UCRAID (Ukrainian Citizen and refugee electronic support in Respiratory diseases, Allergy, Immunology and Dermatology) action plan.

Eight million Ukrainians have taken refuge in the European Union. Many have asthma and/or allergic rhinitis and/or urticaria, and around 100,000 may have a severe disease. Cultural and language barriers are a major obstacle to appropriate management. Two widely available mHealth apps, MASK-air® (Mobile Airways Sentinel NetworK) for the management of rhinitis and asthma and CRUSE® (Chronic Urticaria Self Evaluation) for patients with chronic spontaneous urticaria, were updated to include Ukrainian versions that make the documented information available to treating physicians in their own language. The Ukrainian patients fill in the questionnaires and daily symptom-medication scores for asthma, rhinitis (MASK-air) or urticaria (CRUSE) in Ukrainian. Then, following the GDPR, patients grant their physician access to the app by scanning a QR code displayed on the physician's computer enabling the physician to read the app contents in his/her own language. This service is available freely. It takes less than a minute to show patient data to the physician in the physician's web browser. UCRAID-developed by ARIA (Allergic Rhinitis and its Impact on Asthma) and UCARE (Urticaria Centers of Reference and Excellence)-is under the auspices of the Ukraine Ministry of Health as well as European (European Academy of Allergy and Clinical immunology, EAACI, European Respiratory Society, ERS, European Society of Dermatologic Research, ESDR) and national societies.

Rediscovering Allergic Rhinitis: The Use of a Novel mHealth Solution to Describe and Monitor Health-Related Quality of Life in Elderly Patients.

INTRODUCTION: Allergic rhinitis (AR) is a disease characterized by IgE-mediated hypersensitivity responses akin to allergic asthma. Although common in children and young adults, AR can be particularly vexing in the elderly: several studies have underlined its impact on the patient's self-perceived health-related quality of life (HR-QoL). Available literature data on AR-affected elderly patients remain sparse and often focused on specific characteristics. mHealth solutions such as MASK-air® can be used in assessing salient clinical characteristics and unique shifts in self-perceived HR-QoL in old age people. With this pilot study, we aim to assess these variables in two cohorts of AR-affected elderly patients - one actively involved in the daily use of mHealth applications and the other having never used such a solution - by applying a widespread, validated, and standardized tool. METHODS: AR-affected patients aged ≥65 years accessing the outpatient clinic of the Bari Geriatric Immuno-allergology Unit between March and July 2021 were enrolled and assigned to "mHealth" (MASK-air®) and "non-mHealth" cohorts accordingly. Each participant was given a 19-item questionnaire delivered via a custom software solution, with the EuroQoL EQ-5D-5L used to assess HR-QoL. RESULTS: 93 patients (51 mHealth users, 43 non-mHealth users) were enrolled. AR was often either standalone or associated with asthma and conjunctivitis, and 57.4% of the participants reported a negative influence of AR on daily activities. Analysis of HR-QoL showed significantly worse scores in mobility and anxiety/depression dimensions for female patients regardless of app usage, while male non-mHealth users had worse self-care scores. Female mHealth users had worse scores for the self-care and activity dimensions, whereas female non-mHealth users showed worse scores on the pain scale. In general, mHealth users showed a greater degree of anxiety/depression when compared to non-mHealth users, relating to a greater awareness of their health status. CONCLUSION: The use of an mHealth solution, along with a concise, clinically-validated, comprehensive HR-QoL assessment toolset such as the EQ-5D, can prove beneficial in defining the unique characteristics of AR in the elderly. It can enable a detailed exploration of the impact on specific aspects of quality of life in old age. Raising patient awareness towards a health condition can improve compliance to treatment as well as follow-up. A lack of uniformity in approach, along with missing data pertaining to the general population are critical issues that require further studies. A more thorough diffusion of mHealth usage is also necessary among the geriatric population.

Implementation of the MASK-Air® App for Rhinitis and Asthma in Older Adults: MASK@Puglia Pilot Study.

INTRODUCTION: MASK-air® is an app whose aim is to reduce the global burden of allergic rhinitis and asthma. A transfer of innovative practices was performed to disseminate and implement MASK-air® in European regions. The aim of the study was to examine the implementation of the MASK-air® app in older adults of the Puglia TWINNING in order to investigate (i) the rate of acceptance in this population, (ii) the reasons for refusal and (iii) the evaluation of the app after its use. METHODS: All consecutive geriatric patients aged between 65 and 90 years were included by the outpatient clinic of the Bari Geriatric Immunoallergology Unit. After a 1-h training session, older adults used the app for 6 months. A 6-item questionnaire was developed by our unit to evaluate the impact of the app on the management of the disease and its treatment. RESULTS: Among the 174 recruited patients, 102 accepted to use the app (mean age, SD: 72.4 ± 4.6 years), 6 were lost to follow-up, and 63 had a low education level. The reasons given not to use the app included lack of interest (11%), lack of access to a smartphone or tablet (53%), low computer literacy (28%), and distrust (8%). At follow-up, the overall satisfaction was high (89%), the patient considered MASK-air® "advantageous" (95%), compliance to treatment was improved (81%), and the rate of loss to follow-up had decreased to 6%. CONCLUSION: Older adults with a low level of education can use the MASK-air® app after a short training session.

Anisakiasis: The Importance of Prevention and the Role of Diet Therapy in Allergic Patients.

INTRODUCTION: Anisakiasis is a zoonosis of parasitic origin whose diffusion seems to be continuously increasing. OBJECTIVE: The aim of this study was to evaluate the benefits of a fish-free diet in patients allergic to Anisakis simplex as well as underlining the importance of awareness and prevention. Furthermore, we aimed to investigate the critical issues related to the spread of anisakiasis in relation to eating habits. METHODS: Patients were assessed by means of skin prick tests (SPTs) and targeted laboratory testing, with an 18-month-long fish-free diet being recommended in cases of severe sensitization. The degree of awareness about anisakiasis was evaluated from interviews. Patients were subjected to follow-up visits after 18 months. RESULTS: A total of 70 cases of sensitization to A. simplex were evaluated. The Interview answers highlighted a general state of misinformation among patients and healthy subjects along with a remarkable underestimation of anisakiasis-related risks. An overall lack of care regarding eating habits and diet plans also emerged. In 21 patients affected by severe sensitization, clinical and laboratory evaluations were repeated after 18 months of the subjects being on a fish-free diet. There was a remarkable improvement in serum IgE levels and clinical symptoms. CONCLUSION: Data analysis proved the need to implement new and more effective awareness-raising and prevention campaigns in order to reduce the incidence of anisakiasis. It is crucial to establish an adequate diet therapy for sensitized patients. Evaluation of cytokine patterns suggests how a polyphenol-rich regime can activate regulatory T cell function and possibly reduce the allergic and inflammatory components of the disease.

Importance of hypersensitivity in adverse reactions to drugs in the elderly.

BACKGROUND: The use of drugs in the elderly is very extensive because of the frequent occurrence of chronic diseases. Adverse drug reactions (ADRs) commonly occur in geriatric patients receiving multiple therapeutic regimens. In the literature, little attention has been given to ADRs in the elderly, and particularly to allergic reactions. OBJECTIVE: The aim of the present study is to provide data on possible inappropriate prescriptions in the elderly in relation to allergic reactions and to identify a list of drugs which are likely inducers of allergic reactions. METHODS: We retrospectively evaluated ADRs in patients referring to Immunoallergy Unit of Hospital Policlinico in Bari on the basis of Beers criteria. Among adverse reactions, hypersensitivity reactions were extracted and a comparison between different age groups was assessed. RESULTS: Out of 823 patients with ADRs, in 30.6% hypersensitivity drug reactions (HDR) were diagnosed. Data about drug intake, comorbidities and clinical presentation were collected, aiming to identify possible risk factors. An evaluation of drugs most commonly involved was assessed. CONCLUSIONS: HDR are reported to represent 5-10% of all ADRs, while in our study population the prevalence was about 30%. This suggests the need to develop strategies to minimize the incidence of drug allergy in the elderly, as well to reduce the phenomenon of inappropriate prescriptions.

Immunosenescence in aging: between immune cells depletion and cytokines up-regulation.

BACKGROUND: The immunosenescence is a relatively recent chapter, correlated with the linear extension of the average life began in the nineteenth century and still in progress. The most important feature of immunosenescence is the accumulation in the "immunological space" of memory and effector cells as a result of the stimulation caused by repeated clinical and subclinical infections and by continuous exposure to antigens (inhalant allergens, food, etc.). This state of chronic inflammation that characterizes senescence has a significant impact on survival and fragility. In fact, the condition of frail elderly occurs less frequently in situations characterized by poor contact with viral infections and parasitic diseases. Furthermore the immunosenescence is characterized by a particular "remodelling" of the immune system, induced by oxidative stress. Apoptosis plays a central role in old age, a period in which the ability of apoptosis can change. The remodelling of apoptosis, together with the Inflammaging and the up-regulation of the immune response with the consequent secretion of pro-inflammatory lymphokines represents the major determinant of the rate of aging and longevity, as well as of the most common diseases related with age and with tumors. Other changes occur in the innate immunity, the first line of defence providing rapid, but unspecific and incomplete protection, consisting mostly of monocytes, natural killer cells and dendritic cells, acting up to the establishment of a adaptive immune response, which is slower, but highly specific, which cellular substrate consists of T and B lymphocytes. The markers of "Inflammaging" in adaptive immunity in centenarians are characterized by a decrease in T cells "naive." The reduction of CD8 virgins may be related to the risk of morbidity and death, as well as the combination of the increase of CD8+ cells and reduction of CD4+ T cells and the reduction of CD19+ B cells. The immune function of the elderly is weakened to due to the exhaustion of T cell-virgin (CD95-), which are replaced with the clonal expansion of CD28-T cells. CONCLUSIONS: The increase of pro-inflammatory cytokines is associated with dementia, Parkinson's disease, atherosclerosis, diabetes type 2, sarcopenia and a high risk of morbidity and mortality. A correct modulation of immune responses and apoptotic phenomena can be useful to reduce age-related degenerative diseases, as well as inflammatory and neoplastic diseases.

Clinical and cytologic characteristics of allergic rhinitis in elderly patients.

BACKGROUND: The constant increase in the elderly population worldwide has led to a greater interest in immunologic responses during aging. Thus, special attention to allergic diseases in elderly people has begun to emerge, but little is known about the effect and features of allergic rhinitis in elderly people. OBJECTIVE: To evaluate the clinical and cytologic characteristics of respiratory allergy and its impact on the quality of life in elderly people. METHODS: Elderly patients with rhinitis referred to our allergy unit during a 3-month period underwent clinical evaluation and responded to the Rhinasthma Questionnaire. All patients also underwent skin prick testing, measurement of total IgE level, and nasal cytologic analysis. The data were compared with a control group of young adults. RESULTS: Fifty-four patients older than 65 years (mean age, 69.3 years) and 89 young adults (mean age, 26.3 years) with allergic rhinitis were studied. The elderly patients had a less positive family history of atopy (P=.02) and had rhinitis plus conjunctivitis more frequently (P=.002) than young adults, whereas the difference between groups in total IgE level was not statistically significant. On nasal cytologic analysis, the differential count of inflammatory cells did not differ between groups, but in the elderly patients the epithelial-goblet cell ratio was decreased. The quality of life in elderly people was more impaired than in young adults (P=.01). CONCLUSION: In elderly people with allergic rhinitis, the clinical characteristics are different and quality of life is more heavily impaired compared with young adults.

Case Report: Autoimmune Pemphigus Vulgaris in a Patient Treated With Cemiplimab for Multiple Locally Advanced Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Pemphigus vulgaris (PV) is a rare and severe autoimmune blistering disorder affecting the skin and mucous membranes, characterized by the production of autoantibodies against two desmosomal adhesion proteins, desmoglein 1 and 3. In patients with advanced squamous cell carcinoma of the skin unfit for surgery and radiotherapy, immune check-point inhibitors, including the anti-Programmed Death-1 (PD-1) agent cemiplimab have been successfully employed proving relevant clinical outcomes. Cemiplimab is a monoclonal antibody capable of inhibiting PD-1 signalling that has recently been approved for the treatment of patients with metastatic or locally advanced cutaneous squamous cell carcinoma. Although the peculiar setting of advanced CSCC involving elderly patients, rare and unusual skin immune-related adverse events such as PV could be observed in cemiplimab treated patients. CASE REPORT: A 95-year-old man without a history of autoimmune disease was treated with cemiplimab for multiple and advanced squamous cell carcinomas of the head obtaining a complete response to therapy. After seven cycles of cemiplimab administered every 21 days, the patient developed a mucocutaneous blistering eruption. Clinical diagnosis of PV was suspected on the basis of the diffuse involvement of trunk and extremities with large blisters and necrotic eschar. It was carried out an ELISA test, that showed high level of circulating antibodies against desmoglein 1, thus confirming the diagnosis of PV. For this reason, cemiplimab infusion was discontinued and complete resolution of skin lesions was obtained using oral prednisone 0,8 mg/kg/daily for four weeks. Once remission was achieved, a maintenance dose of 10 mg/day was administered, observing a good control of bullous disease and low value of desmoglein 1. Response to CSCC persisted also during cemiplimab discontinuation, until obtaining a complete remission still persisting at 9 months after the last cycle of therapy. CONCLUSION: The case we observed is the first description of PV revealed from cemiplimab therapy, thus suggesting that cemiplimab could allow the arise of underlying autoimmune PV, through a mechanism both T and B-cell-mediated.

Therapeutic hotline: Re-induction may be useful to manage psoriasis relapse during long-term maintenance treatment with infliximab: a retrospective analysis.

Infliximab is an anti-tumor necrosis factor-alpha monoclonal antibody that is highly effective for the treatment of psoriatic disease. During maintenance treatment, some patients may experience a disease relapse, and, in such circumstances, dose intensification is frequently used to regain efficacy. We report our cumulative experience on the use of infliximab re-induction in patients whose psoriasis relapsed during long-term maintenance treatment with infliximab. From September 2005 to January 2009, 22 patients required re-induction because of a relapse of their psoriasis. Re-induction was effective in restoring response in most patients and was well tolerated in all cases, without occurrence of serious or unexpected adverse events.

Adverse drug reactions as the cause of emergency department admission: focus on the elderly.

The use of medications could be responsible of both side effects and adverse drug reaction (ADR). Identifying risk factors could improve the possibility of avoiding severe reactions in old people. We investigated the prevalence of unpredictable drug adverse reactions among patients admitted to the emergency departments (EDs) of three large Italian hospitals in the period 2005-2008. Clinical characteristics and demographics were carefully recorded in a dedicated database. The assessment of the drug reactions was carried out by an allergist after the first emergency evaluation. Over the considered period, 56,031 patients were admitted at the ED, 2644 (21.2%) of which for ADR. Out of those patients, 55 (2.1%) were identified as unpredictable ADRs. In 96% of the cases the clinical presentation was cutaneous and antibiotics were the most frequently responsible drugs. Patients over 65 years accounted for 37% of the reactions. In those patients the multiple drug regimens were significantly more frequent, as well as the presence of comorbidities. Smoking habit, alcohol abuse and personal and familiar history of atopy did not differ between the younger and the elderly. In the older group, antibiotics were more frequently involved, whereas in the <65 years, nonsteroidal antinflammatory drugs accounted for most reactions. Our date outline that in the elderly the comorbidities and correlated multiple regime therapy cause an increased incidence of ADRs, thus suggesting a careful management of therapeutics regimens by means of educational campaigns for patients and guidelines for doctors finalized to avoid excessive drug prescription.

A Multicenter Study of IgE Sensitization to Anisakis simplex and Diet Recommendations.

BACKGROUND: Allergy to Anisakis simplex (s.) is spreading due to the increased consumption of raw, smoked or marinated fish. In man, Anisakis s. can directly attack the gastrointestinal mucosa, provoking a parasitosis known as anisakiasis, or giving rise to the formation of IgE and, finally, inducing IgE-mediated reactions like urticaria, angioedema and anaphylactic shock. During recent years, a dietary approach to Anisakis s. infestation has also been addressed. METHODS: A total of 620 patients with urticaria, angioedema, or both and a history of anaphylaxis following consumption of raw, smoked or marinated fish were recruited, evaluated for specific IgE levels to Anisakis s. and subjected to Skin Prick test. Following 18 month fish-free diet, patients were reevaluated at 6, 12 and 18 months, respectively. Patients undergoing diet were selected among those who had a clinical history with multiple accesses to first aid. RESULTS: After 6-month fish-free diet, we recorded an improvement of symptoms and a remarkable reduction of specific IgE levels. The extension of the diet over 6 months in some cases resulted in a further reduction of specific IgE levels. CONCLUSION: Data obtained confirm the importance of a fish-free diet in patients with severe symptoms since a new antigenic exposure coincides with a relapse of symptoms and increased IgE levels. This last point should be kept in mind and carefully evaluated in patients at risk for anaphylaxis or angioedema.

Cytokine Profile in Patients Infected with Anisakis simplex in Endemic Areas: Dietary Intervention with Polyphenols: A Working Hypothesis.

Anisakiasis is a zoonosis due to infection with the nematode Anisakis (A.) simplex. Humans represent an accidental host after ingesting raw fish infected with A. simplex. A. simplex larvae lead to a robust host immune response mostly at gastro-intestinal level and, usually, T helper (h)2 lymphocytes play a protective against this nematode. However, larvae can elude immunity triggering activation of T regulatory (Treg) cells, which, in turn, suppress Th2 responses via production of interleukin (IL)-10. According to our own experience in the area of Bari (south Italy) where anisakiasis is endemic, chronic urticaria (CU) is very often associated to A. simplex infection. The cytokine profile in CU patients with Anisakis infection is characterized by an elevated release of interferon-γ and IL-17, while IL-10 production is very low. This pattern of pro-inflammatory cytokine response was consistently detectable in patients who underwent a raw fish free diet regimen over a period of six months. In the light of the above considerations, we hypothesize that treating these patients with polyphenols it may be beneficial in terms of activation of Treg cell function. In fact, polyphenols have the capacity to expand Treg cell response in vitro. In this regard, activation of human Treg cells, by analogy to other helminthiasis, may lead to a reduction of allergic/inflammatory reaction in the course of human anisakiasis.

Contact allergy to topical corticosteroids: update and review on cross-sensitization.

Contact allergy to topical corticosteroids (TCs) is an emerging problem, whose diagnosis can be complex owing to the peculiar characteristics of steroid allergens and the possible inadequacy of current diagnostic methods, including concentration and vehicle used in patch testing. The occurrence of cross-reactions among different TCs is not rare, but prediction of these is not sufficiently reliable. Moreover, the distinction between true cross-reactivity and concomitant sensitization may be difficult. The original classification proposed by Coopman et al. has been distinguished corticosteroids into four groups according to their molecular structure. These authors hypothesized that allergic contact reactions were more frequent with corticosteroids belonging to the same group. However, the clinical practice has evidenced that cross reactivity exists also among corticosteroids belonging to different groups. The potential to cross-react among corticosteroids is thought to be related not only to the structural homology but also to the stereoisomerism and metabolism of these drugs. Recent evidence suggests that mechanisms responsible for cross-reactivity may occur at T lymphocyte level during antigen presentation. Further investigations are needed to gain a more complete understanding of this important topic. This article also reviews some patents related to the treatment of contact dermatitis and other inflammatory skin diseases.

Persistent B-cell lymphopenia, multiorgan disease, and erythema multiforme caused by Mycoplasma pneumoniae infection.

We report a 6-year-old girl in whom Mycoplasma pneumoniae infection presenting with erythema multiforme, multiorgan, and hematologic dysfunctions induced a long-standing, marked B-cell lymphopenia. An increase of CD8+ lymphocytes was also detected. We suggest that a selective cytotoxic T lymphocyte-dependent B cell lysis and the expansion of super-antigen activated CD8+ T cells may account for the multiorgan and hematologic disturbances triggered by M. pneumoniae.