Pediatric asthma and altitude: a complex interplay between different environmental factors

Asthma is one of the most common non-communicable diseases, and its prevalence and morbidity are influenced by a wide array of factors that are only partially understood. In addition to individual predisposition linked to genetic background and early life infections, environmental factors are crucial in determining the impact of asthma both on an individual patient and on a population level.Several studies have examined the role of the environment where asthmatic subjects live in the pathogenesis of asthma. This review aims to investigate the differences in the prevalence and characteristics of asthma between the pediatric population residing at higher altitudes and children living at lower altitudes, trying to define factors that potentially determine such differences. For this purpose, we reviewed articles from the literature concerning observational studies assessing the prevalence of pediatric asthma in these populations and its characteristics, such as spirometric and laboratory parameters and associated sensitization to aeroallergens.Despite the heterogeneity of the environments examined, the hypothesis of a beneficial effect of residing at a higher altitude on the prevalence of pediatric asthma could be confirmed, as well as a good profile on airway inflammation in asthmatic children. However, the possibility of a higher hospitalization risk for asthma in children living at higher altitudes was demonstrated. Moreover, a positive association between residing at a higher altitude and sensitization to pollens and between lower altitude and sensitization to house dust mites could be confirmed in some pediatric patients, even if the results are not homogeneous, probably due to the different geographical and climatic regions considered. Nonetheless, further studies, e.g., extensive and international works, need to be conducted to better understand the complex interplay between different environmental factors, such as altitude, and the pathogenesis of asthma and how its prevalence and characteristics could vary due to climate change.

Narrative review on the management of moderate-severe atopic dermatitis in pediatric age of the Italian Society of Pediatric Allergology and Immunology (SIAIP), of the Italian Society of Pediatric Dermatology (SIDerP) and of the Italian Society of Pediatrics (SIP)

Currently, there are a few detailed guidelines on the overall management of children and adolescents with moderate-severe atopic dermatitis. AD ​​is a complex disease presenting with different clinical phenotypes, which require an individualized and multidisciplinary approach. Therefore, appropriate interaction between primary care pediatricians, pediatric allergists, and pediatric dermatologists is crucial to finding the best management strategy. In this manuscript, members of the Italian Society of Pediatric Allergology and Immunology (SIAIP), the Italian Society of Pediatric Dermatology (SIDerP), and the Italian Society of Pediatrics (SIP) with expertise in the management of moderate-severe atopic dermatitis have reviewed the latest scientific evidence in the field. This narrative review aims to define a pathway to appropriately managing children and adolescents with moderate-severe atopic dermatitis.

Oral Immunotherapy for Food-Allergic Children: A Pro-Con Debate

The prevalence of food allergy has increased in recent years, especially in children. Allergen avoidance, and drugs in case of an allergic reaction, remains the standard of care in food allergy. Nevertheless, increasing attention has been given to the possibility to treat food allergy, through immunotherapy, particularly oral immunotherapy (OIT). Several OIT protocols and clinical trials have been published. Most of them focus on children allergic to milk, egg, or peanut, although recent studies developed protocols for other foods, such as wheat and different nuts. OIT efficacy in randomized controlled trials is usually evaluated as the possibility for patients to achieve desensitization through the consumption of an increasing amount of a food allergen, while the issue of a possible long-term sustained unresponsiveness has not been completely addressed. Here, we evaluated current pediatric OIT knowledge, focusing on the results of clinical trials and current guidelines. Specifically, we wanted to highlight what is known in terms of OIT efficacy and effectiveness, safety, and impact on quality of life. For each aspect, we reported the pros and the cons, inferable from published literature. In conclusion, even though many protocols, reviews and meta-analysis have been published on this topic, pediatric OIT remains a controversial therapy and no definitive generalized conclusion may be drawn so far. It should be an option provided by specialized teams, when both patients and their families are prone to adhere to the proposed protocol. Efficacy, long-term effectiveness, possible role of adjuvant therapies, risk of severe reactions including anaphylaxis or eosinophilic esophagitis, and impact on the quality of life of both children and caregivers are all aspects that should be discussed before starting OIT. Future studies are needed to provide firm clinical and scientific evidence, which should also consider patient reported outcomes.

Netherton Syndrome in Children: Management and Future Perspectives

Netherton syndrome (NS) is a genetic, multisystemic disease classically distinguished by a triad of clinical manifestations: congenital ichthyosiform erythroderma, hair shaft abnormalities, and immune dysregulation. Due to the complex pathogenesis of the disease, there are no specific therapies currently accessible for patients with NS. An early diagnosis is crucial to start the correct management of these patients. A multidisciplinary approach, including specialists in immunology, allergology, and dermatology, is necessary to set up the best therapeutic pathway. We conducted a review with the aim to summarize the different therapeutic strategies currently accessible and potentially available in the future for children with NS. However, given the limited data in the literature, the best-tailored management should be decided upon the basis of the specific clinical characteristics of the patients with this rare clinical condition. Further comprehension of the pathophysiology of the disease could lead to more efficacious specific therapeutic options, which could allow a change in the natural history of NS.

Assessing patients' characteristics and treatment patterns among children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is the most common immune-mediated skin disease in childhood. Several treatment options for pediatric AD, both topical and systemic, are currently available. We carried out a single-center observational study with the aim of describing characteristics and treatment patterns in pediatric AD patients.

METHODS

The study included 867 patients aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with a previous doctor-confirmed diagnosis of AD who underwent balneotherapy at the Comano Thermal Spring Water Center (Comano, Trentino, Italy) from April to October 2014.

RESULTS

Among the patients included in the study, 41.2% had mild (SCORing Atopic Dermatitis, SCORAD 0-15), 43.6% moderate (SCORAD 16-40) and 15.2% severe AD (SCORAD > 40). A higher occurrence of reported food allergy was observed among children with more severe AD (p < 0.0001), while no association was found between AD severity and reported inhalant allergy or passive smoking (p = 0.15 and 0.92, respectively). Emollients (55.1%) and topical corticosteroids (TCS; 45.7%) were the main treatment options used in the previous month. The use of oral steroids and topical calcineurin inhibitors (TCI) was considerably less common (6.3 and 4.5%, respectively), while no patients were on systemic agents other than steroids. Among patients with severe AD, 9.8% had not used TCS, TCI or any systemic treatments. Moreover, 20.0% of the patients in the study population had followed elimination diets, although only 27.2% of them had a reported food allergy.

CONCLUSIONS

A significant difference in the prevalence of reported food allergy emerged across the different AD severity categories. Furthermore, although further data are necessary to confirm our findings, undertreatment in children with AD appeared to be very common, at least among those attending the Comano Thermal Spring Water Center. Moreover, many patients followed elimination diets in the absence of reported food allergy.

Characteristics associated with clinical response to Comano thermal spring water balneotherapy in pediatric patients with atopic dermatitis

BACKGROUND

Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients.

METHODS

An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated.

RESULTS

A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course.

CONCLUSIONS

Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.

A caregiver-reported global severity assessment in pediatric atopic eczema: the Comano score

Atopic eczema (AE) is the most common inflammatory skin disease in infancy and its prevalence is rising worldwide. It has a wide social impact on the affected children and their families’ lives. AE can have a chronic and heterogeneous course, with periods of remission and relapse of the clinical manifestations. For this reason, its severity assessment through standardized outcome measures becomes a fundamental guide for health professionals, who can manage AE following evidence-based medicine principles in their everyday clinical practice or in clinical trials.

Several scoring systems have been recognized to assess the clinical manifestations of AE, both from the physician’s and the patient’s point of view. Despite the scoring systems standardized for adults, there are very few published options about the expression of a patient/caregiver-centered global severity assessment specifically for pediatric AE. For this reason, the aim of our study was to evaluate a new, quick, user-friendly and feasible caregiver-reported global severity assessment for pediatric AE. Based on a 0–10 numerical rating scale in pediatric AE, we named this scoring system the Comano score.

We carried out a cross-sectional observational study enrolling a total of 867 patients aged from 1 to 16 years (males 49.5%, mean patient’s age 5.9 years, standard deviation ±3.6 years) with a previous doctor-confirmed diagnosis of AE, who underwent balneotherapy at Comano Thermal Center (Comano, Trentino, Italy). A strong correlation between Comano score and SCORing Atopic Dermatitis (SCORAD) was observed (r = 0.74, p < 0.0001).

According to our results, the Comano score may be a promising new tool for the expression of a caregiver-reported global severity assessment in pediatric AE. However, further data are needed to confirm our preliminary findings before health professionals can use this scoring system in their everyday clinical practice to manage pediatric AE. Still, as a patient-focused measure, the Comano score may facilitate delivering person-centered care so as to define a measure for a clinical impact that can be meaningful to the subject, which is gaining importance in modern medicine.

Persistence and Microevolution of Pseudomonas aeruginosa in the Cystic Fibrosis Lung: A Single-Patient Longitudinal Genomic Study

Background: During its persistence in cystic fibrosis (CF) airways, P. aeruginosa develops a series of phenotypic changes by the accumulation of pathoadaptive mutations. A better understanding of the role of these mutations in the adaptive process, with particular reference to the development of multidrug resistance (MDR), is essential for future development of novel therapeutic approaches, including the identification of new drug targets and the implementation of more efficient antibiotic therapy. Although several whole-genome sequencing studies on P. aeruginosa CF lineages have been published, the evolutionary trajectories in relation to the development of antimicrobial resistance remain mostly unexplored to date. In this study, we monitored the adaptive changes of P. aeruginosa during its microevolution in the CF airways to provide an innovative, genome-wide picture of mutations and persistent phenotypes and to point out potential novel mechanisms allowing survival in CF patients under antibiotic therapy. Results: We obtained whole genome sequences of 40 P. aeruginosa clinical CF strains isolated at Trentino Regional Support CF Centre (Rovereto, Italy) from a single CF patient over an 8-year period (2007-2014). Genotypic analysis of the P. aeruginosa isolates revealed a clonal population dominated by the Sequence Type 390 and three closely related variants, indicating that all members of the population likely belong to the same clonal lineage and evolved from a common ancestor. While the majority of early isolates were susceptible to most antibiotics tested, over time resistant phenotypes increased in the persistent population. Genomic analyses of the population indicated a correlation between the evolution of antibiotic resistance profiles and phylogenetic relationships, and a number of putative pathoadaptive variations were identified. Conclusion: This study provides valuable insights into the within-host adaptation and microevolution of P. aeruginosa in the CF lung and revealed the emergence of an MDR phenotype over time, which could not be comprehensively explained by the variations found in known resistance genes. Further investigations on uncharacterized variations disclosed in this study should help to increase our understanding of the development of MDR phenotype and the poor outcome of antibiotic therapies in many CF patients.

Consensus Conference on Clinical Management of pediatric Atopic Dermatitis

The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.

Balneotherapy for atopic dermatitis in children at Comano spa in Trentino, Italy

BACKGROUND

No controlled studies have investigated whether balneotherapy is effective in atopic dermatitis (AD).

OBJECTIVES

To investigate the efficacy and safety of balneotherapy performed at Comano spa (Trentino, Italy) compared to topical corticosteroids (TCS) in the treatment of AD.

METHODS

This was an open, randomized, clinical trial including 104 children (aged 1-14 years) with mild to moderate AD who were assigned either to balneotherapy (n = 54) or TCS (n = 50) once daily for 2 weeks. AD severity and quality of life were measured using the SCORAD, investigator global assessment (IGA), patients' self global assessment (PSGA), children's dermatology life quality index (CDLQI) and family dermatitis impact questionnaire (FDIQ). Subjective measures were re-evaluated 4 months after the end of therapy.

RESULTS

Balneotherapy and TCS resulted in a significant reduction of all parameters at week 2. TCS were more effective than balneotherapy regarding SCORAD (46% ± 7.71 vs 26% ± 9.4, mean ± SD; p < 0.03). In contrast, IGA, PSGA, CDLQI and FDIQ improvement was similar. At month 4, the number and duration of relapses were less in patients treated with balneotherapy compared to those treated with TCS (p <0.0001).

CONCLUSIONS

Balneotherapy at Comano spa appears to be beneficial in children with mild to moderate AD.

The modified Burton-Pellegrini method for the treatment of trapeziometacarpal arthritis. Medium-term results

An original modification in the Burton-Pellegrini technique was used to treat 20 cases of trapeziometacarpal arthritis between 1992 and 2001. A retrospective evaluation concerned 13 cases and was based on functional and radiographic criteria measuring the height of the column of the thumb at rest and under stress. Mean follow-up was 54.2 months (range 24-144). The height of the column of the thumb was decreased in relation to that of healthy hands and shortening under stress was significantly correlated with an increase in pain under stress (R2 = 44.7; p = 0.012). The observation of hyperextension of the MP (> 20 degrees) at follow-up was correlated with worse functional results. The method proposed has proven to be reliable, safe, capable of guaranteeing greater force as compared to other surgical methods described in the literature. The study emphasizes the need for a careful preoperative evaluation and possible treatment of MP joint hyperextension.

Microalbuminuria, left ventricular mass and ambulatory blood pressure in essential hypertension

The objective of the present study was to assess the relationship between microalbuminuria (Malb) and left ventricular hypertrophy (LVH), when levels of ambulatory BP was token in to account as a confounder factor. Patients with essential hypertension, aged 25 to 50 years old, never treated with antihypertensive drugs, were included in the study. The inclusion criteria were: (a) absence of diabetes, renal disease or urinary tract infection; (b) urinary albumin excretion (UAE) estimated in urine of 24 hours in two separate days; (c) echocardiography suitable for measurement of left ventricular mass (LVM); and (d) good quality ambulatory blood pressure monitoring during 24 hours. UAE was measured using a immunonephelometric assay (Behring Institute) and Malb was considered when UAE 30 to 300 mg/24 hours during the two days. LVM was calculated by the Devereaux formula and referred to height (LVMI g/m). AMBP was performed using an oscilometric device (Spacelabs 90202 or 90207) during a regular working day. Readings were programmed every 20 minutes between 6 a.m. to midnight and thereafter every 30 minutes. The average BP during a 24 hour period was calculated. One hundred and fifty one patients (96 male, mean age 37 +/- 8 years, body mass index 27.7 +/- 3.7 g/m2) were included. The average values of office BP was 148 +/- 15/96 +/- 8 mm Hg, and the average BP during 24 hours was 137 +/- 13/88 +/- 12 mm Hg. UAE was 30.1 +/- 52.3 mg/24 hr and the LVMI 140.6 +/- 44.1 g/m. The percentage of Malb patients was 28% and those with LVH 34%. A significant relationship between UAE and office and ambulatory SBP and DBP was observed. LVMI was also significantly related to ambulatory SBP and DBP, a relationship that was not found for office BP. In a multiple regression model, significant relationship between UAE and LVMI emerged, independent of diastolic ambulatory BP, age and sex (P < 0.04). In conclusion; we observed a significant relationship between UAE and LVMI, in part, independent of blood pressure. The fact that Malb is associated with the presence of LVH, supports the idea that Malb is a risk marker in essential hypertensive patients.

Factors related to the presence of microalbuminuria in essential hypertension

The objective of the present study was to assess factors related to the presence of microalbuminuria in essential hypertension. Ninety-five patients with essential hypertension (58 males and 37 females, mean age 38.6 +/- 6.1 years) who had never been treated previously for hypertension were included in the study. Patients with nephropathy or diabetes mellitus, hyperglycemia > 120 mg/dL, glomerular filtration rate < 80 mL/min/1.73 m2, urinary tract infection, or positive dipstick for albumin or glucose were excluded. Blood pressure, echocardiographically determined left ventricular mass, serum biochemistry, and lipid profile were obtained. Twenty-four-hour urinary albumin excretion (UAE) was measured on two separate days using an immunonephelometric assay. Microalbuminuria (UAE 30 to 300 mg/24 h) occurred in 26% of patients and was associated with higher diastolic blood pressure (DBP), left ventricular mass index (LVMI), and a higher prevalence of hypertriglyceridemia and hyperapolipoproteinemia B (apo-B). Logistic regression analysis showed that the risk of microalbuminuria was independently related to diastolic blood pressure and hypertriglyceridemia when controlling for age, sex, body mass index, LVMI, and apo-B. Multiple regression analysis likewise confirmed that both DBP and LVMI were linearly related to UAE independent of age, sex, body mass index, total cholesterol, triglycerides, and apo-B. In conclusion, our study indicates that among hypertensive patients with elevated excretion rates of urinary albumin, even at the subclinical level, an increased cardiovascular risk exists compared to normoalbuminuric patients with a similar blood pressure. Assessment of the presence of microalbuminuria may be useful in the evaluation and management of hypertension.

Effects of posture, effort and psychophysiological activation on atrio-ventricular node and Kent bundle refractoriness

A new protocol is described for non-invasive evaluation of electrophysiological effects of autonomic nervous system on both normal and abnormal atrio-ventricular conduction in patients with Wolff-Parkinson-White (WPW) syndrome. In 64 WPW patients with stable Kent-type ventricular preexcitation transoesophageal atrial pacing has been carried out to quantify changes in both atrioventricular (AV) node and Kent bundle refractoriness and maximal conductive capability induced by posture, physical exercise and psychophysiological activation. A significant shortening of AV nodal and accessory pathway refractory periods was found, induced by manoeuvres enhancing the sympathetic outflow, being the AV node the most sensitive structure. This finding suggests that an exhaustive investigation protocol of WPW patients should include the evaluation of the neurovegetative effects on cardiac electrophysiological parameters, under conditions which can reproduce as close as possible the individual situations a patient has to face in his real life.