Proportional Venn diagram and determinants of allergic respiratory diseases in Italian adolescents

Issue 2 - "Update on adverse respiratory effects of indoor air pollution". Part 2): Indoor air pollution and respiratory diseases: Perspectives from Italy and some other GARD countries

OBJECTIVE

to synthesize the Italian epidemiological contribution to knowledge on indoor pollution respiratory impact, and to analyze the perspective of some GARD countries on the health effects of indoor air pollution.

RESULTS

Italian epidemiological analytical studies confirmed a strong relationship between indoor air pollution and health in general population. Environmental tobacco smoke, biomass (wood/coal) fuel for cooking/heating and indoor allergens (house dust mites, cat and dog dander, mold/damp) are the most relevant indoor pollution sources and are related to respiratory and allergic symptoms/diseases in Italy and in other GARD countries such as Mexico, Brazil, Vietnam, India, Nepal and Kyrgyzstan. Community-based global health collaborations are working to improve prevention, diagnosis and care of respiratory diseases around the world, specially in low- and middle-income countries, through research and education.

CONCLUSIONS

in the last thirty years, the scientific evidence produced on respiratory health effects of indoor air pollution has been extensive, but the necessity to empower the synergies between scientific community and local administrations remains a challenge to address in order to implement effective interventions. Based on abundant evidence of indoor pollution health effect, WHO, scientific societies, patient organizations and other members of the health community should work together to pursue the GARD vision of "a world where all people breathe freely" and encourage policy makers to increase their engagement in advocacy for clean air.

Microfluidic Chip Coupled with MALDI-TOF MS for Multitarget Detection of Allergens in Crucian Carp (Carassius auratus)

The goal of the present study was to establish a rapid, simple method for simultaneous allergy testing of sera from multiple fish-allergic patients. Sera from fish-allergic patients were pooled and used for capturing allergens in fish muscle of crucian carp (Carassius auratus), which was studied as a fish model. Sarcoplasmic proteins of crucian carp (Carassius auratus) were extracted for the analysis of allergens. Anti-human IgE antibody-functionalized magnetic beads were utilized to collect IgE antibodies from human pooled sera. The isolation of allergenic proteins was immunomagnetically performed in microfluidic channels, and the elution of the captured allergenic proteins was done with 5% (v/v) acetic acid aqueous solution. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and peptide mass fingerprinting were used for the analysis of tryptic digests of eluted proteins. Ten potential allergenic proteins were identified from crucian carp (Carassius auratus). The present protocol provides a rapid, efficient, and simple method for simultaneous detection of multiple allergens, based on multitargeted antibodies from pooled sera of allergic patients. The constructed multiple antibody-modified MBs can be applied for the deallergenicity of food matrices. The efficiency of allergen detection can be greatly improved, with promising application in allergen discovery and filtration for other muscle-based foods.

Impact of indoor environment on children's pulmonary health

INTRODUCTION

A child's living environment has a significant impact on their respiratory health, with exposure to poor indoor air quality (IAQ) contributing to potentially lifelong respiratory morbidity. These effects occur throughout childhood, from the antenatal period through to adolescence. Children are particularly susceptible to the effects of environmental insults, and children living in socioeconomic deprivation globally are more likely to breathe air both indoors and outdoors, which poses an acute and long-term risk to their health. Adult respiratory health is, at least in part, determined by exposures and respiratory system development in childhood, starting in utero.

AREAS COVERED

This narrative review will discuss, from a global perspective, what contributes to poor IAQ in the child's home and school environment and the impact that indoor air pollution exposure has on respiratory health throughout the different stages of childhood.

EXPERT OPINION

All children have the right to a living and educational environment without the threat of pollution affecting their health. Action is needed at multiple levels to address this pressing issue to improve lifelong respiratory health. Such action should incorporate a child's rights-based approach, empowering children, and their families, to have access to clean air to breathe in their living environment.

The impact of poor housing and indoor air quality on respiratory health in children

It is becoming increasingly apparent that poor housing quality affects indoor air quality, significantly impacting on respiratory health in children and young people. Exposure to damp and/or mould in the home, cold homes and the presence of pests and pollutants all have a significant detrimental impact on child respiratory health. There is a complex relationship between features of poor-quality housing, such as being in a state of disrepair, poor ventilation, overcrowding and being cold, that favour an environment resulting in poor indoor air quality. Children living in rented (private or public) housing are more likely to come from lower-income backgrounds and are most at risk of living in substandard housing posing a serious threat to respiratory health. Children have the right to safe and adequate housing, and research has shown that either rehousing or making modifications to poor-quality housing to improve indoor air quality results in improved respiratory health. Urgent action is needed to address this threat to health. All stakeholders should understand the relationship between poor-quality housing and respiratory health in children and act, working with families, to redress this modifiable risk factor.

Educational aims

The reader should understand how housing quality and indoor air quality affect respiratory health in children.The reader should understand which children are at most risk of living in poor-quality housing.The reader should understand what policy recommendations have been made and what actions need to be undertaken to improve housing quality and respiratory health in children and young people.

Diagnosis and Management of Allergic Rhinitis in Asthmatic Children

Allergic rhinitis (AR) is a common upper airways inflammatory condition especially in paediatric population; its burden potentially impacts on quality of life, quality of sleep and daily performance, which can be difficult to perceive but not less relevant in the middle-long term. The present review aims to provide an updated overview on AR epidemiology, diagnosis and with a special focus on its connections with bronchial asthma. In fact, when considering asthmatic pediatric population, AR is probably the most important risk factor for asthma onset and the most impactful extra-bronchial determinant of asthma control. Under this perspective, allergen immunotherapy (AIT) should always be considered in the light of a precision medicine approach. In fact, AIT does represent a unique opportunity to specifically interfere with AR immunological background, improve both AR and bronchial asthma control and prevent allergic disease evolution. Verifying the patient's eligibility to that option should be considered as a priority for every physician managing children suffering from AR, especially when associated with bronchial asthma.

Investigating the Relationship between Parental Education, Asthma and Rhinitis in Children Using Path Analysis

Parental socioeconomic position (SEP) is a known determinant of a child's health. We aimed to investigate whether a low parental education, as proxy of SEP, has a direct effect on physician-diagnosed asthma, current asthma and current allergic rhinitis in children, or whether associations are mediated by exposure to other personal or environmental risk factors. This study was a secondary data analysis of two cross-sectional studies conducted in Italy in 2006. Data from 2687 adolescents (10-14 years) were analyzed by a path analysis model using generalized structural equation modelling. Significant direct effects were found between parental education and family characteristics (number of children (coefficient = 0.6229, p < 0.001) and crowding index (1.1263, p < 0.001)) as well as with exposure to passive smoke: during pregnancy (maternal: 0.4697, p < 0.001; paternal: 0.4854, p < 0.001), during the first two years of children's life (0.5897, p < 0.001) and currently (0.6998, p < 0.001). An indirect effect of parental education was found on physician-diagnosed asthma in children mediated by maternal smoking during pregnancy (0.2350, p < 0.05) and on current allergic rhinitis mediated by early environmental tobacco smoke (0.2002; p < 0.05). These results suggest the importance of promotion of ad-hoc health policies for promoting smoking cessation, especially during pregnancy.

12-month prevalence of atopic dermatitis in resource-rich countries: a systematic review and meta-analysis

There is a lack of robust prevalence estimates of atopic dermatitis (AD) globally and trends over time due to wide variation of populations and age groups studied, different study methodologies and case definitions used. We sought to characterize 12-month AD prevalence across the life span and change over time in resource-rich countries focusing on population-based studies and using a standardized AD case definition. This systematic review was conducted according to PRISMA guidelines. Medline (Ovid), Embase, WOS core collection, Cinahl, and Popline were searched for studies published since inception through August 15, 2016. Studies were synthesized using random effects meta-analysis. Sources of heterogeneity were investigated using subgroup analyses and meta-regression. From 12,530 records identified, 45 studies met the inclusion criteria. Meta-analysis with random effects revealed the 12-month period prevalence of 9.2% (95% confidence interval 8.4-10.1%). The prevalence was significantly higher among 0-5-year-old children (16.2%; 95% confidence interval 14.2-18.7%) than in older age groups. Studies using a random sampling strategy yielded lower prevalence estimates than studies relying on other sampling methods. There was no clear time trend in AD prevalence over the period of 1992-2013.

Asthma Comorbidities: Frequency, Risk Factors, and Associated Burden in Children and Adolescents

Identifying asthma comorbidities in children is fundamental for improving disease management. We aimed to investigate the frequency of allergy-related comorbidities in children and adolescents with asthma, and to identify associated risk factors and disease burden. Between September 2015 and December 2018, 508 asthmatic patients (5–17 years) were consecutively enrolled. Parents answered a standardized questionnaire on the history of disease and risk factors. Comorbidities were classified based on the involvement of respiratory and/or extra-respiratory districts: asthma only (A, 13%), asthma with respiratory comorbidities (AR, 37%), asthma with extra-respiratory comorbidities (AER, 10%), and asthma with both respiratory and extra-respiratory comorbidities (ARER, 40%). Multinomial logistic regression showed that membership in the AR group was significantly associated with a maternal history of asthma (OR = 3.08, 95% CI: 1.23–7.72), breastfeeding ≥ three months (OR = 1.92, 1.06–3.46), early mold exposure (OR = 2.39, 1.12–5.11), and current environmental tobacco smoke exposure (OR = 2.06, 1.11–3.83). Membership in the AER group was significantly associated with the female gender (OR = 3.43, 1.54–7.68), breastfeeding ≥ three months (OR = 2.77, 1.23–6.22). ARER was significantly associated with all the aforementioned exposures. Patients with AR reported exacerbations in the last 12 months more frequently (p = 0.009). Several personal and environmental risk factors are associated with comorbidities in asthmatic children and adolescents, possibly worsening the disease burden.

Endotyping Seasonal Allergic Rhinitis in Children: A Cluster Analysis

Background

Seasonal Allergic Rhinitis (SAR) is a heterogeneous inflammatory disease. We hypothesized that a cluster analysis based on the evaluation of cytokines in nasal lavage (NL) could characterize distinctive SAR endotypes in children.

Methods

This cross-sectional study enrolled 88 children with SAR. Detailed medical history was obtained by well-trained physicians. Quality of life and sleep quality were assessed through standardized questionnaires [Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) and Pittsburgh Sleep Quality Index (PSQI) respectively]. Children were grouped through K-means clustering using Interleukin (IL)-5, IL-17, IL-23, and Interferon (INF)-γ in NL.

Results

Out of the 88 patients enrolled, 80 were included in the cluster analysis, which revealed three SAR endotypes. Cluster 1 showed lower levels of IL-5 and IL-17 and intermediate levels of IL-23 and IFN-γ; Cluster 2 had higher levels of IL-5 and intermediate levels of IL-17, IL-23, and IFN-γ; Cluster 3 showed higher levels of IL-17, IL-23, and IFN-γ and intermediate levels of IL-5. Cluster 1 showed intermediate values of nasal pH and nasal nitric oxide (nNO), and a lower percentage of neutrophils at nasal cytology than Clusters 2 and 3. Cluster 2 had a lower level of nasal pH, a higher nNO, higher scores in the ocular domain of PRQLQ, and worse sleep quality than Clusters 1 and 3. Cluster 3 showed a higher percentage of neutrophils at nasal cytology than Clusters 1 and 2.

Conclusions

Our study identified three endotypes based on the evaluation of cytokines in NL, highlighting that childhood SAR is characterized by heterogeneous inflammatory cytokines.

Effects of Polycyclic Aromatic Hydrocarbons on Lung Function in Children with Asthma: A Mediation Analysis

Studies investigating the association between urinary Polycyclic Aromatic Hydrocarbons (PAHs) and asthma in children provided inhomogeneous results. We aimed to use Mediation Analysis to discover whether a link between urinary PAHs and lung function exists and if it might be ascribed to a direct or a symptom-mediated (indirect) effect in children with asthma. This single-center prospective study was conducted in Palermo, Italy, between March and July 2017 and involved 50 children with persistent mild-moderate asthma, aged 6–11 years. At each time visit (day 0, 30, 60, and 90), physical examination, spirometry, and urine collection for detection of urinary cotinine and PAHs were performed. A symptom score was computed. The sum of individually calculated molar mass of nine PAH metabolites (ΣPAH), naphthalene metabolites (ΣPAHn) and phenanthrene metabolites (ΣPAHp) were calculated. Three children withdrew from the study due to technical problems (n = 1) and adverse events (n = 2). PAHs indirect effects on FEV1 (ΣPAH: −0.011, p = 0.04; ΣPAHn: −0.011, p = 0.04; ΣPAHp: −0.012, p < 0.001) and FVC (ΣPAH: −0.012, p = 0.02; ΣPAHn: −0.0126, p = 0.02; ΣPAHp: −0.013, p < 0.001) were statistically significant. In conclusion, PAHs exposures have significant indirect (symptom-mediated) effects on lung function, emphasizing the role of PAHs-induced respiratory morbidity in decreasing lung function in children with asthma.

Health effects of air pollution: a Southern European perspective

Objective

To summarize the main updated evidence about the health effects of air pollution, with a special focus on Southern Europe.

Data sources

Literature was obtained through PubMed Central and the official websites of European Agencies and Scientific Societies.

Study selection

Recent shreds of evidence about the health effects of air pollution coming from international reports and original research were collected and described in this review.

Results

Air pollution is an avoidable risk factor that causes a huge burden for society, in terms of death, health disorders, and huge socio-economic costs. The southern European countries face a more threatening problem because they experience the effects of both anthropogenic pollutants and natural dusts (particulate matter [PM]). The European Environment Agency reported the number of premature deaths in the 28 countries of the European Union attributable to air pollutant exposure in the year 2016: 374,000 for PM_2.5, 68,000 for nitrogen dioxide, and 14,000 for ozone. In Italy, time series and analytical epidemiological studies showed increased cardio-respiratory hospital admissions and mortality, as well as increased risk of respiratory diseases in people living in urban areas.

Conclusions

Based on abundant evidence, the World Health Organization, which hosts the Global Alliance against Chronic Respiratory Diseases (GARD), the scientific respiratory societies, and the patients’ associations, as well as others in the health sector, must increase their engagement in advocacy for clean air policies.

Risk factors associated with health-related quality of life in pediatric asthma

To evaluate the quality of life (QOL) of children with asthma and analyze the related factors. A total of 360 children diagnosed with asthma were enrolled. We conducted the pediatric asthma quality of life questionnaire (PAQLQ). The differences in clinical characteristics between the two groups were compared. Clinical characteristics were compared between high and low QOL. More female was observed in low QOL group (p = 0.013). Patients with higher income (p = 0.003) were shown with higher QOL. Female patients presented significantly lower values for activity limitation (p = 0.016) and emotional function (p = 0.016) as compared to male patients. For patients who have low income, the QOL scores for dimensions of activity limitation was significantly worse than those have higher income (p = 0.001). Univariable results showed that gender (p = 0.013) and income (p = 0.001) were factors associated with QOL in asthma children. However, multivariate analysis suggested that only gender (OR = 0.558, p = 0.008) and income (OR = 1.762, p < 0.001) were the independent factors that affected the QOL levels. In this study, we found that the QOL dimensions of pediatric asthma differed between various subpopulations. For patients with risk factors of poor QOL, target intervention is advised in order to increase QOL.

Atopic dermatitis in schoolchildren and adolescents: a critical review of Italian epidemiological data and systemic treatments

INTRODUCTION

The epidemiology of atopic dermatitis (AD) is largely different in pre-school and schoolchildren. We summarized the available epidemiological data on schoolchildren (6-11 years) and adolescents (12-17 years) in Italy and reviewed information on systemic treatments for moderate-to-severe AD in adolescents.

EVIDENCE ACQUISITION

In January 2019, we searched for data on prevalence and/or incidence of AD and on the efficacy, effectiveness and safety of systemic AD therapies. Papers were evaluated and selected, and relevant information was extracted. Twenty papers from 17 studies reported original epidemiological information on AD in Italy.

EVIDENCE SYNTHESIS

Most studies were conducted before 2005. Though variations emerged between studies, the lifetime prevalence of AD was estimated between 15-17% in schoolchildren and between 8-13% in adolescents. The (12-months) period prevalence of AD was estimated between 8-10% in children and between 8-11% in adolescents. Up-to-date information on the prevalence of severe AD is not available. Cyclosporine A may be used in pediatric age patients (children and adolescents) with persistent or severe AD refractory to topical treatments, but its use has several limitations, and is not recommended in patients younger than 16 years. The treatment paradigm of AD is still far from being satisfactory.

CONCLUSIONS

We provided a quantitative synthesis of AD epidemiology in Italian schoolchildren and adolescents. Recent data are needed, as most information dates back to the 1990s or early 2000s, and data on the incidence of AD, the proportion of severe cases, and treatment of severe cases in the real-world setting are scanty.

Determinants of Allergic Sensitization, Asthma and Lung Function: Results from a Cross-Sectional Study in Italian Schoolchildren

Prenatal smoking exposure and early-life respiratory infections are major determinants of asthma during childhood. We investigate the factors influencing allergic sensitization (AS), asthma, and lung function in children and the balance between individual and environmental characteristics at different life stages. 1714 children aged 7–16 years and living in southern Italy were investigated using a parental questionnaire, skin prick tests, and spirometry. We found 41.0% AS prevalence: among children without parental history of asthma, male sex, maternal smoking during pregnancy (MatSmoke), and acute respiratory diseases in the first two years of life (ARD2Y) were significant risk factors for AS. MatSmoke was associated (OR = 1.79) with ARD2Y, and this association was influenced by sex. ARD2Y was, in turn, a significant risk factor (OR = 8.53) for childhood current asthma, along with AS (OR up to 3.03) and rhinoconjuctivitis (OR = 3.59). Forced mid-expiratory flow (FEF_25–75%) was negatively affected by ARD2Y, with a sex-related effect. Thus, males exposed to MatSmoke had significantly lower FEF_25–75% than unexposed males. Despite the difficulty of discriminating among the complex interactions underlying the development of allergic respiratory diseases, ARD2Y appears to strongly influence both asthma and lung function during childhood. In turn, ARD2Y is influenced by prenatal exposure to tobacco smoke with a sex-dependent effect.

Air Pollution and Estimated Health Costs Related to Road Transportations of Goods in Italy: A First Healthcare Burden Assessment

Background: The Italian Society of Environmental Medicine has performed a preliminary assessment of the health impact attributable to road freight traffic in Italy. Methods: We estimated fine particulate matter (PM10, PM2.5) and nitrogen oxides (NOx) generated by road transportation of goods in Italy considering the number of trucks, the emission factors and the average annual distance covered in the year 2016. Simulations on data concerning Years of Life Lost (YLL) attributable to PM2.5 (593,700) and nitrogen oxides NO2 (200,700) provided by the European Environmental Agency (EEA) were used as a proxy of healthcare burden. We set three different healthcare burden scenarios, varying from 1/5 to 1/10 of the proportion of the overall particulate matter attributable to road freight traffic in Italy (about 7% on a total of 2262 tons/year). Results: Road freight traffic in Italy produced about 189 tons of PM10, 147 tons of PM2.5 and 4125 tons of NOx in year 2016, resulting in annual healthcare costs varying from 400 million up to 1.2 billion EUR per year. Conclusion: Road freight traffic has a relevant impact on air pollution and healthcare costs, especially if considered over a 10-year period. Any solution able to significantly reduce the road transportation of goods could decrease avoidable mortality due to air pollution and related costs.

Targeting quality of life in asthmatic children: The MyTEP pilot randomized trial

BACKGROUND

Quality of life (QoL) is an important outcome in the management of children with asthma. Mobile Health (m-Health) and Therapeutic Education Programs (TEPs) are increasingly recognized as essential components of pediatric asthma management to improve disease outcomes.

OBJECTIVE

To evaluate the effect of an education program (MyTherapeutic Education Program, MyTEP) that couples multidisciplinary TEP intervention with an m-Health Program (mHP) in improving QoL in asthmatic children.

METHODS

This single-center study employed a nonblinded randomized clinical trial design. Italian-speaking children (6-11 years) with mild-moderate asthma were eligible for participation. Participants were randomly paired 1:1 with a control group that received mHP (smartphone app) or an intervention group that received MyTEP (TEP plus a smartphone app). Patients were followed up for 3 months. Descriptive statistics, Least Square (LS) mean change and Generalized Linear Mixed model were used for analysis.

RESULTS

Fifty patients were enrolled. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) score improved in both MyTEP (p = 0.014) and mHP (p = 0.046) with the minimally clinically significant difference of ⩾0.5 points reached in 23% of MyTEP and in 16% of mHP. Changes in PAQLQ scores were significantly greater in MyTEP than in mHP (LS mean difference: 0.269 p = 0.05). PAQLQ score was: positively associated with MyTEP (p = 0.023) and study time (p = 0.002); and inversely associated with current passive smoke exposure (p = 0.003).

CONCLUSION

Despite the small sample size and short observation period, this study demonstrated that implementing a multidisciplinary TEP with an m-Health program results in gains in QoL of children with asthma.

Repeatability of exhaled breath fingerprint collected by a modern sampling system in asthmatic and healthy children

E-noses provide potential non-invasive metabolic biomarkers for diagnosing and monitoring pulmonary diseases. The primary aim of the present study was to assess the within-day and between-day repeatability of a modern breath sampling system (Pneumopipe^® plus an array of e-nose sensors) in asthmatic and healthy children. The secondary aim was to compare the repeatability of the breath sampling system, spirometry and exhaled nitric oxide (eNO). Fifteen children (age 6-11 years) with asthma and thirty healthy children matched by age and gender (1:2 allocation) were recruited; of them, three healthy children did not complete the study. All measurements were collected twice during the baseline visit, 30 min apart, and once during the final visit, after 7 d. Repeatability was assessed through the intra-cluster correlation coefficient (ICC), and a significance test was performed to detect an at least 'fair' repeatability (ICC > 0.2). In asthmatic children, the within-day (0-30 min) ICCs for e-nose sensors (8 sensors × 4 desorption temperatures) ranged from 0.24 to 0.84 (median 0.57, IQR 0.47-0.71), while the between-day (0-7 d) ICCs ranged from 0.25 to 0.83 (median 0.66, IQR 0.55-0.72). In healthy children, the within-day ICCs for e-nose sensors ranged from 0.29 to 0.85 (median 0.58, IQR 0.49-0.63), while the between-day ICCs ranged from 0.33 to 0.82 (median 0.55, IQR 0.49-0.63). In both groups, most of the within-day and between-day ICCs for e-nose sensors were statistically significant. Moreover, the within-day and between-day ICCs for all spirometry parameters and eNO were significant and similar to those of the most reliable sensors. The modern breath sampling system showed more than acceptable within-day and between-day repeatability, in both asthmatic and healthy children. The present study was registered on the central registration system ClinicalTrials.gov (ID: NCT03025061).

An association analysis to identify genetic variants linked to asthma and rhino-conjunctivitis in a cohort of Sicilian children

Asthma and rhino-conjunctivitis are common chronic diseases in childhood. In this cross-sectional study, we performed a gene association analysis with current asthma and rhino-conjunctivitis in a cohort of Sicilian children aged 10–15 years. Overall, our findings reveal the importance of different genetic variants at 4p14, 16p12.1, 17q12, 6p12.2 and 17q21.1, identifying possible candidate genes responsible for susceptibility to asthma and rhino-conjunctivitis.

Efficacy of Buffered Hypertonic Saline Nasal Irrigation for Nasal Symptoms in Children with Seasonal Allergic Rhinitis: A Randomized Controlled Trial

BACKGROUND

Saline nasal irrigation is labelled as an add-on treatment in patients with allergic rhinitis (AR). The primary aim of this study was to compare the efficacy of 21-day use of buffered hypertonic saline (BHS) versus normal saline solution (NSS) on reducing nasal symptoms in children with seasonal AR (SAR). Comparing their efficacy on nasal cytology counts (NCC), quality of life, and sleep quality was the secondary aim.

METHODS

In this 21-day, open-label, randomized controlled study, 36 SAR children (aged 6-13 years) with a Total 5 Symptom Score (T5SS) ≥5 received twice-daily BHS or NSS delivered through a nasal douche. Efficacy measures were least square mean changes (LSmc) in T5SS, NCC, Paediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ), and Pittsburgh Sleep Quality Index (PSQI) scores.

RESULTS

BHS improved the T5SS total score to a greater extent than NSS (LSmc -6.45 vs. -5.45, p < 0.001). Concerning NCC, BHS significantly reduced the scores of neutrophils (LSmc -0.76, p = 0.004) and eosinophils (LSmc -0.46, p = 0.018), while NSS did not. Similarly, only BHS yielded a significant improvement in the PRQLQ score (LSmc -0.57, p = 0.009), whereas the improvement in PSQI score was comparable between the BHS (LSmc -0.77, p = 0.025) and NSS (LSmc -1.39, p < 0.001) groups. Overall, BHS was well tolerated.

CONCLUSIONS

In children with SAR, BHS is effective in improving nasal symptoms and NCC, with an associated beneficial effect on quality of life.

Global Lung Function Initiative 2012 reference values for spirometry in South Italian children

RATIONALE

Despite the widespread use of the Global Lung Function Initiative (GLI) 2012 reference values, there is still the need of testing their applicability in local areas.

OBJECTIVES

The aims of this study are to evaluate applicability of GLI reference equations in a large population-based sample of normal schoolchildren from Sicily, and to compare GLI and previous prediction equations in terms of spirometry test interpretation.

METHODS

GLI equations were evaluated in 1243 normal schoolchildren, 49% males, aged 7-16 years, height 116-187 cm. Normality assumptions for the GLI z-scores (FEV₁, FVC, FEV₁/FVC) were tested, and bootstrap confidence intervals for the mean (0 expected) and the variance (1 expected) were derived. GLI and other reference equations were compared in terms of probabilities to fall below the lower limit of normal (LLN).

RESULTS

The GLI z-score normality assumption held for males but not for females (p < 0.001). According to the mean z-score, predicted values were: slightly underestimated for FEV₁ (0.15 in males, 0.07 in females); overestimated for FVC (-0.27 in males, -0.32 in females); highly underestimated for FEV₁/FVC (0.75 in males, 0.81 in females). Variability was correctly estimated. The probability of FEV₁<LLN correctly approached 0.05 when using GLI, Hankinson and Quanjer equations. Wang equations yielded correct probabilities of abnormal FVC; Pistelli equations yielded correct probabilities of abnormal FEV₁/FVC for females.

CONCLUSIONS

GLI 2012 references underestimate FEV₁/FVC predicted values in a sample of normal South Italian children. Physicians interpreting spirometry should be aware to test reference values prior to their use in a local area.

Environment and Health: Not Only Cancer

The Hippocratic tradition emphasized environmental causes of diseases and the need for harmony between the individual and the natural environment as the right philosophy to maintain a good health status. Public awareness and scientific attention concerning environmental pollution is usually focused on the consequent increased risk of developing cancer. Air pollution has been recognized by the World Health Organization (WHO) to cause cardiovascular and respiratroy diseases, as well as lung cancer, after acute/chronic exposure to fine particulates (PM2.5 and PM10) even at concentrations which are 50% lower than those accepted as legal limits in many developed countries. An increase of 10 µg/m³ of PM2.5 produces a +4%-6% of overall mortality, a +10% of cardiovascular disease prevalence (arithmyas, acute myocardial infarctions, and heart failure) and a +22% of lung cancer prevalence. In addition to these chronic effects, acute hospitalizations are also affected, especially among susceptible populations such as children and diabetic patients. Water and soil contamination also have an additional detrimental effect on people's health. Other issues concerning environment contamination and human health include male/female fertility, metabolic and thyroid conditions, but also professional exposures resulting in occupational diseases. Moreover, in the perspective of "gender medicine", different acute or chronic effects of environmental pollution should be specifically assessed both in men and in women. This special issue on "Environmental Diseases" is aimed at providing a global overview about different threats to human health possibily originating from environmental contamination.

Interrelationships between Atopic Disorders in Children: A Meta-Analysis Based on ISAAC Questionnaires

Purpose

To study the prevalence and interrelationship between asthma, allergic rhinitis and eczema using data obtained from ISAAC questionnaires.

Method

The Medline, Pubmed Publisher, EMBASE, Google Scholar and the Cochrane Controlled Clinical Trials Register databases were systematically reviewed to evaluate epidemiological data of children with atopic disorders. To study these interrelationships, a new approach was used. Risk ratios were calculated, describing the risk of having two different atopic disorders when the child is known with one disorder.

Results

Included were 31 studies, covering a large number of surveyed children (n=1,430,329) in 102 countries. The calculated worldwide prevalence for asthma, eczema and allergic rhinitis is 12.00% (95% CI: 11.99-12.00), 7.88% (95% CI: 7.88-7.89) and 12.66% (95% CI: 12.65-12.67), respectively. The observed prevalence [1.17% (95% CI: 1.17-1.17)] of having all three diseases is 9.8 times higher than could be expected by chance. For children with asthma the calculated risk ratio of having the other two disorders is 5.41 (95% CI: 4.76-6.16), for children with eczema 4.24 (95% CI: 3.75-4.79), and for children with allergic rhinitis 6.20 (95% CI: 5.30-7.27). No studied confounders had a significant influence on these risk ratios.

Conclusions

Only a minority of children suffers from all three atopic disorders, however this co-occurrence is significantly higher than could be expected by chance and supports a close relationship of these disorders in children. The data of this meta-analysis supports the hypothesis that there could be a fourth distinct group of children with all three disorders. Researchers and clinicians might need to consider these children as a separate group with distinct characteristics regarding severity, causes, treatment or prognosis.

Allergy and asthma: Effects of the exposure to particulate matter and biological allergens

The prevalence of asthma and allergies including atopy has increased during the past decades, particularly in westernized countries. The rapid rise in the prevalence of such diseases cannot be explained by genetic factors alone. Rapid urbanization and industrialization throughout the world have increased air pollution and population exposures, so that most epidemiologic studies are focusing on possible links between air pollution and respiratory diseases. Furthermore, a growing body of evidence shows that chemical air pollution may interact with airborne allergens enhancing the risk of atopic sensitization and exacerbation of symptoms in sensitized subjects. These phenomena are supported by current in vitro and animal studies showing that the combined exposure to air pollutants and allergens may have a synergistic or additive effect on asthma and allergies, although there is an insufficient evidence about this link at the population level. Further research is needed in order to elucidate the mechanisms by which pollutants and biological allergens induce damage in exposed subjects. The abatement of the main risk factors for asthma and allergic diseases may achieve huge health benefits. Thus, it is important to raise awareness of respiratory allergies as serious chronic diseases which place a heavy burden on patients and on society as a whole.

An elevated body mass index increases lung volume but reduces airflow in Italian schoolchildren

Background

Asthma and obesity are important and growing health issues worldwide. Obesity is considered a risk factor for asthma, due to the induction of changes in airway mechanics and altered airway inflammation.

Methods

We cross-sectionally investigated the effect of increased weight on pulmonary function in a large population sample of healthy children, aged 10–17 yrs living in Palermo, Italy. Explanatory effect of weight on lung function variables were evaluated by multiple linear regression models, taking into account height, gender, and age-class.

Results

Among the 2,393 subjects, FVC and FEV₁ were positively correlated to weight. Multiple regression models showed that the weight beta coefficient for FEV₁ was significantly lower with respect to that for FVC (0.005 and 0.009 l/kg, respectively), indicating a different magnitude in explanatory effect of weight on FVC and FEV₁. Both FEV₁/FVC and FEF_25–75%/FVC ratios were negatively correlated to weight, while FEF_25–75% was not significantly correlated. Similar results were obtained also when 807 symptomatic subjects were introduced in the model through a sensitivity analysis.

Conclusion

In healthy children, the disproportionate increase of FEV₁ and FVC with weight produces airflow decrease and consequently apparent poorer lung function independently from respiratory disease status.

Effect of indoor nitrogen dioxide on lung function in urban environment

BACKGROUND

High levels of indoor NO2 are associated with increased asthma symptoms and decreased expiratory peak flows in children. We investigated the association of exposure to domestic indoor NO2, objectively measured in winter and spring, with respiratory symptoms and lung function in a sample of adolescents from a southern Mediterranean area.

METHODS

From a large school population sample (n=2150) participating in an epidemiological survey in the urban area of the City of Palermo (southern Italy), a sub-sample of 303 adolescents was selected which furnished an enriched sample for cases of current asthma. All subjects were evaluated by a health questionnaire, skin prick tests and spirometry. One-week indoor NO2 monitoring of their homes was performed by diffusive sampling during spring and again during winter.

RESULTS

We found that about 25% of subjects were exposed to indoor NO2 levels higher than the 40µg/m(3) World Health Organization limit, during both spring and winter. Moreover, subjects exposed to the highest indoor NO2 concentrations had increased frequency of current asthma (p=0.005), wheeze episodes in the last 12 months (p<0.001), chronic phlegm (p=0.013), and rhinoconjunctivitis (p=0.008). Finally, subjects with a personal history of wheeze ever had poorer respiratory function (FEF25-75%, p=0.01) when exposed to higher indoor NO2 concentrations.

CONCLUSIONS

Home exposure to high indoor NO2 levels frequently occurs in adolescents living in a southern Mediterranean urban area and is significantly associated with the risks for increased frequency of both respiratory symptoms and reduced lung function.

Multiple IgE recognition on the major allergen of the Parietaria pollen Par j 2

The interaction between IgE antibodies and allergens is a key event in triggering an allergic reaction. The characterization of this region provides information of paramount importance for diagnosis and therapy. Par j 2 Lipid Transfer Protein is one of the most important allergens in southern Europe and a well-established marker of sensitization in Parietaria pollen allergy. The main aim of this study was to map the IgE binding regions of this allergen and to study the pattern of reactivity of individual Parietaria-allergic patients. By means of gene fragmentation, six overlapping peptides were expressed in Escherichia coli, and their IgE binding activity was evaluated by immunoblotting in a cohort of 79 Parietaria-allergic patients. Our results showed that Pj-allergic patients display a heterogeneous pattern of IgE binding to the different recombinant fragments, and that patients reacted simultaneously against several protein domains spread all the over the molecule, even in fragments which do not contain structural features resembling the native allergen. Our results reveal the presence of a large number of linear and conformational epitopes on the Par j 2 sequence, which probably explains the high allergenic activity of this allergen.

RHINASTHMA-Adolescents: a new quality of life tool for patients with respiratory allergy

BACKGROUND

Specific instruments for health-related quality of life (HRQoL) assessment in adolescents with rhinoconjunctivitis or asthma are available. None of them evaluates rhinitis and asthma together, although they often coexist. Our aim was to validate a HRQoL questionnaire for adolescents with rhinoconjunctivitis, asthma, or both.

METHODS

A pool of 38 items covering the main symptoms and problems related to respiratory allergy was generated based on literature review, clinical experience, and unstructured interviews to 54 adolescents. The items were randomly listed and presented to 88 consecutive outpatients (44 M; mean age 15.2 ± 3.1). Patients had to indicate which item they had experienced and, for each selected item, its importance on a four-point scale (1 = not at all; 4 = very much). Twelve items were excluded from the list, because of low importance. In the validation phase, 102 patients (54 M; mean age 15.36 ± 1.12) completed the KINDL, a generic HRQoL tool, and the new questionnaire (RHINASTHMA-Adolescents).

RESULTS

Factor analysis revealed a five-dimensional structure, which explained up to 71.23% of the total variance. Association between RHINASTHMA-Adolescents and KINDL scores was all in the expected direction. Internal consistency for the extracted factors was satisfactory: Upper Airways (0.81), Lower Airways (0.89), Emotions (0.85), Social Relationship (0.79), Daily life management (0.74). Reliability was good for all factors with a Pearson coefficient ranged from 0.91 to 0.99.

CONCLUSIONS

RHINASTHMA-Adolescents is the first tool for evaluating HRQoL in patients with rhinitis and/or asthma. It provides a simple assessment and met the standards of validity, internal consistency, and reliability.

eulerAPE: drawing area-proportional 3-Venn diagrams using ellipses

Venn diagrams with three curves are used extensively in various medical and scientific disciplines to visualize relationships between data sets and facilitate data analysis. The area of the regions formed by the overlapping curves is often directly proportional to the cardinality of the depicted set relation or any other related quantitative data. Drawing these diagrams manually is difficult and current automatic drawing methods do not always produce appropriate diagrams. Most methods depict the data sets as circles, as they perceptually pop out as complete distinct objects due to their smoothness and regularity. However, circles cannot draw accurate diagrams for most 3-set data and so the generated diagrams often have misleading region areas. Other methods use polygons to draw accurate diagrams. However, polygons are non-smooth and non-symmetric, so the curves are not easily distinguishable and the diagrams are difficult to comprehend. Ellipses are more flexible than circles and are similarly smooth, but none of the current automatic drawing methods use ellipses. We present eulerAPE as the first method and software that uses ellipses for automatically drawing accurate area-proportional Venn diagrams for 3-set data. We describe the drawing method adopted by eulerAPE and we discuss our evaluation of the effectiveness of eulerAPE and ellipses for drawing random 3-set data. We compare eulerAPE and various other methods that are currently available and we discuss differences between their generated diagrams in terms of accuracy and ease of understanding for real world data.

The burden of rhinitis and rhinoconjunctivitis in adolescents

Purpose

Rhinitis and conjunctivitis are common diseases worldwide that are frequently associated. Nevertheless, the risk factors for rhinoconjunctivitis are not well-described and the impact of conjunctivitis on rhinitis and asthma in children remains unknown. This study explored the different risk factors and evaluated the burden of rhinoconjunctivitis among adolescents.

Methods

This was a cross-sectional study conducted on a random sample of schoolchildren, aged 10-17 years, using skin prick tests and a self-administered questionnaire on respiratory health investigating the impact of rhinitis and rhinoconjunctivitis on daily activities.

Results

A complete evaluation was obtained for 2,150 children. The prevalence of rhinitis alone was 18.2% and rhinitis associated with conjunctivitis was 20.5%. Rhinoconjunctivitis was more frequently associated with females, a parental history of atopy, domestic exposure to mold/dampness, passive smoke exposure, and reported truck traffic in residential streets. Moreover, rhinoconjunctivitis was associated with a higher level of allergic sensitization. The prevalence of current asthma was 1.7% in subjects without rhinitis or rhinoconjunctivitis, 5.1% in rhinitis and 10.7% in rhinoconjunctivitis. In a logistic model, rhinoconjunctivitis yielded a 2-fold risk for current asthma with respect to rhinitis. Subjects with rhinoconjunctivitis had poorer quality of life (QoL); there was an impact on daily activities in 4.6% of rhinitis and 10.7% of rhinoconjunctivitis.

Conclusions

Ocular symptoms increase the role of rhinitis as a risk factor for asthma and its impact on daily activities in children.

Rhinitis as a risk factor for depressive mood in pre-adolescents: a new approach to this relationship

BACKGROUND

Respiratory allergic symptoms impact on social life and school activities, influencing the patient's mood states. We evaluated the relationships between allergic respiratory diseases and depressive/anxious mood in a large sample of Italian middle school students, using the partial directed acyclic graph (P-DAG).

METHODS

We studied 1283 subjects aged 10-13. A health respiratory questionnaire including questions relevant to socioeconomic status (HCI) and a test for depression and anxiety were administered. All subjects performed spirometry and skin prick tests.

RESULTS

A causal role of rhinitis on depression was found: the likelihood of being depressed increased from 11.2 to 17.7%, when rhinitis was present. Moreover, a direct effect of low HCI on depressive mood was shown (p < 0.0001) as well as the correlation between anxiety and depression (p < 0.0001). Gender was not a direct causal factor for depressive mood, but their relation was mediated through anxious mood. Anxiety appeared to have a stronger association with depression than gender. Allergic sensitization was significantly related to both asthma and rhinitis (p < 0.0001, respectively). Asthma and rhinitis were also directly associated (p < 0.0001). Conversely, asthma was not directly associated with depressive mood, but their relation was mediated through rhinitis. Body mass index (BMI) and impaired lung function (IPF) were not associated with the other variables.

CONCLUSIONS

The use of this novel approach to analyzing the dynamic relationships allowed us to find a causal role of rhinitis on depressive state. Moreover, anxious condition and low socioeconomic status contributed to induce depressive mood.

Pollen-induced allergic rhinitis in 1360 Italian children: comorbidities and determinants of severity

BACKGROUND

Pollen-induced allergic rhinoconjunctivitis (AR) is highly prevalent and rapidly evolving during childhood. General practitioners may not be fully aware of the nature and severity of symptoms experienced by patients and might underestimate the prevalence of moderate or severe disease. Thus, the relevance of early diagnosis and intervention may be overlooked.

OBJECTIVES

To investigate the severity of pollen-induced AR and its determinants in Italian children referred to allergy specialists and who had never received specific immunotherapy (SIT).

METHODS

Children (age 4-18 yr) affected by pollen-induced AR who had never undergone SIT were recruited between May 2009 and June 2011 in 16 pediatric outpatient clinics in 14 Italian cities. Recruited children's parents answered standardized questionnaires on atopic diseases (International Study of Allergy and Asthma in Childhood, Allergic Rhinitis and its Impact on Asthma, Global Initiative for Asthma). The children underwent skin-prick test (SPT) with several airborne allergens and six food allergens. Information on socio-demographic factors, parental history of allergic diseases, education, perinatal events, breastfeeding, nutrition and environmental exposure in early life was collected through an informatics platform shared by the whole network of clinical centers (AllergyCARD™).

RESULTS

Among the 1360 recruited patients (68% males, age 10.5 ± 3.4 yr), 695 (51%) had moderate-to-severe AR, 533 (39%) asthma, and 325 (23.9%) oral allergy syndrome (OAS). Reported onset of pollen-induced AR was on average at 5.3 ± 2.8 yr, and its mean duration from onset was 5.2 ± 3.3 yr. Only 6.2% of the patients were pollen-monosensitized, and 84.9% were sensitized to ≥3 pollens. A longer AR duration was significantly associated with moderate-to-severe AR symptoms (p 0.004), asthma (p 0.030), and OAS comorbidities (p < 0.001).

CONCLUSIONS

This nationwide study may raise awareness of the severity of pollen-induced AR among Italian children who have never received pollen SIT. The strong association between pollen-induced AR duration and several markers of disease severity needs replication in longitudinal studies, while suggesting that countrywide initiatives for earlier diagnosis and intervention should be planned.

Rupatadine oral solution in children with persistent allergic rhinitis: A randomized, double-blind, placebo-controlled study

BACKGROUND

Allergic rhinitis (AR) is one of the most common chronic diseases in childhood. No large, multicentre clinical trials in children with persistent allergic rhinitis (PER) have previously been performed. Rupatadine, a newer second-generation antihistamine, effective and safe in adults, is a promising treatment for children with AR. The aim of the present study was to evaluate the efficacy and safety of a new rupatadine oral solution in children aged 6-11 yr with PER.

METHODS

A multicenter, randomized, double-blind, placebo-controlled study was carried out worldwide. Patients between 6 and 11 yr with a diagnosis of PER according to ARIA criteria were randomized to receive either rupatadine oral solution (1 mg/ml) or placebo over 6 wk. The primary efficacy end-point was the change from baseline of the total nasal symptoms score (T4SS) after 4 wk of treatment.

RESULTS

A total of 360 patients were randomized to rupatadine (n = 180) or placebo (n = 180) treatment. Rupatadine showed statistically significant differences vs. placebo for the T4SS reduction both at 4 (-2.5 ± 1.9 vs. -3.1 ± 2.1; p = 0.018) and 6 wk (-2.7 ± 1.9 vs. -3.3 ± 2.1; p = 0.048). Rupatadine also showed a statistically better improvement in the children's quality of life compared with placebo. Adverse reactions were rare and non-serious in both treatment groups. No QTc or laboratory test abnormalities were reported.

CONCLUSIONS

Rupatadine oral solution (1 mg/ml) was significantly more effective than placebo in reducing nasal symptoms at 4 and 6 wk and was well tolerated overall. This is the first large clinical report on the efficacy of an H1 receptor antagonist in children with PER in both symptoms and quality of life.

VennPlex--a novel Venn diagram program for comparing and visualizing datasets with differentially regulated datapoints

With the development of increasingly large and complex genomic and proteomic data sets, an enhancement in the complexity of available Venn diagram analytical programs is becoming increasingly important. Current freely available Venn diagram programs often fail to represent extra complexity among datasets, such as regulation pattern differences between different groups. Here we describe the development of VennPlex, a program that illustrates the often diverse numerical interactions among multiple, high-complexity datasets, using up to four data sets. VennPlex includes versatile output features, where grouped data points in specific regions can be easily exported into a spreadsheet. This program is able to facilitate the analysis of two to four gene sets and their corresponding expression values in a user-friendly manner. To demonstrate its unique experimental utility we applied VennPlex to a complex paradigm, i.e. a comparison of the effect of multiple oxygen tension environments (1–20% ambient oxygen) upon gene transcription of primary rat astrocytes. VennPlex accurately dissects complex data sets reliably into easily identifiable groups for straightforward analysis and data output. This program, which is an improvement over currently available Venn diagram programs, is able to rapidly extract important datasets that represent the variety of expression patterns available within the data sets, showing potential applications in fields like genomics, proteomics, and bioinformatics.

Allergic airway diseases in childhood - marching from epidemiology to novel concepts of prevention

In the past years, a wide range of epidemiological, clinical, and experimental studies have produced remarkable advances in the field of respiratory allergies in childhood. By the recent investigations on epidemiological trends, risk factors, and prevention of asthma and allergic rhinitis, various exiting concepts have been challenged, and novel innovative approaches have been developed. Pediatric Allergy and Immunology (PAI), with a number of highly relevant contributions between 2010 and 2012, has become an important forum in this area. The prevalence of asthma in some developed countries may have reached a plateau, while in developing countries, where the prevalence was previously low, allergic diseases are still on the increase. A wide array of risk and protective factors, including hygiene, infections, outdoor and indoor air pollution, allergen exposure, breast-feeding practices, nutrition, and obesity, play a multifaceted role in shaping the observed worldwide trends of respiratory allergies. Under the guidance of recent research, prediction and prevention strategies in the clinical practice are progressively changing, the focus moving away from avoidance of allergen exposure and toward tolerance induction.

Pediatric allergy and immunology in Italy

In Italy, according to the International Study on Asthma and Allergies in Childhood study, the prevalence of current asthma, allergic rhinoconjunctivitis, and atopic eczema in 2006 was 7.9%, 6.5%, and 10.1% among children aged 6-7 and 8.4%, 15.5%, and 7.75% among children aged 13-14 yr. University education in this field is provided by the Postgraduate Schools of Pediatrics and those of Allergology and Clinical Immunology, as well as several annual Master courses. The Italian Society of Pediatric Allergology and Immunology (SIAIP) was founded in 1996 and counts about 1000 members. SIAIP promotes evidence-based management of allergic children and disseminates information to patients and their families through a quite innovative website and the National Journal 'Rivista Italiana di Allergologia Pediatrica'. In the last decade, four major regional, inter-regional, and national web-based networks have been created to link pediatric allergy centers and to share their clinical protocols and epidemiologic data. In addition, National Registers of Primary Immune-deficiencies and on Pediatric HIV link all clinical excellence centers. Research projects in the field of pediatric allergy and immunology are founded by the Italian Ministry of Education, University and Research (MIUR) and by the National Research Council (CNR), but the overall investments in this research area are quite low. Only a handful Italian excellence centers participate in European Projects on Pediatric Allergy and Immunology within the 7th Framework Program. The European Academy of Allergy and Clinical Immunology currently hosts two Italians in its Executive Committee (EC) and one in the EC of the Pediatric Section; moreover, major European Academy of Allergy and Clinical Immunology meetings and courses in the area of pediatrics (e.g., PAAM, Venice, 2009) have been held in Italy in the last 3 yr. Italian hallmarks in the management of allergic diseases in childhood are a quite alive and spread interest in Molecular Allergology and a remarkable predominance of sublingual (SLIT) compared to the subcutaneous (SCIT) immunotherapy.