap in our understanding of allergen-specific T cell phenotypes, although how these populations contribute to IgE memory responses remains poorly understood. Within, we discuss the mechanisms by which memory B and T cells are activated, integrating knowledge from human systems and fundamental research. We then focus on memory reactivation, specifically, on the pathways of secondary IgE responses. Throughout, we identify areas of future research which will help identify immunotargets for a transformative therapy for food allergy. post-print 3742 KB

Ácaros e animais domésticos são importantes fontes de aeroalérgenos em veículos de transporte público, que podem representar um sério problema em indivíduos sensibilizados. O objetivo deste estudo foi determinar os níveis dos alérgenos de ácaros (Der p 1 e Der f 1) e de gato (Fel d 1) em ônibus e taxis, bem como avaliar o alérgeno predominante em cada tipo de veículo de transporte público. Alérgenos de ácaros e de gato foram mensurados por ELISA tipo “sanduíche” em amostras de poeira coletada de assentos estofados de 60 ônibus com ventilação natural (VN), 60 ônibus com ventilação artificial (VA) e 60 táxis. Trinta amostras de poeira do filtro dos condicionadores de ar dos ônibus VA foram também incluídas. Níveis de Der p 1 and Der f 1 foram significativamente maiores em ônibus VA que VN, enquanto níveis de Fel d 1 não foram significativamente diferentes entre os tipos de ônibus. Não houve diferença significativa entre os níveis de alérgenos de ácaros em diferentes seções dos ônibus, enquanto níveis de Fel d 1 foram significativamente maiores em assentos do fundo e do meio do que os assentos da frente de ônibus VN. Alérgenos de ácaros e de gato em taxis foram significativamente maiores no assento traseiro dos passageiros do que no assento do motorista Uma grande proporção de amostras de poeira dos veículos, especialmente em ônibus VA (82% para Der p 1 and 58% para Der f 1) apresentaram níveis sensibilizantes dos alérgenos de ácaros, enquanto > 60% das amostras de todos os tipos de veículos continham níveis sensibilizantes para Fel d 1. Amostras de poeira coletada de assentos mostraram níveis significativamente maiores de alérgenos de ácaros e de gato do que amostras coletadas do filtro dos condicionadores de ar dos ônibus VA. 'Pode-se concluir que veículos de transporte público constituem um importante reservatório de alérgeno e contaminação contínua deste ambiente interno. Profissionais da saúde devem estar cientes desta possibilidade adicional de exposição alergênica na conduta clínica de seus pacientes sensibilizados a ácaros e animais domésticos. Mites and pets are important sources of indoor allergens in public transport vehicles that couid represent a serious problem in sensitized subjects. The aim of this study was to determine Der p 1, Der f 1 and Fel d 1 allergen leveis in buses and taxis, and to evaluate the predominant allergen in each public transport vehicle. Mite and cat allergens were measured by a sandwich ELISA in dust samples coilected from upholstered seats of 60 natural ventilation buses (NVB), 60 artificial ventilation buses (AVB) and 60 taxis. Thirty dust samples from air-conditioning filters of AVB were also included. Der p 1 and Der f 1 leveis were significantly higher in AVB than NVB, while Fel 1 leveis were not significantly different between the types of buses. No significant differences were found for mite allergen leveis in various sites of both types of buses, whereas Fel d 1 leveis were significantly higher in rear and middle than front seats in NVB. Mite and cat allergen leveis in taxis were significantly higher in passengeris rear than driveris seats. A high proportion of dust samples of vehicles, especially AVB (82% for Der p 1 and 58% for Der f 1) had sensiíizing leveis for mite allergens, while > 60% of samples from all vehicles had sensitizing leveis for Fel d 1 allergen. Samples from seats showed significantly higher leveis of mite and cat allergens than air-conditioning filter of AVB. It can be concluded that public transport vehicles constitute an important allergen reservoir for continuous contamination of the indoor environment. Health professionals should be aware of this additional possibility of allergen exposure on medicai management of their mite and cat sensitized patients. Dissertação (Mestrado)

Equine Culicoides hypersensitivity (CH) is the most common allergic condition in horses affecting the skin. This review focuses on immunopathology and molecular mechanisms of equine CH. The role of eosinophils is emphasized, as well as disease severity and the influence of long-term chronic allergen exposure on T helper (Th) 2 cells. Using current knowledge from human allergic disorders, similar effects are hypothesized in equine patients. Key aspects of CH diagnosis and treatment are discussed, focusing on allergen specific immunotherapy and allergen-independent approaches, such as targeting hypereosinophilia through interleukin-5 and allergic non-histaminic pruritus though interleukin-31.

Background: In patients with a diagnosis of asthma, there is currently no consensus which allergy tests should be performed to confirm a diagnosis of allergy. Aims and Objectives: We aimed to gain insight in the decision making in allergy testing in patients with (severe) asthma in Belgium. Methods: Twenty-five respiratory physicians across Belgium were interviewed by means of a questionnaire. Results: Among respiratory physicians, an allergic component is suspected for the following reasons (in decreasing order of importance): seasonal allergen exposure, rhinosinusitis, family history of asthma, eczema, perennial allergen exposure, food allergy, animal exposure. If the patient has no obvious allergic complaints, allergic testing is nevertheless performed in 84% of the patients. As to the choice of allergy tests performed upon initial allergy work-up, 48% of respiratory physicians starts with skin prick tests alone, 12% with ImmunoCAP® tests alone and 16% performs both SPT and ImmunoCAP. The remaining physicians make a decision on an individual basis. Conclusions: There is a large heterogeneity among Belgian respiratory physicians regarding decision making in allergy testing in patients with asthma. Comorbidities and exposure play an important role in the suspicion of an allergic component in patients with asthma.

Anaphylaxis is an acute, life-threatening reaction that can occur due to a variety of triggers. It is often associated with allergen exposure, such as food, venom, or medications; however, there are other less-common causes, and many patients are ultimately classified as idiopathic. In this report, we described a patient with recurrent reactions attributed to food exposure. Further evaluation revealed an alternative, less common diagnosis.

Dermatophagoides pteronyssinus e D. farinae são as espécies de ácaros mais prevalentes e de grande importância nas doenças alérgicas respiratórias. Alérgenos de gato também têm demonstrado sua importância por suas características aerodinâmicas. O objetivo deste trabalho foi avaliar a exposição aos alérgenos de ácaros da poeira domiciliar (Der p 1 e Der f 1) e gato (Fel d 1) em hotéis da cidade de Uberlândia, Brasil. Método: Foram coletadas 150 amostras de poeira de cama e carpete de quartos de 20 hotéis selecionados na cidade de Uberlândia, entre os meses de julho a outubro de 2002. A umidade relativa do ar e a temperatura foram mensuradas no mesmo instante da coleta da amostra de poeira. Os níveis dos respectivos alérgenos foram determinados por ELISA. Resultados: Níveis médios de Der f 1 (11,3 pg/g de poeira) foram significativamente maiores que Der p 1 (0,15 pg/g de poeira) e Fel d 1 (0,11 pg/g de poeira) nas amostras coletadas de cama (P < 0,001), independente das categorias de hotéis. Níveis de Der f 1 foram sígníficatívamente maiores em amostras de poeira coletadas de cama (11,3 pg/g de poeira) que de carpete (6,4 pg/g de poeira; P < 0,05). A maioria das amostras apresenta ou níveis de Der f 1 sensibilizantes e/ou desencadeantes de sintomas respiratórios associados à temperatura de 26-31 °C e 36-55% de umidade relativa do ar, sendo que a presença de condicionadores de ar nos quartos não influenciou no nível de alérgenos de ácaros. Conclusão: Estes resultados indicam que Der f 1 é o alérgeno predominante em hotéis da cidade de Uberlândia, particularmente em amostras de poeira de cama, independente da categoria do hotel. Além disso, os dados deste trabalho poderão ser úteis para o conhecimento e monitoramento dos níveis de alérgenos em hotéis, visando o bem estar de seus hóspedes potencialmente alérgicos. Dermatophagoides pteronyssinus e D. farinae are the most prevalent mite species throughout the world and their allergens are involved in airway sensitization and allergic diseases. The importance of cat allergens has also been demonstrated due to their aerodynamic features. The purpose of this study was to evaluate the exposure to house dust mite (Der p 1 and Der f 1) and cat (Fel d 1) allergens in hotels from Uberlândia, Brazil. Meíhods: One-hundred and forty-nine dust samples were collected from bedding (mattresses and pillows) and carpet of bedrooms in 20 hotels enrolled for the study from July to October 2002. Temperature and relative air humidity were measured at the same moment of dust sampling. Allergen leveis were measured by two-site ELISA. Results: Mean leveis of Der f 1 (11.3 pg/g of dust) were significantly higher than Der p 1 (0.15 pg/g of dust) and Fel d 1 (0.11 pg/g of dust) in bedding dust samples (P < 0.001), regardless of the hotel categories. Der f 1 leveis were significantly higher in bedding (11.3 pg/g of dust) than carpet (6.4 pg/g of dust) dust samples (P < 0.05). Most of the samples showed Der f 1 sensitizing and/or exacerbating of allergic symptoms leveis associated with 26 -31 °C temperatura and 36 - 55% relative humidity, while the presence of air conditioners in bedrooms did not influence in the mite allergen leveis. Conclusion: These results indicate that Der f 1 is the most prevalent allergen in hotels from Uberlândia, especially in bedding dust samples, regardless of the hotel categories. Furthermore, these data could be useful to the knowledge and monitoring of allergen leveis in hotels in order to promote the comfort and well-being of their potentially allergic guests. Dissertação (Mestrado)

Allergic contact dermatitis is a delayed type IV hypersensitivity skin reaction to external stimuli. Patterns of dermatitis depend on allergen exposure and patch testing is the gold standard to identify causal agents. The American Contact Dermatitis Society identifies an "Allergen of the Year" in order to highlight facts about particular allergens, which may range from showing increasing prevalence of disease, to documenting low levels of relevant allergic reactions. This article reviews the allergens of the year from 2000 to 2020 with an emphasis on clinical relevance. Categories of allergens include adhesives, dyes, medications, metals, preservatives, rubber accelerators, surfactants, and other skin care product ingredients.

Traditional measures of socioeconomic status (SES) are associated with asthma morbidity, but their specific contributions are unclear. Increased exposure to indoor allergens among low SES children is an important consideration. Material hardship, a concept describing poor access to basic goods and services, may explain the relationship between low SES and indoor allergen exposure, and thereby, the increased risk of asthma morbidity. We sought to (i) describe the specific hardships experienced by low-Income, urban, minority children with asthma and indoor allergen sensitization and (ii) determine if material hardship is associated with indoor allergen exposure in this population. We conducted a cross-sectional analysis of children undergoing the baseline assessment for a clinical trial of home environmental modification. Participants were scored in five domains of material hardship. Domain scores were assigned based on caregiver responses to a questionnaire and were summed to generate a total material hardship score. Linear regression was used to examine the relationship between material hardship scores and bedroom floor concentrations of five common indoor allergens. Participants experienced high levels of material hardship in each of the five domains, with 33% not having access to a car, 35% not being able to pay utility bills, and 28% not being able to pay rent in the past year. Each one-point increase in material hardship was associated with an increase in cockroach allergen of 16.2% (95% CI: 9.4%, 24.6%) and an increase in mouse allergen of 9.4% (95% CI: 1.0%, 18.5%). After adjusting for traditional measures of SES, including household income, health insurance type, caregiver education, and caregiver employment status, the association between material hardship and cockroach allergen, but not mouse allergen, remained. These data suggest that a significant proportion of families of low-income, minority children with asthma may experience material hardship, and that they may be at greater risk of cockroach allergen exposure than their peers with similar income, but without material hardship.

In asthma, a significant portion of the interaction between genetics and environment occurs through microbiota. The proposed mechanisms behind this interaction are complex and at times contradictory. This review covers recent developments in our understanding of this interaction: the "microbial hypothesis" and the "farm effect"; the role of endotoxin and genetic variation in pattern recognition systems; the interaction with allergen exposure; the additional involvement of host gut and airway microbiota; the role of viral respiratory infections in interaction with the 17q21 and CDHR3 genetic loci; and the importance of in utero and early-life timing of exposures. We propose a unified framework for understanding how all these phenomena interact to drive asthma pathogenesis. Finally, we point out some future challenges for continued research in this field, in particular the need for multiomic integration, as well as the potential utility of asthma endotyping.

Objective Shared decision-making is a patient-centered approach that involves a mutual discussion about management or treatment options, which account for the patient's underlying values and preferences for therapy. Little is known about the role of shared decision-making in the care of patients with food allergy. Data Sources A narrative review of the shared decision-making and food allergy outcomes literature in the past 20 years was performed. Results In shared decision-making, care must be taken to help clarify the patient's values regarding their care options, but not instill the clinician's values or preferences into that choice. It is essential to understand the mutual roles of the clinician in the process of providing evidence-based options for care, advocating for treatments that are aligned with their goals and preferences, and allowing patients to make fully informed decisions within this paradigm. Decision support tools such as decision aids can assist patients in the values clarification process, particularly in which preference-sensitive care exists, in which options hold significant tradeoffs and varying outcomes, and the decision is reflective of personal values and preferences. There are multiple potential preference-sensitive care scenarios in food allergy in which shared decision-making could be optimized, including the development of decision aids. These areas include early allergenic solid introduction, preemptive epinephrine use in which there is allergen exposure but no symptoms, automatic activation of EMS after using epinephrine, and choices of food allergy treatment. Only one decision aid in food allergy exists. Conclusion Shared decision-making is an approach that could greatly enhance food allergy care and improve patient-reported outcomes.

Immediate administration of intramuscular epinephrine to a patient experiencing anaphylaxis is the first-line therapy for this life-threatening allergic reaction. Alhough anaphylaxis is generally a rare occurrence, it has dire consequences if left untreated. In infants, anaphylaxis is typically triggered by exposure to egg, cow's milk, or peanuts. The rapid onset of symptoms in multiple organ systems makes an accurate diagnosis in infants difficult because there are numerous ways in which anaphylaxis may present. The symptoms of infant anaphylaxis are often underrecognized or misdiagnosed for less serious illnesses or even normal findings, including drooling, loose stools, and irritability. Because infants are mostly nonverbal-and most pediatric emergency department visits for anaphylaxis cases are the first diagnosis-ascertaining potential exposure to common allergens is difficult; this further complicates diagnosis in these youngest patients for whom the clinical presentation of anaphylaxis varies widely. A key factor in diagnosing anaphylaxis is the temporal profile of symptom development following allergen exposure; however, some children with anaphylaxis develop symptoms that reoccur hours or days after an initial anaphylactic reaction, making diagnosis challenging. Advanced practice nurses are often the first health care provider to encounter a patient who may be experiencing anaphylaxis. Although diagnostic criteria exist for anaphylaxis, specific criteria for the diagnosis of anaphylaxis in infants have not been developed. As such, it is important to understand and recognize the variable presentation of anaphylaxis in infants and to rapidly diagnose and treat with epinephrine.

Purpose of review The purpose of the article is to provide a historical overview of literature regarding pollen sensitization and ocular allergy with an emphasis on developments that have occurred over the past 5 years. Recent findings Currently, pollen studies have examined the molecular and cellular pathways involved in initiating allergic conjunctivitis to find targets for therapeutics. Studies have also documented the threshold, linear increase and plateau point in the relationship between pollen levels and allergic conjunctivitis symptoms. Summary Traditionally, intact pollen grains are counted as a means of correlating patient symptoms to allergen exposure. However, establishing a dose-response relationship between pollen grain exposure and allergic conjunctivitis has proven to be difficult. It has been observed that ocular allergies induce a two-fold response including early-phase and late-phase IgE-mediated reactions. Sensitization itself is a combination of pollen exposure over time in genetically predisposed individual. However, symptoms appear to reach an asymptotic point at which clinical severity plateaus. More studies are needed to clearly define differences in pollen sensitization by plant species.

Allergen information on food labels is not standardized, making allergen avoidance difficult for consumers. This study investigated the speed and accuracy of allergen identification on commercial packaging across different types of warning labels. The results identified packaging label characteristics significantly correlated with faster and more accurate identification of allergens. Standardizing warning and safe-to-consume labels may reduce risk of accidental allergen exposure for consumers managing food allergies.

Introduction Exposure to rat and mouse allergens during work in laboratory animal facilities represents a risk for being sensitized and developing allergic diseases, and it is important to keep the exposure level as low as possible. The objective of this study was to characterize the personal Mus m 1 and Rat n 1 exposure during work in laboratory animal facilities, and to investigate the effect of identified predictors of increased and reduced exposure. Methods Mus m 1 and Rat n 1 were analysed in whole day or task-based personal air samples by enhanced sensitivity sandwich enzyme-linked immunosorbent assay. Information about cage-and-rack systems, tasks, and other conditions known to influence the allergen exposure was registered. Predictors for allergen exposure were identified by multiple linear regression analyses. Results The median allergen exposure was 3.0 ng m−3 Mus m 1 and 0.5 ng m−3 Rat n 1, with large task-dependent variations among the samples. The highest exposed job group were animal technicians. Cage emptying and cage washing in the cage washroom represented the highest exposure, whereas animal experiments in the lab/operation room represented the lowest exposure, with laminar airflow bench being an exposure-reducing determinant. Cage changing was the highest exposed task in the animal room, where individually ventilated cages (IVCs) were predictors of reduced exposure for both Mus m 1 and Rat n 1, whereas cage-rack systems with open shelves and sliding doors were predictors of increased Rat n 1 exposure. Cages of IVC type with positive air pressure (IVC+) as well as open shelves and sliding doors were strong predictors of increased exposure during cage emptying and cage washing. Conclusions Significant different exposure levels depending on type of work and task imply different risks of sensitization and allergy development. The fact that IVC+ cages have opposite impact on Mus m 1 and Rat n 1 exposure during different tasks may have positive clinical implications when taken into account.

Allergic asthma is becoming increasingly prevalent in the developed world, and many common allergens are capable of inducing allergic asthma responses, particularly in atopic individuals. Unmethylated CpG-oligonucleotide (ODN) therapy can shift the immune response to mitigate these allergic responses. Therapeutic and prophylactic delivery of soluble CpG-ODN in preclinical studies has shown promise in treating existing asthma and preventing allergic responses upon subsequent allergen exposure, respectively. However, when CpG-ODN is coupled with nanoparticles or self assembled into nanostructures, improved efficacy of CpG-ODN treatment for several common allergens is observed in preclinical studies and clinical trials. Here we discuss the role of CpG-ODN in treating allergic asthma and how nanoparticle-based delivery can further enhance its therapeutic properties.

Allergic rhinitis is a disease underestimated by patients, and underdiagnosed and thus undertreated by physicians since most of the patients present with symptoms of moderate-to-severe disease, overall diminished quality of life, impairing sleep quality and cognitive function, and a substantial impact on work productivity, school absenteeism, and costs. The relationship between treating physician and patients is crucial in all chronic diseases. Review the main changes and innovations of recent years in the ARIA guidelines. The most recent publications of the ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines were reviewed. ARIA 2016 strengthens the role of patients in the control and treatment of their symptoms by the use of technology, which improves physician-patient communication. The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. It confirms that inhaled corticosteroids are the most effective drugs for the management of seasonal or perennial allergic rhinitis, not surpassed by combination therapies with oral or topical antihistamines. On the other hand, no significant differences between the use of oral or topical antihistamines are evidenced. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. A step-up/step-down individualized approach to AR pharmacotherapy might hold the potential for optimal control of AR symptoms while minimizing side effects and costs. After choosing the best pharmacological therapy, compliance is a critical issue in the management of all chronic diseases. In order to improve compliance, it is important to consider patient preferences and views of patients and their caregivers, as ARIA guidelines remarks in the 2016 update. ARIA guideline has evolved to a technology-based implementation strategy to help rhinitis sufferers to have an active and healthy life and to reduce health and social inequalities caused by this very common disease, irrespective of their age, sex, or socio-economic status.

Severe anaphylaxis is a generalized reaction in which cardiovascular and respiratory involvement lead to a fatal or near-fatal outcome. Triggers of severe anaphylaxis differ from one age group to another and are mostly represented by drugs and hymenoptera stings in adults and food in children. Several risk factors and cofactors can increase the odds of severe anaphylaxis by different and still undefined mechanisms. Major risk factors for severe anaphylaxis include old age, male sex, and preexisting medical conditions such as mast cell disorders, cardiovascular diseases, and uncontrolled asthma. Antihypertensive drugs appear to increase the severity of anaphylaxis probably by impairing compensatory mechanism to support blood pressure during the reaction. Severe reactions are also associated with transient cofactors such as exercise following specific allergen exposure, treatment with nonsteroidal anti-inflammatory drugs, and alcohol consumption. Identification of risk factors and potential concurrent cofactors for each individual patient is mandatory to prevent severe anaphylaxis. Risk stratification is crucial to develop personalized prevention strategies and action plans to avoid potentially life-threatening reactions.

Allergen immunotherapy (AIT) is a safe, effective treatment for allergic rhinoconjunctivitis and allergic asthma. However, AIT's clinical effect is still contested-primarily due to heterogeneity in clinical trial designs, study populations, therapeutic formulations, and efficacy criteria. After discussing current concepts and unmet needs, an international panel of experts made several recommendations: (i) explore and validate definitions for (clinical) responders in AIT trials; (ii) use of well-documented, standardized provocation tests prior to inclusion of subjects with relevant diseases in AIT trials; (iii) monitoring neo-sensitizations and occurrence of new allergy in extended AIT trials, and exclusion of polyallergic participants; (iv) validation of allergen exposure chambers with regard to natural exposure; (v) in studies of seasonal allergies, focus on peak exposure but also consider organizing two parallel, geographically distinct but otherwise identical trials; (vi) discuss adaptive trial designs with the regulatory authorities; (vii) use e-health and m-health technologies to capture more information on individual exposure to allergens; (viii) initiate research on potential psychological, biochemical, immune, neural, and even genomic markers of the placebo response; (ix) identify trial designs and primary endpoints that will give children with allergies easier, faster access to AIT formulations; and (x) promote and apply standardized methods for reporting systemic and local adverse events. The latest technologies and trial designs may provide novel, ethical ways of reducing bias and heterogeneity in AIT clinical trials. There is scope for physicians, patient organizations, companies, and regulators to improve clinical trials in AIT and, ultimately, to provide patients with better treatments.