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Zajac D, Wojciechowski P. The Role of Vitamins in the Pathogenesis of Asthma. Int J Mol Sci 2023; 24:ijms24108574. [PMID: 37239921 DOI: 10.3390/ijms24108574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/27/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Vitamins play a crucial role in the proper functioning of organisms. Disturbances of their levels, seen as deficiency or excess, enhance the development of various diseases, including those of the cardiovascular, immune, or respiratory systems. The present paper aims to summarize the role of vitamins in one of the most common diseases of the respiratory system, asthma. This narrative review describes the influence of vitamins on asthma and its main symptoms such as bronchial hyperreactivity, airway inflammation, oxidative stress, and airway remodeling, as well as the correlation between vitamin intake and levels and the risk of asthma in both pre- and postnatal life.
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Affiliation(s)
- Dominika Zajac
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 02-106 Warszawa, Poland
| | - Piotr Wojciechowski
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 02-106 Warszawa, Poland
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2
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Bloodworth JC, Hoji A, Wolff G, Mandal RK, Schmidt NW, Deshane JS, Morrow CD, Kloepfer KM, Cook-Mills JM. Dysbiotic lung microbial communities of neonates from allergic mothers confer neonate responsiveness to suboptimal allergen. FRONTIERS IN ALLERGY 2023; 4:1135412. [PMID: 36970065 PMCID: PMC10036811 DOI: 10.3389/falgy.2023.1135412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/17/2023] [Indexed: 03/12/2023] Open
Abstract
In humans and animals, offspring of allergic mothers have increased responsiveness to allergens. This is blocked in mice by maternal supplementation with α-tocopherol (αT). Also, adults and children with allergic asthma have airway microbiome dysbiosis with increased Proteobacteria and may have decreased Bacteroidota. It is not known whether αT alters neonate development of lung microbiome dysbiosis or whether neonate lung dysbiosis modifies development of allergy. To address this, the bronchoalveolar lavage was analyzed by 16S rRNA gene analysis (bacterial microbiome) from pups of allergic and non-allergic mothers with a basal diet or αT-supplemented diet. Before and after allergen challenge, pups of allergic mothers had dysbiosis in lung microbial composition with increased Proteobacteria and decreased Bacteroidota and this was blocked by αT supplementation. We determined whether intratracheal transfer of pup lung dysbiotic microbial communities modifies the development of allergy in recipient pups early in life. Interestingly, transfer of dysbiotic lung microbial communities from neonates of allergic mothers to neonates of non-allergic mothers was sufficient to confer responsiveness to allergen in the recipient pups. In contrast, neonates of allergic mothers were not protected from development of allergy by transfer of donor lung microbial communities from either neonates of non-allergic mothers or neonates of αT-supplemented allergic mothers. These data suggest that the dysbiotic lung microbiota is dominant and sufficient for enhanced neonate responsiveness to allergen. Importantly, infants within the INHANCE cohort with an anti-inflammatory profile of tocopherol isoforms had an altered microbiome composition compared to infants with a pro-inflammatory profile of tocopherol isoforms. These data may inform design of future studies for approaches in the prevention or intervention in asthma and allergic disease early in life.
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Affiliation(s)
- Jeffery C. Bloodworth
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Aki Hoji
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Garen Wolff
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Rabindra K. Mandal
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Nathan W. Schmidt
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jessy S. Deshane
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Casey D. Morrow
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kirsten M. Kloepfer
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Joan M. Cook-Mills
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, United States
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Primary Prevention of Pediatric Asthma through Nutritional Interventions. Nutrients 2022; 14:nu14040754. [PMID: 35215404 PMCID: PMC8875095 DOI: 10.3390/nu14040754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Asthma is the most common chronic non-communicable disease in children, the pathogenesis of which involves several factors. The increasing burden of asthma worldwide has emphasized the need to identify the modifiable factors associated with the development of the disease. Recent research has focused on the relationship between dietary factors during the first 1000 days of life (including pregnancy)—when the immune system is particularly vulnerable to exogenous interferences—and allergic outcomes in children. Specific nutrients have been analyzed as potential targets for the prevention of childhood wheeze and asthma. Recent randomized controlled trials show that vitamin D supplementation during pregnancy, using higher doses than currently recommended, may be protective against early childhood wheezing but not school-age asthma. Omega-3 fatty acid supplementation during pregnancy and infancy may be associated with a reduced risk of childhood wheeze, although the evidence is conflicting. Data from observational studies suggest that some dietary patterns during pregnancy and infancy might also influence the risk of childhood asthma. However, the quality of the available evidence is insufficient to allow recommendations regarding dietary changes for the prevention of pediatric asthma. This review outlines the available high-quality evidence on the role of prenatal and perinatal nutritional interventions for the primary prevention of asthma in children and attempts to address unmet areas for future research in pediatric asthma prevention.
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Cook-Mills JM, Averill SH, Lajiness JD. Asthma, allergy and vitamin E: Current and future perspectives. Free Radic Biol Med 2022; 179:388-402. [PMID: 34785320 PMCID: PMC9109636 DOI: 10.1016/j.freeradbiomed.2021.10.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/12/2021] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
Asthma and allergic disease result from interactions of environmental exposures and genetics. Vitamin E is one environmental factor that can modify development of allergy early in life and modify responses to allergen after allergen sensitization. Seemingly varied outcomes from vitamin E are consistent with the differential functions of the isoforms of vitamin E. Mechanistic studies demonstrate that the vitamin E isoforms α-tocopherol and γ-tocopherol have opposite functions in regulation of allergic inflammation and development of allergic disease, with α-tocopherol having anti-inflammatory functions and γ-tocopherol having pro-inflammatory functions in allergy and asthma. Moreover, global differences in prevalence of asthma by country may be a result, at least in part, of differences in consumption of these two isoforms of tocopherols. It is critical in clinical and animal studies that measurements of the isoforms of tocopherols be determined in vehicles for the treatments, and in the plasma and/or tissues before and after intervention. As allergic inflammation is modifiable by tocopherol isoforms, differential regulation by tocopherol isoforms provide a foundation for development of interventions to improve lung function in disease and raise the possibility of early life dietary interventions to limit the development of lung disease.
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Affiliation(s)
- Joan M Cook-Mills
- Herman B Wells Center for Pediatric Research, Departments of Pediatrics and Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
| | - Samantha H Averill
- Herman B Wells Center for Pediatric Research, Departments of Pediatrics and Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jacquelyn D Lajiness
- Herman B Wells Center for Pediatric Research, Departments of Pediatrics and Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
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Toledano JM, Moreno-Fernandez J, Puche-Juarez M, Ochoa JJ, Diaz-Castro J. Implications of Vitamins in COVID-19 Prevention and Treatment through Immunomodulatory and Anti-Oxidative Mechanisms. Antioxidants (Basel) 2021; 11:antiox11010005. [PMID: 35052509 PMCID: PMC8773198 DOI: 10.3390/antiox11010005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Abstract
Since the appearance of the coronavirus disease 2019 (COVID-19) and its announcement as a global pandemic, the search for prophylactic and therapeutic options have become a priority for governments and the scientific community. The approval of several vaccines against SARS-CoV-2 is being crucial to overcome this situation, although the victory will not be achieved while the whole population worldwide is not protected against the virus. This is why alternatives should be studied in order to successfully support the immune system before and during a possible infection. An optimal inflammatory and oxidative stress status depends on an adequate diet. Poor levels of several nutrients could be related to an impaired immune response and, therefore, an increased susceptibility to infection and serious outcomes. Vitamins exert a number of anti-microbial, immunomodulatory, anti-inflammatory, and antioxidant activities, which can be of use to fight against this and several other diseases (especially vitamin D and C). Even though they cannot be considered as a definitive therapeutic option, in part owing to the lack of solid conclusions from well-designed clinical trials, currently available evidence from similar respiratory diseases may indicate that it would be rational to deeply explore the use of vitamins during this global pandemic.
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Affiliation(s)
- Juan M. Toledano
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Nutrition and Food Sciences Ph.D. Program, University of Granada, 18071 Granada, Spain
| | - Jorge Moreno-Fernandez
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - María Puche-Juarez
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Nutrition and Food Sciences Ph.D. Program, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - Julio J. Ochoa
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - Javier Diaz-Castro
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Instituto de Investigación Biosanitaria (IBS), 18016 Granada, Spain
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Oliver PJ, Arutla S, Yenigalla A, Hund TJ, Parinandi NL. Lipid Nutrition in Asthma. Cell Biochem Biophys 2021; 79:669-694. [PMID: 34244966 DOI: 10.1007/s12013-021-01020-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2021] [Indexed: 12/27/2022]
Abstract
Asthma is a heterogeneous pulmonary disease that has constantly increased in prevalence over the past several decades. Primary symptoms include airway constriction, airway hyperresponsiveness, and airway remodeling with additional symptoms such as shortness of breath, wheezing, and difficulty breathing. Allergic asthma involves chronic inflammation of the lungs, and the rise in its yearly diagnosis is potentially associated with the increased global consumption of foods similar to the western diet. Thus, there is growing interest into the link between diet and asthma symptoms, with mounting evidence for an important modulatory role for dietary lipids. Lipids can act as biological mediators in both a proinflammatory and proresolution capacity. Fatty acids play key roles in signaling and in the production of mediators in the allergic and inflammatory pathways. The western diet leads to a disproportionate ω-6:ω-3 ratio, with drastically increased ω-6 levels. To counteract this, consumption of fish and fish oil and the use of dietary oils with anti-inflammatory properties such as olive and sesame oil can increase ω-3 and decrease ω-6 levels. Increasing vitamin intake, lowering LDL cholesterol levels, and limiting consumption of oxidized lipids can help reduce the risk of asthma and the exacerbation of asthmatic symptoms. These dietary changes can be achieved by increasing intake of fruits, vegetables, nuts, oily fish, seeds, animal-related foods (eggs, liver), cheeses, grains, oats, and seeds, and decreasing consumption of fried foods (especially fried in reused oils), fast foods, and heavily processed foods.
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Affiliation(s)
- Patrick J Oliver
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.,Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Sukruthi Arutla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.,Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Anita Yenigalla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.,Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Thomas J Hund
- Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Narasimham L Parinandi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA. .,Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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Sozańska B, Sikorska-Szaflik H. Diet Modifications in Primary Prevention of Asthma. Where Do We Stand? Nutrients 2021; 13:nu13010173. [PMID: 33429965 PMCID: PMC7827701 DOI: 10.3390/nu13010173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 12/26/2022] Open
Abstract
The steep increase in asthma prevalence, observed worldwide in recent decades, has created an urgent need to search for effective methods of its prevention. Among other environmental factors, changes in diet habits and the potential influence of individual food components on immunological processes have been extensively studied as a potential method of intervention in primary prevention of asthma. The preventive role of some nutrients has been confirmed: unpasteurized milk reduced the risk of asthma in epidemiological studies, vitamin D supplementation was effective in preventing the transient forms of wheezing in small children and high maternal intake of fish oil reduced the risk of persistent wheeze and asthma in children. However, not all studies provided consistent results, and many food ingredients are still pending for defining their role in asthma development. Moreover, a novel approach looking not only at single food ingredients, but the whole dietary patterns and diversity has recently been proposed. In this paper, we discuss the current role of nutrients in asthma primary prevention and the reasons for inconsistencies in the study results. We look at single diet components, but also the whole dietary patterns. We describe the proposed mechanisms of action at different stages of life, identify the role of modifiers and delineate future perspectives on the application of nutrients in targeting strategies for asthma primary prevention.
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Shams MH, Jafari R, Eskandari N, Masjedi M, Kheirandish F, Ganjalikhani Hakemi M, Ghasemi R, Varzi AM, Sohrabi SM, Baharvand PA, Safari M. Anti-allergic effects of vitamin E in allergic diseases: An updated review. Int Immunopharmacol 2020; 90:107196. [PMID: 33221170 DOI: 10.1016/j.intimp.2020.107196] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/31/2020] [Accepted: 11/08/2020] [Indexed: 02/05/2023]
Abstract
Allergic diseases are caused by the immune system's response to innocent antigens called allergens. Recent decades have seen a significant increase in the prevalence of allergic diseases worldwide, which has imposed various socio-economic effects in different countries. Various factors, including genetic factors, industrialization, improved hygiene, and climate change contribute to the development of allergic diseases in many parts of the world. Moreover, changes in lifestyle and diet habits play pivotal roles in the prevalence of allergic diseases. Dietary changes caused by decreased intake of antioxidants such as vitamin E lead to the generation of oxidative stress, which is central to the development of allergic diseases. It has been reported in many articles that oxidative stress diverts immune responses to the cells associated with the pathogenesis of allergic diseases. The aim of this short review was to summarize current knowledge about the anti-allergic properties of vitamin E.
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Affiliation(s)
- Mohammad-Hossein Shams
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Medical Immunology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Reza Jafari
- Faculty of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Nahid Eskandari
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohsen Masjedi
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farnaz Kheirandish
- Department of Medical Parasitology and Mycology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran; Razi Herbal Medicines Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | | | - Ramin Ghasemi
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali-Mohammad Varzi
- Department of Medical Immunology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran; Razi Herbal Medicines Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Seyyed-Mohsen Sohrabi
- Department of Medical Immunology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | | | - Mozhgan Safari
- Department of Pediatrics, School of Medicines, Hamedan University of Medical Science, Hamedan, Iran
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Pellow J, Nolte A, Temane A, Solomon EM. Health supplements for allergic rhinitis: A mixed-methods systematic review. Complement Ther Med 2020; 51:102425. [DOI: 10.1016/j.ctim.2020.102425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/23/2023] Open
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Trambusti I, Nuzzi G, Costagliola G, Verduci E, D'Auria E, Peroni DG, Comberiati P. Dietary Interventions and Nutritional Factors in the Prevention of Pediatric Asthma. Front Pediatr 2020; 8:480. [PMID: 33014920 PMCID: PMC7461983 DOI: 10.3389/fped.2020.00480] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022] Open
Abstract
Asthma is the most frequent chronic disease in children, and its pathogenesis involves genetic, epigenetic, and environmental factors. The rapid rise in the prevalence of asthma registered over the last few decades has stressed the need to identify the environmental and modifiable factors associated with the development of the disease. In particular, there is increasing interest in the role of modifiable nutritional factors specific to both the prenatal and post-natal early life as, during this time, the immune system is particularly vulnerable to exogenous interferences. Several dietary factors, including maternal diet during pregnancy, the duration of breastfeeding, the use of special milk formulas, the timing of the introduction of complementary foods, and prenatal and early life supplementation with vitamins and probiotics/prebiotics, have been addressed as potential targets for the prevention of asthma. In this review, we outline recent findings on the potential role of prenatal and perinatal dietary and nutritional interventions for the primary prevention of pediatric asthma. Moreover, we addressed unmet needs and areas for future research in the prevention of childhood-onset asthma.
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Affiliation(s)
- Irene Trambusti
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Nuzzi
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elvira Verduci
- Department of Health Sciences, University of Milan, Milan, Italy.,Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Enza D'Auria
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Diego G Peroni
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Pasquale Comberiati
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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