Ozlem Goksel

Background and Objective: Severe asthma (SA) is commonly complicated by multiple comorbidities, which significantly worsen clinical outcomes. However, the recognition of asthma comorbidities in clinical practice remains unclear. We aimed to assess gaps in comorbidity documentation in SA registries, evaluate comorbidity prevalence and variation across Europe, and explore physician perspectives on multimorbidity management, with a focus on real-world recognition and documentation of comorbidities. Methods: We analysed data from 13,245 SA patients across 22 European registries. Thirty-two clinically relevant comorbidities were grouped into five categories (type 2 (T2)-related, pulmonary, extrapulmonary, psychophysiological, and steroid–related) to assess registry capture and national prevalence. A pan-European online survey of 239 SA specialists explored clinical approaches and resources for multimorbidity management. Results: Across the registries, T2-related and pulmonary comorbidities were captured more consistently than extrapulmonary, psychophysiological, and steroid-related conditions, with substantial variation between countries. The most prevalent recorded comorbidities included chronic sinusitis (40%), nasal polyps (35%), obesity (30%), allergic rhinitis (30%), and gastroesophageal reflux disease (29%) but their prevalence varied widely across countries. Forty-one percent of surveyed physicians lacked multidisciplinary team (MDT) access, with lack of time (36%) and funding (26%) reported as the main barriers. Eighty-five percent of respondents acknowledged the impact of multimorbidity on asthma outcomes and expressed a need for improved training and patient education to improve its management. Conclusion: Comorbidities are highly prevalent in European SA populations but remain inconsistently documented across registries, especially steroid–related conditions. However, these findings should be interpreted in the context of heterogeneity in registry structure, diagnostic pathways, and data capture practices across countries. Limited resources further constrain optimal multimorbidity management. These findings highlight the need for standardized registry protocols, improved MDT access, and targeted education. This study provides the first pan-European evaluation of comorbidity capture in SA registries alongside physician perspectives on multimorbidity.

Type 2 (T2) immunity is classically associated with defense against helminths and environmental threats, from a physiological perspective, and with allergies and eosinophilic inflammatory diseases, in a pathological sense. However, growing evidence reveals that T2 pathways also support other essential homeostatic functions, including tissue protection and repair. There are major clues from the early evolution of T2 responses for protection against massive tissue damage and positive selection for survival against parasites starting over 500 million years ago. These responses likely co‐evolved stepwise with immune‐regulatory circuits, culminating in the emergence of the fully functional human‐type IgG4 in the great apes (Hominidae) within the last ~10 million years. The involvement of body barriers along with the strong influence of local epithelial cells and their interaction with the microbiome and the immune system is a common characteristic of T2 inflammation. An expanding list of new T2 diseases is being reported, characterized by epithelial cell and immune system activation, epithelial barrier damage, and microbial dysbiosis, including opportunistic pathogen colonization and loss of commensals. This evolving understanding coincides with the clinical success of biologics targeting key T2 mediators such as IL‐4, IL‐5, IL‐13, IL‐31, TSLP, and IgE, which have transformed the management of severe allergic diseases and other T2‐driven pathologies. However, the contribution of T2 immunity to homeostatic programs raises questions about the long‐term consequences of sustained T2 suppression. In this review, we examine the dual role of T2 immunity in health and disease, revisit its evolutionary origins, highlight its protective functions beyond allergy, and discuss the potential implications of prolonged T2 pathway blockade.

Background/Objectives: Chemotherapy drug (ChD)-induced maculopapular eruptions (MPEs) may interrupt optimal cancer treatment when no equally effective alternative therapy is available. Evidence supporting rapid drug desensitization (RDD) for delayed-type MPE remains scarce. We aimed to evaluate the feasibility and safety of RDD in patients with ChD-induced MPE. Methods: Adult patients with ChD-induced MPE who underwent RDD between January 2021 and January 2024 were evaluated. Delayed MPE recurrence was assessed until the subsequent chemotherapy cycle. Results: A total of 63 RDD procedures were performed in 10 patients with ChD-induced MPE, most commonly triggered by taxanes and platinum agents. The median onset of the index reaction was 60.0 h (24.0–336.0), and delayed intradermal tests were positive in 2 of 9 tested patients (22.2%). No delayed MPE recurrences were observed during the predefined follow-up period until the subsequent chemotherapy cycle. Immediate breakthrough reactions occurred in 3 of 10 patients (30.0%), corresponding to 17 of 63 RDD procedures (27.0%), and were limited to mild flushing and pruritus that resolved with antihistamines with or without low-dose corticosteroids. All RDD procedures were successfully completed without severe systemic reactions, and all patients were discharged on the same day. Conclusions: In carefully selected patients with delayed-type MPE, RDD appears to be a feasible and safe short-term strategy for enabling continuation of essential chemotherapy within the predefined observation period. As this pilot study includes a small and heterogeneous patient population with limited follow-up, the findings should be considered preliminary and hypothesis-generating and warrant confirmation in larger prospective studies with longer follow-up.

The Impact of the Exposome on Epithelial Barriers: New Approach Methodologies for Translational Research - Thoracic Research and Practice

Background: Digital symptom monitoring via e‐Diary apps can support the diagnosis and management of chronic diseases with trigger‐induced exacerbations such as pollen allergies. Attrition is a major challenge for continuous e‐Diary usage with an unsupervised approach. Objective: To investigate adherence to e‐Diary reporting, its early determinants and predictors in a blended care setting among pollen allergic patients with heterogeneous cultural backgrounds. Methods: The @IT.2020 observational multicenter study recruited patients with diagnosed seasonal allergic rhinitis from seven Southern European/Mediterranean countries. Baseline characteristics were investigated through questionnaires, skin prick tests and serum specific IgE measurements. The study doctors asked patients to record their allergy symptoms via e‐Diary (AllergyMonitor, TPS) daily during the clinically relevant season of pollination and increased mould concentrations. Results: Among 815 patients (467 adults, 348 children), the average prescribed e‐Diary recording period was 106 (SD 47.1) days, with an average completion rate of 75.2% (SD 21.2%). Children (≥ 10 years) filled 73.8% (95% CI 68.1–79.4) of prescribed days without parental support. We identified a stable ‘higher’ and a more variable ‘lower’ adherence cluster. Adherence was weakly associated with disease severity, but not with age, gender, country, education or digital literacy. Short‐term (first 3 weeks) adherence was strongly associated with long‐term adherence (partial R ² = 0.387, p < 0.001), with 87.6% of lower adherent patients remaining poorly adherent beyond 3 weeks. Conclusion: In a blended care setting, adherence to e‐Diary compilation among pollen allergic patients is high, irrespective of age and cultural background. Early identification of lower adherence is possible and might inform early interventions to improve patient adherence.

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.

The Severe Asthma Questionnaire (SAQ) is a validated tool used to assess health-related quality of life (HRQoL) in patients with severe asthma. This study aimed to evaluate the Turkish language validity, reliability, and concurrent validity of the SAQ in comparison with other validated tools in Turkish. This was a multi-centre, real-life, prospective observational study. Patients with severe asthma who had been receiving biologic therapy for at least six months were enrolled. After translation with cultural adaptation, the Turkish version of the SAQ (TR-SAQ), the Asthma Control Test (ACT), and the Asthma Quality of Life Questionnaire (AQLQ) were administered alongside pulmonary function tests on the same day. The TR-SAQ was repeated on day 14 ± 2. The validity and reliability were assessed based on the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria. Among the 197 severe asthma patients included, 73.4% (n:144) were female, with a mean age of 53.6 ± 13 years. The mean total score of the SAQ (16-item) was 5.09 ± 1.41 (out of 7), and the global SAQ score was 68.24 ± 21.23. The TR-SAQ demonstrated high internal consistency (Cronbach's alpha = 0.955). Test-retest reliability was r = 0.785 (p < 0.001). The Kaiser-Meyer-Olkin value was 0.93, and Bartlett's test p-value was 0.05). Turkish physicians can use TR-SAQ, a valid, reliable HRQoL assessment tool, for severe asthma patients.