Vincenzo Patella

This expert position paper was developed by experts from nine Italian scientific societies with the aim of addressing in an integrated and multidisciplinary way the complex interactions between environmental and occupational exposures, climate change, and the onset of respiratory allergic diseases in the adult and paediatric population. Air pollution is the leading environmental risk factor for human health worldwide and in Italy. According to the State of Global Air 2025, it caused 7.9 million deaths in 2023, making it the second leading risk factor for mortality. In response to growing scientific evidence, the World Health Organization (WHO) updated its Air Quality guidelines in 2021, recommending substantially lower pollutant limits than those established by previous European legislation. The new European Ambient Air Quality Directive (2024/2881/EU), which entered into force in December 2024, introduces stricter air quality standards to be achieved by 2030, while strengthening monitoring systems and public access to air quality information. Italian epidemiological studies have consistently shown that exposure to particulate matter [PM: atmospheric PM with a diameter ≤ 10 μm (PM10) and atmospheric PM with a diameter ≤ 2.5 μm (PM2.5)], nitrogen dioxide (NO2), and ozone (O3) is associated with increased odds of rhinitis, asthma, chronic obstructive pulmonary disease (COPD), respiratory hospitalizations, and mortality both in the short and long term. These effects are mediated by inflammatory responses, oxidative stress, and molecular and epigenetic mechanisms. Children, particularly those living in densely populated urban areas with poor air quality, are among the most vulnerable populations. Climate change, which originates from the same anthropogenic emissions driving air pollution, i.e., from energy, transport, heating, cooling, and agriculture, is further aggravating the burden of respiratory disease through more frequent heatwaves, extreme weather events, and changes in the distribution and flowering seasons of allergenic plants. Rising pollen production, combined with air pollution, enhances allergen exposure and worsens allergic respiratory diseases. Therefore, integrated monitoring of pollen, air pollutants, and meteorological conditions is essential for improving disease prediction and prevention. Particular concern is raised by thunderstorm asthma, characterized by sudden outbreaks of severe asthma following thunderstorms. Indoor air pollution is also emerging as a major public health concern because of the growing use of chemicals and the high fraction of time spent indoors. Passive smoking, combustion products from cooking and heating, volatile organic compounds, and inadequate ventilation are associated with respiratory symptoms and impaired lung function. Schools are of particular concern, as elevated levels of carbon dioxide and PM are frequently reported in classrooms. Occupational exposure to dust, fumes and gases remains an important cause of occupational asthma and respiratory impairment. This document promotes operational proposals for risk prevention and mitigation, encourages scientific research and fosters the dialogue with public health and environmental authorities, in order to strengthen respiratory health protection policies.

Background/objectives: The ongoing Ukrainian conflict constitutes a grave humanitarian emergency, with refugees facing significant language and cultural barriers hindering access to health care. The UCRAID (Ukrainian Citizen and refugee electronic support in Respiratory diseases, Allergy, Immunology and Dermatology) initiative was launched to support Ukrainian refugees through the MASK-air® and CRUSE® apps. The UCRAID@Apulia study aimed to assess the feasibility of UCRAID via a joint medical and socio-linguistic approach. Methods: A multidisciplinary, cross-sectional study was conducted from July 2023 to June 2024 involving adult Ukrainian refugees with asthma, allergic rhinitis, atopic dermatitis or chronic urticaria recruited via a network of Ukrainian associations and institutional partners. Participants were introduced to MASK-air® and CRUSE® and administered a 20-item questionnaire assessing sociocultural and healthcare needs, linguistic barriers, comorbidities (Charlson Comorbidity Index) and health-related quality of life (EQ-5D-5L). Results: Among the 381 eligible patients being offered participation, 53 (13.91%) accepted enrolment. While literacy and occupation levels were high, issues with accommodation and bureaucracy were often cited. Mistrust and fear of reprisals emerged as key deterrents to participation. Chronic urticaria and atopic dermatitis were the prevalent allergic conditions. EQ-5D-5L showed good overall health but was characterized by anxiety/depression (32.1%) and pain (17%). Despite significant language barriers in both Italian and English, all participants successfully used both applications. At a 30-day follow-up, 71% reported at least 5 days of consecutive usage with high satisfaction. Conclusions: Despite low enrolment driven by fear and distrust, mHealth tools like MASK-air® and CRUSE® proved feasible and well-received, with trust building and long-term support being key elements for wider future adoption.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis with heterogeneous clinical manifestations. Identifying reliable biomarkers is crucial to predicting disease evolution and guiding therapy. We analyzed clinical, biological, and functional data from 33 patients with EGPA in the vasculitic phase. Blood eosinophil count (BEC), eosinophilic cationic protein (ECP), antineutrophil cytoplasmic antibodies (ANCAs), specific IgE to staphylococcal enterotoxins (SE-IgE), and serum free light chains (FLCs) were evaluated. Severe eosinophilic asthma (SEA) and chronic rhinosinusitis with nasal polyps (CRSwNPs) were present in 100% and 88.5% of patients, respectively. Median BEC was 1950 cells/mm3, with elevated ECP (60.0 µg/L). SE-IgE was detected in 54.2% of patients. A significant negative correlation emerged between λ FLCs and oral corticosteroid (OCS) dose (r = –0.58, p = 0.009). Forced expiratory volume in 1 second (FEV1) was significantly lower in C-ANCA+ patients (p = 0.006). ECP and SE-IgE may serve as markers of eosinophilic activity and epithelial barrier damage in EGPA. λ FLCs might be a useful indicator of OCS exposure and treatment response. These biomarkers could support the evaluation of disease evolution and treatment response.

Background: Oral and ocular medications are frequently used in the treatment of allergic rhinitis (AR). As part of the update of the Allergic Rhinitis and its Impact on Asthma (ARIA)‐EAACI guidelines, this manuscript presents the ARIA‐EAACI 2024–2025 recommendations for oral and ocular treatments. Methods: The ARIA‐EAACI 2024–2025 guideline panel issued recommendations following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence‐to‐decision framework. Several sources of evidence were used to inform panel judgements and recommendations, including systematic reviews, mHealth and pharmacovigilance data as well as a survey on costs. Results: Eight guideline questions concerning oral treatments for AR and three questions concerning ocular treatments were addressed. These questions led to the recommendations. Overall, these questions concern the choice between different classes of medication. They also discuss the role of oral antihistamines (OAH), leukotriene receptor antagonists (LTRA), ocular antihistamines (OcAH) and ocular mast cell stabilisers. Four questions had not been previously evaluated in ARIA guidelines, while, for the other four, there was a change in the strength or directionality of the recommendations. Overall, these guidelines recommend using intranasal corticosteroids over OAH and using OAH over LTRA. Moreover, they suggest using OAH over OcAH and suggest being against adding LTRA to OAH. Finally, considerations for choosing between different individual OAHs are presented. Conclusion: This ARIA‐EAACI 2024–2025 article supports patients, their caregivers and healthcare professionals in choosing oral and ocular treatments for AR. Decisions on treatment should consider the clinical variability of the disease, patients' values and the affordability of medications.

This review describes the eosinophil journey through the various physiological and pathophysiological phases, from production, maturation, and activation by chemokines and cytokines [especially eotaxin, interleukin (IL)-5, IL-3, and granulocyte-macrophage colony-stimulating factor (GM-CSF)], to interaction with the innate and adaptive immune system and tissue homing. Excessive production and activation of eosinophils lead to the release of granule proteins, such as major basic protein, eosinophil cationic protein, eosinophil peroxidase, and others, resulting in inflammation, cell cytotoxicity, and oxidative stress. The pathogenesis, clinical features, diagnostic processes, and the latest therapeutic approaches to the resulting diseases—which affect the upper and lower airways, gastrointestinal tract, skin, myocardium, and may occur systemically—are discussed.

Background: Autoimmune diseases (AIDs) are characterized by chronic inflammation and tissue damage resulting from abnormal immune responses. While genetic and environmental factors play significant roles in disease development, essential micronutrient deficiencies (MNDs) represent a critical and often overlooked contributor. Methods: This review examines the interactions between micronutrients and immune cells, focusing on vitamin D, vitamin B12, folate (FA), and iron, and their roles in AIDs, such as rheumatoid arthritis, autoimmune thyroid disorders, multiple sclerosis, systemic lupus erythematosus, and other connective tissue diseases. We explore the immunomodulatory effects of these micronutrients, their impact on immune tolerance, and the mechanisms by which MNDs contribute to disease progression. Results: MNDs are commonly observed in patients with AIDs and are associated with worsening immune dysregulation, increased inflammation, and disease severity. Vitamin D plays a pivotal role in modulating immune responses and attenuating inflammation, while iron and FA are essential for immune cell proliferation and function. Vitamin B12 supports methylation processes and genomic stability. Conclusions: MNDs significantly influence the pathogenesis and progression of AIDs. Routine micronutrient screening and targeted supplementation should be considered as part of clinical management, offering potential adjunctive benefits alongside conventional therapies. Further research is needed to define optimal dosing strategies and to identify patient subgroups most likely to benefit from nutrition-based interventions.

Background: Allergic rhinitis (AR) impacts quality of life, work and school productivity. Over the last years, an important body of evidence resulting from mHealth data has led to a better understanding of AR. Such advances have motivated an EAACI‐endorsed update of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines (ARIA 2024–2025). This manuscript presents the ARIA 2024–2025 recommendations for intranasal treatments, one of the mainstays for AR management. Methods: The ARIA 2024–2025 guideline panel issued recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence‐to‐decision framework. Several sources of evidence were used to inform panel judgments and recommendations, including systematic reviews, evaluation of mHealth and pharmacovigilance data, as well as a survey of experts on costs. Results: Eleven guideline questions concerning intranasal treatments for AR were prioritized, leading to recommendations. Overall, these questions concern the choice between different classes of intranasal medications—most notably, intranasal corticosteroids (INCS), antihistamines (INAH), fixed combinations of INAH+INCS and decongestants—or between different individual medications within each class. Four questions had not been evaluated in previous ARIA guidelines, while for the other three there was a change in the strength or directionality of recommendations. Overall, recommendations point to the suggested use of INAH+INCS over INAH or INCS and INCS over INAH. Conclusion: This ARIA 2024–2025 article supports patients, their caregivers, and healthcare professionals in choosing an intranasal treatment. However, decisions on AR treatment should consider the clinical variability of the disease, patients' values, and the affordability of medications.

The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines produced their first edition in 1999, with subsequent revisions in 2008, 2010, 2016 and 2019. A new iteration of ARIA—ARIA 2024–2025—in collaboration with EAACI is currently being developed, focusing on the management of allergic rhinitis. ARIA 2024–2025 follows the GRADE framework and is endorsed by the European Academy of Allergy and Clinical Immunology (EAACI). A set of approaches has been used to develop guideline questions, including surveying key opinion leaders and using artificial intelligence (AI)‐based tools to analyse web searches on allergic rhinitis and to generate questions. Each prioritised guideline question is assessed through an Evidence‐to‐Decision (EtD) framework. EtDs support the systematic and transparent formulation of recommendations, comprising 12 criteria for which the best available evidence should be sought. In the context of ARIA‐EAACI 2024–2025, such evidence is derived not only from randomised controlled trials but also—among others—from patient‐generated data sources that better reflect the affected individuals' perspectives. Moreover, ARIA‐EAACI 2024–2025 incorporates evidence on planetary health. Developed guideline recommendations will support the creation of digitalised decision algorithms and care pathways. This paper describes the methodology used to develop the person‐centred, digitally enabled and AI‐assisted ARIA‐EAACI 2024–2025. Among others, it describes (i) the development and prioritisation of guideline questions, (ii) sources of evidence for EtDs and (iii) the development of digitalised decision algorithms and care pathways.

Key points Allergen immunotherapy (AIT) is a disease-modifying treatment with long-term effects that persist after its discontinuation.