Mast Cell-Targeting Therapies in Mast Cell Activation Syndromes.

PURPOSE OF REVIEW: Provide an overview of the expanding landscape of mast cell (MC)-targeting treatments in mast cell activation syndromes (MCAS). RECENT FINDINGS: Tyrosine-kinase inhibitors (TKIs) targeting wild-type and mutated KIT can efficiently induce MC depletion. Avapritinib and midostaurin can also temper IgE-mediated degranulation. Avapritinib has been recently approved by the FDA for the treatment of indolent systemic mastocytosis (ISM). Targeting activation pathways and inhibitory receptors is a promising therapeutic frontier. Recently, the anti Siglec-8 antibody lirentelimab showed promising results in ISM. MCAS is a heterogeneous disorder demanding a personalized therapeutic approach and, especially when presenting as anaphylaxis, has not been formally captured as outcome in prospective clinical trials with TKI. Long-term safety of TKI needs to be addressed. New drugs under investigation in diseases in which non-neoplastic MCs play a pivotal role can provide important inputs to identify new efficient and safe treatments for MCAS.

Comparison of the passive mast cell activation test with the basophil activation test for diagnosis of perioperative rocuronium hypersensitivity.

BACKGROUND: Rocuronium is a major cause of perioperative hypersensitivity (POH). Skin tests (STs) and quantification of specific immunoglobulin E antibodies (sIgEs) can yield incongruent results. In such difficult cases, the basophil activation test (BAT) can be helpful. Here, we evaluated the passive mast cell activation test (pMAT) as a substitute of BAT as part of the diagnostic tests for rocuronium allergy. METHODS: Sera from patients with a suspected POH reaction potentially related to rocuronium were included. All patients had a complete diagnostic investigation, including STs, quantification of sIgEs to morphine and rocuronium, and BAT. For execution of pMAT, human mast cells were generated from healthy donor peripheral blood CD34+ progenitor cells and sensitised overnight with patient sera. RESULTS: In total, 90 sera were studied: 41 from ST+sIgE+ patients, 13 from ST-sIgE- patients, 20 from ST+sIgE- patients, and 16 from ST-sIgE+ patients. According to BAT results, patients were further allocated into subgroups. Of the 38 BAT+ patients, 25 (66%) showed a positive pMAT as well. Of the 44 BAT- patients, 43 (98%) also showed a negative pMAT. Mast cells that were not passively sensitised did not respond to rocuronium. CONCLUSIONS: We show that the pMAT, in many cases, can substitute for BAT in the diagnosis of rocuronium hypersensitivity and advance diagnosis in difficult cases with uncertain ST or sIgE results when BAT is not locally available.

Novel insights into the associations between immune cell population distribution in mammary glands and milk minerals in Holstein cows.

Udder health has a crucial role in sustainable milk production, and various reports have pointed out that changes in udder condition seem to affect milk mineral content. The somatic cell count (SCC) is the most recognized indicator for the determination of udder health status. Recently, a new parameter, the differential somatic cell count (DSCC), has been proposed for a more detailed evaluation of intramammary infection patterns. Specifically, the DSCC is the combined proportions of polymorphonuclear neutrophils and lymphocytes (PMN-LYM) on the total SCC, with macrophages (MAC) representing the remainder proportion. In this study, we evaluated the association between DSCC in combination with SCC on a detailed milk mineral profile in 1,013 Holstein-Friesian cows reared in 5 herds. An inductively coupled plasma-optical emission spectrometry was used to quantify 32 milk mineral elements. Two different linear mixed models were fitted to explore the associations between the milk mineral elements and first, the DSCC combined with SCC, and second, DSCC expressed as the PMN-LYM and MAC counts, obtained by multiplying the proportion of PMN-LYM and MAC by SCC. We observed a significant positive association between SCC and milk Na, S, and Fe levels. Differential somatic cell count showed an opposite behavior to the one displayed by SCC, with a negative association with Na and positive association with K milk concentrations. When considering DSCC as count, Na and K showed contrasting behavior when associated with PMN-LYM or MAC counts, with decreasing of Na content and increasing K when associated with increasing PMN-LYM counts, and increasing Na and decreasing K when associated with increasing MAC count. These findings confirmed that an increase in SCC is associated with altered milk Na and K amounts. Moreover, MAC count seemed to mirror SCC patterns, with the worsening of inflammation. Differently, PMN-LYM count exhibited patterns of associations with milk Na and K contents attributable more to LYM than PMN, given the nonpathological condition of the majority of the investigated population. An interesting association was observed for milk S content, which increased with increasing of inflammatory conditions (i.e., increased SCC and MAC count) probably attributable to its relationship with milk proteins, especially whey proteins. Moreover, milk Fe content showed positive associations with the PMN-LYM population, highlighting its role in immune regulation during inflammation. Further studies including individuals with clinical condition are needed to achieve a comprehensive view of milk mineral behavior during udder health impairment.

The Severity and Frequency of Systemic Reactions to Hazelnut Are Significantly Higher in Hazelnut Allergic Patients Monosensitized to Cor a 8 than in Patients Polysensitized to Cor a 1, Cor a 8, and Cor a 9.

INTRODUCTION: Hazelnuts are a leading trigger of food allergy. To date, several molecular components of hazelnut are available for component-resolved diagnosis. However, little is known about how simultaneous sensitization to multiple allergens affects the severity of the hazelnut-induced reaction. In a previous study, our group demonstrated a lower risk of systemic reactions to peach in patients sensitized to both Pru p 3 and Pru p 1 than in the patient monosensitized to peach LTP. We aimed to assess whether this was also true in hazelnut allergy in a cohort of adult patients. METHODS: Patients were selected based on a history of symptoms such as urticaria, vomiting, diarrhea, asthma, and anaphylaxis indicative of hazelnut IgE-mediated food allergy and graded according to a clinical severity scale. For all patients, specific IgE was determined for Cor a 1 and Cor a 8 and, for most patients, also Cor a 9. Patients were offered an oral food challenge in open format (OFC) with a cocoa-based roasted hazelnut spread on a voluntary basis in order to prescribe an appropriate diet. RESULTS: A total of two hundred and fourteen patients were recruited. Among these, 43 patients were monosensitized to Cor a 8. One hundred and seventy-one patients were sensitized to Cor a 1 (79.9%), and, among them, 48/171 (28.1%) were also Cor a 8 positive. Cor a 9 was evaluated in 124/214 patients, testing positive in 21/124 (16.9%). Patients monosensitized to Cor a 8 experienced systemic reactions more frequently than those sensitized to Cor a 1 ± Cor a 8 (p < 0.00001), with significantly more severe reactions (p < 0.0005) and testing more frequently positive at OFC (p < 0.0001). Regarding Cor a 9, the sensitized patients were significantly younger (p = 0.0013) and showed reactions of similar severity to patients who tested Cor a 9 negative, and these reactions were milder than in patients monosensitized only to Cor a 8. DISCUSSION/CONCLUSION: Sensitization to Cor a 1 seems to protect from the development of the severe systemic reactions induced by Cor a 8 sensitization, Cor a 9 does not influence the severity of symptoms in adult patients. The OFC with roasted hazelnut may help in dietary guidance.

Diagnostic Significance of Tryptase for Suspected Mast Cell Disorders.

Tryptase has proven to be a very useful and specific marker to demonstrate mast cell activation and degranulation when an acute (i.e., within 4 h after the event) and baseline value (i.e., at least 24 h after the event) are compared and meet the consensus formula (i.e., an increase of 20% + 2). The upper limit of normal determined by the manufacturer is 11.4 ng/mL; however, this boundary has been the subject of debate. According to ECNM and AIM experts, the normal range of baseline tryptase should be 1 to 15 ng/mL. A genetic trait, hereditary alpha tryptasemia, characterized by an increased alpha coding TPSAB1 copy number is associated with a baseline value above 8 ng/mL. Elevated tryptase can also be found in chronic kidney disease, obesity, and hematological neoplasms. A tryptase > 20 ng/mL serves as a minor criterion to diagnose systemic mastocytosis and an increase in tryptase > 20% + 2 during an acute event is a required criterion in the diagnosis of mast cell activation syndrome. The goal of this review is to demonstrate the (in)significance of tryptase using some clinical vignettes and to provide a practical guide on how to manage and interpret an elevated tryptase level.

Impact of innovative rearing strategies for the Italian heavy pigs: Technological traits and chemical composition of dry-cured hams.

To explore the influence of 4 feeding strategies on dry-cured ham quality, 336 barrows and gilts (3 batches, 112 pigs/batch) of 90 kg body weight (BW), were divided into 4 groups and housed in 8 pens with automated feeders. In the control group (C), the pigs were fed restrictively medium-protein feeds and slaughtered at 170 kg BW (SW) and 265 d of slaughter age (SA). With the older age (OA) treatment, the pigs were restrictively fed low protein feeds and slaughtered at 170 kg SW and 278 d SA. The other two groups were fed ad libitum high protein feeds, the younger age (YA) group was slaughtered at 170 kg SW and 237 d SA, the greater weight (GW) at 265 d of SA and 194 kg SW. The hams were dry-cured and seasoned for 607 d, weighed before and after seasoning and deboning. Sixty hams were sampled and sliced. The lean and the fat tissues were separated and analyzed for proximate composition and fatty acid profile. The model of analysis considered sex and treatment as fixed factors. With respect to C: i) OA lowered the ham weight, the lean protein content, increased marbling and decreased the PUFA proportion in intramuscular and subcutaneous fat; ii) YA hams had thicker fat cover with lower PUFA in intramuscular and subcutaneous fat; iii) GW increased the deboned ham weight, fat cover depth and marbling, reduced PUFA in intramuscular and subcutaneous fat, without alteration of the lean moisture content. Sex had a negligible impact.

Associations between the detailed milk mineral profile, milk composition, and metabolic status in Holstein cows.

The causes of variation in the milk mineral profile of dairy cattle during the first phase of lactation were studied under the hypothesis that the milk mineral profile partially reflects the animals' metabolic status. Correlations between the minerals and the main milk constituents (i.e., protein, fat, and lactose percentages), and their associations with the cows' metabolic status indicators were explored. The metabolic status indicators (MET) that we used were blood energy-protein metabolites [nonesterified fatty acids, ß-hydroxybutyrate (BHB), glucose, cholesterol, creatinine, and urea], and liver ultrasound measurements (predicted triacylglycerol liver content, portal vein area, portal vein diameter and liver depth). Milk and blood samples, and ultrasound measurements were taken from 295 Holstein cows belonging to 2 herds and in the first 120 d in milk (DIM). Milk mineral contents were determined by ICP-OES; these were considered the response variable and analyzed through a mixed model which included DIM, parity, milk yield, and MET as fixed effects, and the herd/date as a random effect. The MET traits were divided in tertiles. The results showed that milk protein was positively associated with body condition score (BCS) and glucose, and negatively associated with BHB blood content; milk fat was positively associated with BHB content; milk lactose was positively associated with BCS; and Ca, P, K and S were the minerals with the greatest number of associations with the cows' energy indicators, particularly BCS, predicted triacylglycerol liver content, glucose, BHB and urea. We conclude that the protein, fat, lactose, and mineral contents of milk partially reflect the metabolic adaptation of cows during lactation and within 120 DIM. Variations in the milk mineral profile were consistent with changes in the major milk constituents and the metabolic status of cows.

A quarter of a century fundamental and translational research in perioperative hypersensitivity and anaphylaxis at the Antwerp university hospital, a Belgian Centre of Excellence of the World Allergy Organization.

Perioperative hypersensitivity constitutes an important health issue, with potential dramatic consequences of diagnostic mistakes. However, safe and correct diagnosis is not always straightforward, mainly because of the application of incorrect nomenclature, absence of easy accessible in-vitro/ex-vivo tests and uncertainties associated with the non-irritating skin test concentrations. In this editorial we summarize the time line, seminal findings, and major realizations of 25 years of research on the mechanisms, diagnosis, and management of perioperative hypersensitivity.

Pulse-driven self-reconfigurable meta-antennas.

Wireless communications and sensing have notably advanced thanks to the recent developments in both software and hardware. Although various modulation schemes have been proposed to efficiently use the limited frequency resources by exploiting several degrees of freedom, antenna performance is essentially governed by frequency only. Here, we present an antenna design concept based on metasurfaces to manipulate antenna performances in response to the time width of electromagnetic pulses. We numerically and experimentally show that by using a proper set of spatially arranged metasurfaces loaded with lumped circuits, ordinary omnidirectional antennas can be reconfigured by the incident pulse width to exhibit directional characteristics varying over hundreds of milliseconds or billions of cycles, far beyond conventional performance. We demonstrate that the proposed concept can be applied for sensing, selective reception under simultaneous incidence and mutual communications as the first step to expand existing frequency resources based on pulse width.

Allergenic and Mas-Related G Protein-Coupled Receptor X2-Activating Properties of Drugs: Resolving the Two.

Since the seminal description implicating occupation of the Mas-related G protein-coupled receptor X2 (MRGPRX2) in mast cell (MC) degranulation by drugs, many investigations have been undertaken into this potential new endotype of immediate drug hypersensitivity reaction. However, current evidence for this mechanism predominantly comes from (mutant) animal models or in vitro studies, and irrefutable clinical evidence in humans is still missing. Moreover, translation of these preclinical findings into clinical relevance in humans is difficult and should be critically interpreted. Starting from our clinical priorities and experience with flow-assisted functional analyses of basophils and cultured human MCs, the objectives of this rostrum are to identify some of these difficulties, emphasize the obstacles that might hamper translation from preclinical observations into the clinics, and highlight differences between IgE- and MRPGRX2-mediated reactions. Inevitably, as with any subject still beset by many questions, alternative interpretations, hypotheses, or explanations expressed here may not find universal acceptance. Nevertheless, we believe that for the time being, many questions remain unanswered. Finally, a theoretical mechanistic algorithm is proposed that might advance discrimination between MC degranulation from MRGPRX2 activation and cross-linking of membrane-bound drug-reactive IgE antibodies.

Basophil Activation Test Shows Poor Sensitivity in Immediate Amoxicillin Allergy.

BACKGROUND: In light of the pandemic of spurious penicillin allergy, correct diagnosis of amoxicillin (AX) allergy is of great importance. The diagnosis of immediate hypersensitivity reactions relies on skin tests and specific IgE, and although reliable, these are not absolutely predictive. Therefore, drug challenges are needed in some cases, which contain the risk of severe reactions. Safe in vitro diagnostics as an alternative for the drug challenge in the diagnostic workup of AX allergy would be more than welcome to fill this gap. In this respect, the basophil activation test (BAT) has shown potential, but its clinical reliability is doubtful. OBJECTIVE: To investigate the reliability of the BAT to AX and determining its exact place in the diagnostic algorithm of AX allergy. METHODS: BAT for AX was performed in 70 exposed control individuals and 66 patients diagnosed according to the European Academy of Allergy and Clinical Immunology guidelines for AX allergy. Upregulation of both CD63 and CD203c was flow-cytometrically assessed. RESULTS: Analyses revealed that 1370 µmol/L and 685 µmol/L were the most discriminative stimulation concentrations for CD63 and CD203c upregulation, respectively, and a diagnostic threshold of 9% for positivity for both markers was identified. At these concentrations, sensitivity and specificity for CD63 upregulation were 13% and 100%, respectively, and for CD203c upregulation, 23% and 98%. CONCLUSIONS: BAT with dual analysis of CD63 and CD203c is of poor performance to document AX allergy. The sensitivity is too low to let it occupy a prominent role in the diagnostic algorithm.

A review of cannabis allergy in the early days of legalization.

Cannabis allergy is a burgeoning field; consequently, research is still in its infancy and allergists' knowledge surrounding this topic is limited. As cannabis legalization expands across the world, it is anticipated that there will be an increase in cannabis use. Thus, we hypothesize that a concomitant rise in the incidence of allergy to this plant can be expected. Initiatives aimed at properly educating health care professionals are therefore necessary. This review presents the most up-to-date information on a broad range of topics related to cannabis allergy. Although the clinical features of cannabis allergy are becoming more well described and recognized, the tools available to make a correct diagnosis are meager and often poorly accessible. In addition, research on cannabis allergy is still taking its first steps, and new and potentially groundbreaking findings in this field are expected to occur in the next few years. Finally, although therapeutic approaches are being developed, patient and physician education regarding cannabis allergy is certainly needed.

Mastocytosis and related entities: a practical roadmap.

Mastocytosis is a complex heterogenous multisystem disorder that is characterized by pathologic activation or accumulation of neoplastic mast cells (MCs) in one or more organs. This clonal MC expansion is often associated with a somatic gain-of-function mutation (D816V in most of the cases) in the KIT gene, encoding for the MC surface receptor KIT (CD117), a stem cell growth factor receptor. Based on clinical and biochemical criteria, the World Health Organization (WHO) divided mastocytosis into different subclasses. The exact prevalence of mastocytosis remains elusive, but it is estimated that the disease affects approximately 1 in 10,000 persons. The clinical presentation of mastocytosis varies significantly, ranging from asymptomatic patients to a life-threatening disease with multiple organ involvement, potentially leading to cytopenia, malabsorption, hepatosplenomegaly, lymphadenopathy, ascites or osteolytic bone lesions with pathological fractures. Patients with mastocytosis may experience symptoms related to release of MC mediators, such as flushing or diarrhea or even more severe symptoms such as anaphylaxis. Recently, a new genetic trait, hereditary alpha tryptasemia (HaT), was described which involves a copy number variation in the TPSAB1-gene. Its role as standalone multisystem syndrome is heavily debated. There is emerging evidence suggesting there might be a link between HaT and due to the increased prevalence of HaT in patients with SM. The aim of this review is to provide a practical roadmap for diagnosis and management of mastocytosis and its associated entities, since there are still many misconceptions about these topics.Abbreviations: AdvSM: Advanced systemic mastocytosis; ASM: Aggressive systemic mastocytosis; aST: acute serum tryptase; BM: Bone marrow; BMM: Bone marrow mastocytosis; bST: baseline serum tryptase; CM: Cutaneous mastocytosis; DCM: Diffuse cutaneous mastocytosis; HVA: Hymenoptera venom allergy; HaT: Hereditary alpha tryptasemia; ISM: Indolent systemic mastocytosis; MC: Mast cell; MCA: Mast cell activation; MCAS: Mast cell activation syndrome; MCL: Mast cell leukemia; MIS: Mastocytosis in the skin; MMAS: Monoclonal mast cell activation syndrome; MPCM: Maculopapular cutaneous mastocytosis; SM: Systemic mastocytosis; SM-AHN: Systemic mastocytosis with associated hematological neoplasm; SSM: Smouldering systemic mastocytosis; VIT: Venom immunotherapy.

Establishing diagnostic strategies for cannabis allergy.

INTRODUCTION: Cannabis is the most widely consumed illicit drug in the world and carries a risk of severe IgE-mediated allergic reactions, requiring appropriate diagnostic management. Currently available diagnostics are still relatively limited and require careful interpretation of results to avoid harmful over- and underdiagnosis. AREAS COVERED: This review focuses on the most up-to-date understandings of cannabis allergy diagnosis, starting with the main clinical features of the disease and the allergenic characteristics of Cannabis sativa, and then providing insights into in vivo, in vitro, and ex vivo diagnostic tests. EXPERT OPINION: At present, the diagnosis of IgE-mediated cannabis allergy is based on a three-step approach that starts with accurate history taking and ends with a confirmation of sensitization to the whole extract and, finally, molecular components. Although much has been discovered since its first description in 1971, the diagnosis of cannabis allergy still has many unmet needs. The lack of commercial standardized and validated extracts and in vitro assays makes a harmonized workup of cannabis allergy difficult. Furthermore, the epidemiological characteristics, and clinical implications of sensitization to different molecular components are not yet fully known. Future research will complete the picture and likely result in an individualized and standardized approach.