Consensus statement of the Italian society of pediatric allergy and immunology for the pragmatic management of children and adolescents with allergic or immunological diseases during the COVID-19 pandemic

Facile preparation and characterization of biodegradable and biocompatible UV shielding transdermal patches based on natural rubber latex- dextrin blends

The physico-chemical and biological properties of natural rubber latex (NRL), entailing its biodegradability and biocompatibility, render it a promising material for various biomedical applications. This research explores the facile blending of NRL with dextrin in different compositions to investigate its potential as a prospective UV shielding transdermal patch for biomedical applications. The superior compatibility between the polymers after blending and the improved thermal stability have been established through FTIR, DSC, and TGA examinations, respectively. Optimization of blended polymers for compatibility, wettability, crystallinity, and static mechanical properties has been performed. Morphology characterization conducted via SEM and AFM techniques suggests a uniform morphology for the optimized blend system. The UV shielding ability of the blend has been confirmed by the evaluation of in-vitro UV shielding performance, UV protection factor (UPF), and the superior protection of the optimized system on living cells upon UV irradiation. The observed cell viability, swelling, erosion, porosity, hemocompatibility, and soil degradation properties suggest the NRL-DXT combination for the possible development of high-quality transdermal patches.

Treatment of Severe Asthma: Case Report of Fast Action of Mepolizumab in a Patient with Recent SARS-CoV-2 Infection

Asthma is one of the most common chronic inflammatory diseases of childhood with a heterogeneous impact on health and quality of life. Mepolizumab is an antagonist of interleukin-5, indicated as an adjunct therapy for severe refractory eosinophilic asthma in adolescents and children aged >6 years old. We present the case of a 9 year-old boy with severe asthma who experienced several asthmatic exacerbations following a SARS-CoV-2 infection, necessitating therapy with short-acting bronchodilators, oral corticosteroids, and hospitalization. We follow the patient using validated questionnaires for the evaluation of asthma control: Children Asthma Control Test, Asthma Control Questionnaire, respiratory function tests, and evaluation of exhaled nitric oxide fraction. After 12 weeks from the start of therapy with mepolizumab, we found significant improvements in lung function, a reduction in the degree of bronchial inflammation, and improvements in quality of life. No asthmatic exacerbations have been reported since the initiation of treatment with mepolizumab. Respiratory infections, such as those related to SARS-CoV-2, represent a significant risk factor for exacerbations in patients with moderate to severe forms of asthma. In our experience, following new episodes of exacerbation, the initiation of treatment with mepolizumab has allowed us to improve asthma control and enhance the quality of life of patients from the first doses. Although mepolizumab showed promise in this child with severe asthma during SARS-CoV-2 infection, the results from this single case cannot be generalized. Further studies are needed to confirm its safety and effectiveness.

Impact of COVID-19 on adverse reactions to subcutaneous specific immunotherapy in children:a retrospective cohort study

BACKGROUND

COVID-19 is a new infectious disease. To investigate whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases the adverse reactions of subcutaneous specific immunotherapy (SCIT) in children.

METHODS

This study was conducted by collecting relevant data from children who underwent house dust mite SCIT from April 3, 2021, to March 18, 2023, including information on the time of COVID-19 infection, symptoms, and adverse reactions after each allergen injection. A mixed effects model was used to analyze the changes in adverse reactions before and after the COVID-19 infection.

RESULTS

Among the records of adverse reactions from 2658 injections in 123 children who underwent SCIT, the overall adverse reaction rate before COVID-19 infection was 39.8% and 30.0% after COVID-19 infection. Compared with pre-infection with COVID-19, the risks of overall adverse reactions, local adverse reactions, and systemic adverse reactions of immunotherapy after COVID-19 infection were reduced (odds ratio [OR] = 0.24, 0.31, and 0.28, all P < 0.05). Among the local adverse reactions, the incidence of the unvaccinated group was the highest (15.3% vs. 7.1%). The incidence of overall and local adverse reactions to SCIT decreased in 2-vaccinated COVID-19 recipients (OR = 0.29-0.31, P < 0.05).

CONCLUSIONS

In children, SARS-CoV-2 infection does not increase the incidence of adverse reactions to SCIT. This finding can provide a basis for the implementation of allergen-specific immunotherapy (AIT) during the COVID-19 pandemic.

Surface Roughness Examination of Glass Ionomer Restorative Cements Treated with Acidic and Basic Pediatric Medications: An In Vitro Study

Background

Consumption of different types of beverages and liquid drugs can affect of the surface properties of restorative material. This may lead to an increased probability of dental caries and periodontal inflammation.

Aim

This study evaluated and compared the effect of amoxicillin suspension (AMS) and azithromycin suspension (AZS) on the surface roughness (SR) of silver-reinforced glass ionomer (SGI) and nano resin-modified glass ionomer (NGI).

Material and Methods

Thirty disks (2 mm height × 4 mm diameter) of each glass ionomer (GI) type were prepared and subdivided into three groups (n = 10), which were separately exposed to AMS, AZS, and artificial saliva (AS). SR was evaluated by atomic force microscopy before and after three-immersion protocols repeated over a 3-week duration with 2-day intervals. In each protocol, the GI samples were exposed weekly to AMS three times daily, AZS once daily, and a full day to AS.

Results

This study demonstrated, for the first time, the effect of a basic drug (AZS) on the SR of GIs. Intra- and inter-group comparisons showed significant changes (P ˂ 0.05) in the SR pattern of the GIs after immersion cycles in AZS, AMS, and AS. However, the acidic medication (AMS) exhibited significantly higher changes in SGI than in NGI.

Conclusions

The SR of NGIs and SGIs can be significantly affected by the use of AMS and AZS suspensions. SGI demonstrated higher SR deterioration than NGI after immersion cycles in AMS.

Respiratory allergic diseases and allergen immunotherapy: A French patient survey before and during the COVID-19 pandemic

Background

The COVID-19 pandemic brought unprecedented global disruption to both healthcare providers and patients with respiratory allergies. There are limited real-life data on the impact of the COVID-19 pandemic on the risk perception of patients with allergy treated with allergen immunotherapy (AIT).

Objective

To understand the risk perception of allergic patients treated with sublingual immunotherapy (SLIT) before and during the pandemic, and their attitudes towards COVID-19 infection and vaccination.

Methods

This was a non-interventional, cross-sectional survey conducted from October to November 2021 in France. Adult patients, who had been prescribed and had received a Stallergenes SLIT (liquid or liquid and tablets) before the pandemic (from August 1, 2018 to March 10, 2020) and during the pandemic (from March 11, 2020 to August 31, 2021), were identified from the Stallergenes named-patient products (NPP) database. Patients completed an online questionnaire. Data were analyzed descriptively.

Results

A total of 5258 patients from all over France completed the questionnaire. Mean (±SD) age of the respondents was 39.3 (±13.0) years and 66.9% were female. Some of them (11.8%) were obese (BMI >30 kg/m2). Main allergic diseases were rhinitis (80.0% of patients) with or without conjunctivitis, and asthma (39.0%). More than half of the patients experienced moderate to severe (58.0%) and persistent allergic rhinitis profile (70.4%). Most patients were poly-allergic (72.7%), mostly to house dust mites (61.9%), grass pollens (61.5%), tree pollens (57.8%), and cat dander (37.2%). Only 14.1% of patients experienced an aggravation of their allergy symptoms during lockdown and 14.8% were infected with COVID-19, with hospitalization required for 1.8%. Only 3.1% of patients reported their SLIT initiation as being postponed due to the pandemic. SLIT was changed, temporarily interrupted or permanently discontinued during the pandemic in 21.9% of patients. Changes mainly concerned the maintenance dose for SLIT-liquid (63.2%). SLIT modification was due to COVID-19 infection in only 4.2%. Most patients did not feel vulnerable (53.1%), anxious (55.2%), at risk to present severe symptoms of COVID-19 (77.1%), or at risk to transmit coronavirus (80.4%). However, greater anxiety was reported in patients with allergic asthma (33.6%) or other respiratory disorders (50.4%). Patients who felt vulnerable partly assigned their vulnerability to their allergic disease (59.3%). Suffering from an allergic disease did not make patients feel more vulnerable to side effects of COVID-19 vaccine for 79.6% of them.

Conclusion

Overall, most patients with allergy and under SLIT were not strongly concerned by the COVID-19 infection. SLIT did not have a negative impact on the COVID-19 symptoms.

Obesity and Preventive Intervention Among Children: A Narrative Review

Childhood obesity has become a major public health concern around the world, with a rise in prevalence over the last few decades. This abstract provides an overview of pediatric obesity, including its causes, implications, and potential treatments. Childhood obesity is caused by a complex combination of environmental, genetic, and behavioral variables. A child's likelihood of developing obesity is influenced by factors, such as socioeconomic status, family dynamics, and cultural norms. Childhood obesity leads to extensive repercussions, elevating the risk of chronic conditions, such as diabetes, cardiovascular diseases, and mental health challenges. Furthermore, children dealing with obesity often face social stigmatization, diminished self-esteem, and academic struggles. Efforts to prevent and manage childhood obesity should employ a comprehensive and multi-tiered approach. This involves enacting policies geared toward enhancing nutrition in schools and communities, advocating for increased physical activity (PA), and curbing sedentary behaviors.

COVID-19 and Its Impact on Common Diseases in the Allergy Clinics

Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has various effects on asthma, allergic rhinitis, atopic dermatitis, and urticaria and may change the course of the disease depending on the severity of the infection and control status of the disease. Conversely, these diseases may also impact the course of COVID-19. Patients with chronic urticaria and atopic dermatitis may have COVID-19-induced disease exacerbations and biological treatments reduce the risk of exacerbations. Poor asthma control is linked to severe COVID-19 while allergic asthma is associated with lower risk of death and a lower rate of hospitalization due to COVID-19 compared with nonallergic asthma. The use of intranasal corticosteroids is associated with lower rates of hospitalization due to COVID-19 in patients with allergic rhinitis, whereas the effect of inhaled corticosteroids is confounded by asthma severity. These observations reinforce the importance of keeping allergic diseases under control during pandemics. The use of biologicals during COVID-19 is generally regarded as safe, but more evidence is needed. The pandemic substantially changed the management of allergic disorders such as home implementation of various biologicals, allergen immunotherapy, food introduction, and increased use of telemedicine and even home management of anaphylaxis to reduce emergency department burden and reduce risk of infection. Physicians need to be aware of the potential impact of COVID-19 on allergic diseases and educate their patients on the importance of continuing prescribed medications and adhering to their treatment plans to maintain optimal control of their disease.

Pathological Lung Ultrasound May Take Time to Resolve Despite Respiratory Symptoms Improvement: A Pediatric Case Series Followed for Long COVID

Background:

Long COVID affects 8 to 10 % of children. Currently, the COVID-19 fo-llow-up protocols in children include chest auscultation, collection of growth parameters, including weight, height and body mass index, execution of the six-minute walking test, basal spirometry, and afterwards, bronchodilation test and lung ultrasound.

Case Presentation:

In this paper, the authors describe a case series of long COVID followed up for 9 months at the Department of Pediatrics of the University Luigi Vanvitelli. The review of the lite-rature was performed on PubMed using the keywords COVID-19, follow-up, children, and lung ul-trasound. The aim of this article was to highlight the need to create custom follow-up programs for long Covid in children through the description of a case followed up at our Pediatric Department and a review of the current literature

Discussion:

The reversal of pathological lung ultrasound signs occurred in six or nine months des-pite the early improvement of respiratory symptoms and pulmonary function. There are limited stu-dies on the ultrasonography follow-up of kids with COVID-19 in the literature, and there are still no follow-up COVID-19 guidelines for paediatric population.

Conclusion:

Pathological lung ultrasound in children recovered from COVID-19, may take time to resolve; therefore, evaluating patients with lung ultrasound in the following months could be a ra-diation-saving approach useful for children who have fully recovered and have no warning signs.

Impact of SARS-CoV-2 Infection in Children with Asthma and Impact of COVID-19 Vaccination: Current Evidence and Review of the Literature

The clinical aspects of SARS-CoV-2 infection, as well as the COVID-19 vaccines' safety, efficacy and effectiveness in pediatric patients with asthma, are crucial to adapting clinical management in this fragile population and for prevention strategies. The aim of this narrative review was to evaluate the impact of SARS-CoV-2 infection in children with asthma and the impact of COVID-19 vaccination. Systematic research using the principal medical databases was conducted using specific search query strings from the early spreading of COVID-19 globally until March 2023; further relevant data were drawn from the main national and supranational institutions. No significant differences in SARS-CoV-2 incidence and morbidity were found in asthmatic pediatric patients compared to non-asthmatic ones; however, subjects with uncontrolled asthma were found to be at increased risk of developing a serious disease during SARS-CoV-2 infection. Regarding COVID-19 vaccines, accumulating data support their safety, efficacy and effectiveness on asthmatic children regardless of asthma severity. Further cohort-based studies are needed as the evidence of new epidemic waves caused by new viral variants makes the current knowledge outdated.

Telemedicine beyond the pandemic: challenges in the pediatric immunology clinic

INTRODUCTION

Telemedicine and electronic medical records (EMRs) have revolutionized healthcare in recent years, offering numerous benefits that improve the delivery of care and the overall patient outcomes.

AREAS COVERED

Telemedicine allows providers to diagnose and treat patients remotely, often eliminating the need for face-to-face visits. Its benefits include improved access to care, convenience for patients, and reduced costs both for patients and providers. When used with remote patient monitoring and remote therapeutic monitoring, continuous care becomes possible. EMRs allow providers to store, access, and share patient information more efficiently than paper charts. The benefits of EMRs include improved patient safety, increased efficiency, and reduced costs.

EXPERT OPINION

The combination of telemedicine with EMRs makes it possible to envision the advent of computer-assisted diagnosis (CAD). This technology uses artificial intelligence and machine learning algorithms to analyze medical information including images, clinical and physiologic data, test results and remotely obtained information to support healthcare providers in making accurate diagnoses. By providing providers with what is essentially a second opinion, CAD systems can help prevent misdiagnoses and improve the quality of care. Such systems are not meant to replace healthcare providers, but rather to support them in making more informed and accurate diagnoses.

Updates in the diagnosis and practical management of allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) is a widespread disease that can be associated with other conditions, including conjunctivitis, rhinosinusitis, asthma, food allergy, and atopic dermatitis. Diagnosis is based on the history and documentation of sensitization, such as the production of allergen-specific IgE, preferably using molecular diagnostics. Treatments are based on patient education, non-pharmacological and pharmacological remedies, allergen-specific immunotherapy (AIT), and surgery. Symptomatic treatments mainly concern intranasal/oral antihistamines and/or nasal corticosteroids.

AREAS COVERED

This review discusses current and emerging management strategies for AR, covering pharmacological and non-pharmacological remedies, AIT, and biologics in selected cases with associated severe asthma. However, AIT presently remains the unique causal treatment for AR.

EXPERT OPINION

The management of allergic rhinitis could include new strategies. In this regard, particular interest should be considered in the fixed association between intranasal antihistamines and corticosteroids, probiotics and other natural substances, and new formulations (tablets) of AIT.

COVID-19 and autoimmune diseases: is there a connection?

PURPOSE OF REVIEW

This review summarizes current evidence on the potential link between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and autoimmunity.

RECENT FINDINGS

Several viral infections are potential triggers of reactive and autoimmune diseases by inducing type II and type IV hypersensitivity reactions. Recent evidence demonstrated that SARS-CoV-2 infection is not an exception, triggering the production of tissue-specific autoantibodies during the acute phase of coronavirus disease 2019 (COVID-19) and leading to autoimmune diseases development as long-term complication. The significant immune dysregulation with cytokine storm and organ damage observed in patients with severe to critical COVID-19 is considered the main mechanism explaining the high levels of autoantibodies, which are also implicated in disease severity and the need for an intensive care assessment. Multisystem inflammatory syndrome in children (MIS-C) is an immune-mediated disease where the recent viral infection leads to systemic inflammation, as already observed in other reactive and autoimmune diseases.

SUMMARY

Autoimmunity may be a complication of SAR-CoV-2 infection. Understanding the pathogenesis of autoimmune manifestations in COVID-19 might help prevent the incidence or exacerbation of autoimmune disorders and design better and more efficient treatment strategies in children and adult populations.

Safety of biologics in severe asthmatic patients with SARS-CoV-2 infection: A prospective study

BACKGROUND

Asthma guidelines have recommended continuing treatment with biologics during coronavirus disease 2019 (COVID-19) pandemic. However, a continuation of treatment with biologics in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been little investigated.

OBJECTIVE

To assess the safety of biologics in patients with SARS-CoV-2 infection.

METHODS

A pilot, monocentric, prospective study. Patients aged 6 years old and older with severe asthma on treatment with biologics and confirmed SARS-CoV-2 infection were enrolled. Patients were followed-up with periodic calls at different time points up to 3 months to detect any adverse effect and its relationship with biologic treatment according to the Naranjo Adverse Probability Scale (NAPS). The severity of SARS-CoV-2 infection and clinical outcome were also assessed.

RESULTS

Overall, we included 21 patients (10 on therapy with omalizumab, 9 with dupilumab, and 2 with mepolizumab). Only a patient-reported two local adverse events. No other adverse event was reported. Twenty out of 21 patients had a mild COVID-19 course, and no adverse outcome was observed.

CONCLUSION

We showed that the scheduled dose of the biologic therapy can be administered safely on time in patients with SARS-CoV-2 infection, as the treatment did not result in adverse events or outcomes.

Respiratory Symptoms, Allergies, and Environmental Exposures in Children with and without Asthma

BACKGROUND

Epidemiological data concerning the level of asthma morbidity indicate that in Poland, asthma is diagnosed in 5-10% of the pediatric population. Aim The purpose of this study was to compare the prevalence of respiratory symptoms and allergies in a group of children with and without asthma and to evaluate the association between exposure to environmental factors and the prevalence of bronchial asthma in a pediatric population.

MATERIAL AND METHODS

A cross-sectional study was conducted on a group of 995 children attending primary schools in the province of Silesia in 2018-2019. The research tool was an anonymous questionnaire developed based on the form used in The International Study of Asthma and Allergies in Childhood (ISAAC). Children's health status, the prevalence of bronchial asthma, and the performance of allergic skin tests were assessed based on parents' indications in a questionnaire. Environmental exposures such as mold and dampness in apartments or ETS were similarly assessed. Analyses were performed using Statistica 13.0; p < 0.05.

RESULTS

A total of 88 subjects (8.8%) suffered from bronchial asthma. Parents of children with asthma, compared to parents of children without the disease, were more likely to rate their children's health as rather good (43.2% vs. 38.0%) or average (21.6% vs. 3.1%). All analyzed respiratory symptoms, as well as allergies, were statistically more frequent in children with bronchial asthma.

CONCLUSIONS

The parent's subjective assessment of the child's health varied significantly according to the asthma diagnosis. Asthma is also associated with other diseases: allergic reactions to pollen, house dust, hay fever, and AD (atopic dermatitis) were statistically significantly more frequent among children diagnosed with bronchial asthma.

The year 2021 in COVID-19 pandemic in children

In this article, the developments in the field of COVID-19 pandemic published in the Italian Journal of Pediatrics in 2021 are reflected. We describe progresses in SARS-CoV-2 transmission route, clinical presentation, diagnosis, treatment, and access to health care facilities in children. They led to substantial changes in the clinical approach.

Comparing available treatments for pollen-induced allergic rhinitis in children

INTRODUCTION

Pollen-induced allergic rhinitis (PIAR) is a widespread disease in children, and its prevalence is rapidly evolving. In addition, it may be associated with other atopic diseases, in particular asthma. In most cases, PIAR can be treated effectively by avoiding exposure to responsible allergens and using symptomatic treatments, including intranasal/oral antihistamines or/and nasal corticosteroids, according to ARIA guidelines. In recent decades, new medicines have been studied and developed: allergen-specific immunotherapy (AIT), anti-IgE antibodies, and probiotics. In addition, nutraceuticals have also been used as add-on treatments. This review aims to discuss and compare the old and new therapeutic strategies for PIAR in children.

AREAS COVERED

Allergic rhinitis is a type 2 inflammatory disease. The management of patients with PIAR entails medications, AIT, and ancillary therapies. In addition, children with PIAR and associated severe asthma may be inclusively treated with biologics. Namely, subjects with allergic comorbidities could benefit from biological agents. However, AIT presently remains the unique causal treatment for PIAR.

EXPERT OPINION

New strategies may include combined treatments, mainly concerning fixed associations with antihistamines and corticosteroids, nutraceutical products, and new AIT formulations.

Impact of screen exposure on pediatric vernal Keratoconjunctivitis: a survey during the COVID-19 pandemic in Italy

BACKGROUND

The SARS-CoV-2 outbreak pushed the Italian government to start a strict lockdown, replacing school attendance with long-distance learning. This caused reduced exposure to sunlight but increased exposure to screens. Vernal keratoconjunctivitis (VKC) is a chronic inflammatory ocular condition in which exposure to light plays a cardinal role. We conducted an online survey to evaluate the impact of screen exposure on children with VKC during the COVID-19 lockdown.

METHODS

We performed a survey-based observational study, asking patients followed at the Allergology clinics of Meyer Children's University Hospital in Florence and of Policlinico Umberto I in Rome to provide grading on 6 subjective ocular clinical manifestations presented during the lockdown and to give an estimate of their hours/day of screen exposure.

RESULTS

Mean scores of signs and symptoms increased homogeneously when studying patients exposed to longer screen time. When comparing scores collected in 2019 to those in 2020, there was not a significant reduction in clinical manifestations, although the situation differed between the two centers due to geographical differences in sunlight exposure.

CONCLUSION

During the lockdown, there was a reduction in sunlight exposure but conversely an increase in the time spent in front of screens that correlated with the worsening of VKC signs and symptoms in direct proportion to the hours/day of screen exposure. Our results also showed a statistically significant difference in the relative impact of long-distance learning on VKC clinical manifestations in the different Italian regions.

Addition of a nutraceutical to montelukast or inhaled steroid in the treatment of wheezing during COVID-19 pandemic: a multicenter, open-label, randomized controlled trial

Background and aim Recurrent wheezing is often triggered by viral respiratory infections. The aims of our study were: i) to evaluate whether the addition of a nutraceutical (Leucodif®), could improve the efficacy of montelukast or inhaled steroids (ICS) compared to the single treatment; ii) to verify whether a treatment is more effective than another. Our study was biased by the COVID-19 pandemic, which resulted in a lockdown of almost two months in Italy. Methods The multicenter, open-label study enrolled 84 children aged 2-6 years diagnosed with recurrent wheezing and randomized them into four treatment arms for three months: ICS treatment; ii) montelukast; iii) montelukast + Leucodif; iv) ICS + Leucodif. Children were assessed at baseline and after one, two, and three months of treatment using the TRACK score for both the caregiver and the physician. Results Out of the 84 patients, 18 patients received ICS therapy, 22 patients ICS + Leucodif, 24 patients montelukast, and 20 patients montelukast + Leucodif. All four treatments resulted in a significant reduction in symptoms with no differences among the various groups. Conclusions Our study demonstrates that montelukast therapy appears to be equally effective as ICS therapy and that the addition of the nutraceutical Leucodif does not appear to improve the treatment outcome. However, in our opinion our study was strongly influenced and biased by the lockdown due to the COVID-19 pandemic, which inherently resulted in reduced exposure to the viruses that commonly cause respiratory infections in children.

Coronavirus disease 2019 and pediatric asthma: friend or foe?

PURPOSE OF REVIEW

The interplay of asthma and coronavirus disease 2019 (COVID-19) in children is yet unknown. The purpose of this review is to determine the interplay of asthma and asthma therapeutics and COVID-19.

RECENT FINDINGS

There is no evidence to date that asthma is a risk factor for more severe COVID-19 outcomes, especially in children. There is actually some basis to suggest that children with atopic asthma may be at reduced risk of asthma exacerbations during COVID-19. The impact of asthma therapeutics on COVID-19 outcomes is unclear, but guidance is relatively uniform in recommending that those with asthma remain on current asthma medications. A focus on social determinants of health may be increasingly important during the pandemic and beyond.

SUMMARY

Asthma in children appears to be more friend, than foe, during COVID-19.

One hundred and ten years of Allergen Immunotherapy: A journey from empiric observation to evidence

One hundred and ten years after Noon's first clinical report of the subcutaneous application of allergen extracts, allergen immunotherapy (AIT) has evolved as the most important pillar of the treatment of allergic patients. It is the only disease-modifying treatment option available and the evidence for its clinical efficacy and safety is broad and undisputed. Throughout recent decades, more insights into the underlying mechanisms, in particular the modulation of innate and adaptive immune responses, have been described. AIT is acknowledged by worldwide regulatory authorities, and following the regulatory guidelines for product development, AIT products are subject to a rigorous evaluation before obtaining market authorization. Knowledge and practice are anchored in international guidelines, such as the recently published series of the European Academy of Allergy and Clinical Immunology (EAACI). Innovative approaches continue to be further developed with the focus on clinical improvement by, for example, the usage of adjuvants, peptides, recombinants, modification of allergens, new routes of administration, and the concomitant use of biologicals. In addition, real-life data provide complementary and valuable information on the effectiveness and tolerability of this treatment option in the clinical routine. New mobile health technologies and big-data approaches will improve daily treatment convenience, adherence, and efficacy of AIT. However, the current coronavirus disease 2019 (COVID-19) pandemic has also had some implications for the feasibility and practicability of AIT. Taken together, AIT as the only disease-modifying therapy in allergic diseases has been broadly investigated over the past 110 years laying the path for innovations and further improvement.

COVID-19 scenario and recommendations on the continuity of immunobiological therapy in patients with atopic asthma in Brazil and Latin America

INTRODUCTION

With the abrupt establishment of the COVID-19 pandemic, treatment for immunological diseases may be influenced by the SARS-CoV-2 infection, including asthma and other allergies. Immunobiologics play a pivotal role in the management of severe symptoms of allergy and an opinion regarding the continuity of this treatment during the COVID-19 pandemic must be issued.

AREAS COVERED

In Brazil and other countries, patients with severe asthma were included in the priority groups for COVID-19 vaccination, even those who are undergoing immunobiological therapy. Data are insufficient to support the influence of this therapy on severe COVID-19 as targeting molecules may play a role in the physiopathology of the infection. Therapeutic strategies for asthma and guidelines/statements of the main societies of Allergy in Latin America on the continuity of treatment with immunobiologics during the COVID-19 pandemic were obtained from the institutional websites, PubMed, Scielo, Google Scholar, and CINAHL electronic platforms by searching for papers published up to September 2021.

EXPERT OPINION

Although the association between asthma and COVID-19 has been under investigation, immunobiological treatment should follow the consensus-based statements recommending the maintenance of the therapy unless the patient is infected by the SARS-CoV-2. However, it must be closely followed by the medical assistant.

Safety of biological therapy in children and adolescents with severe asthma during the COVID-19 pandemic: a case series

Background and aim  It is still unclear whether patients with severe asthma are at greater risk of developing severe COVID-19, particularly pediatric allergic patients under biologic therapy. Studies targeting pediatric patients are currently limited; thus, this study aims to assess the clinical characteristics of young patients with severe asthma under biological therapies during the COVID-19 pandemic. Methods We collected data from February 2020 to April 2021. Patients with severe asthma treated with biological therapies (omalizumab and mepolizumab) have been enrolled. We described demographic data, clinical features, therapies, comorbidities, and laboratory findings for each patient. For patients who got COVID-19, we also described the severity of the disease, the need for hospitalization, and specific therapy. Results A total of 14 patients were included in the study, 11 (78.6%) of them under treatment with omalizumab and 3 (21.6%) with mepolizumab. We identified four patients (28.6%) who tested positive for SARS-CoV-2. Two patients treated with mepolizumab had an asymptomatic disease, and two patients treated with omalizumab had mild disease. Only one patient with mild COVID-19 required hospitalization and specific therapy because of severe obesity. Conclusions No differences regarding the SARS-CoV-2 infection have been found between the two treatments groups. Furthermore, any poor outcome has been observed, confirming the safety of biological therapies. The limited number of patients enrolled and the lack of a control group did not establish a significant risk for infections for these patients.

Safety of allergen-specific immunotherapy in children

Allergic respiratory diseases, such as asthma and allergic rhinitis, are global health issues and have had an increasing prevalence in the last decades. Allergen-specific immunotherapy (AIT) is the only curative treatment for allergic rhinitis and asthma, as it has a disease-modifying effect. AIT is generally administered by two routes: subcutaneous (SCIT) and sublingual immunotherapy (SLIT). Local side effects are common, but usually well-tolerated and self-limited. However, systemic side effects are rare, and associated with uncontrolled asthma and bronchial obstruction, or related to errors in administration. Physicians should constantly assess potential risk factors for not only reporting systemic reactions and fatalities but also implementing other therapies to improve AIT safety. This paper highlights recent evidence on local and systemic reactions related to SCIT and SLIT in children.

The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review

BACKGROUND

Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy.

METHODS

A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19.

RESULTS

Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine.

CONCLUSIONS

Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.

Allergic patients during the COVID-19 pandemic-Clinical practical considerations: An European Academy of Allergy and Clinical Immunology survey

BACKGROUND

The COVID-19 pandemic has affected health care systems unexpectedly. However, data focusing on practical considerations experienced by health care professionals (HCPs) providing care to allergic patients is scarce.

METHODS

Under the framework of the European Academy of Allergy and Clinical Immunology (EAACI), a panel of experts in the field of immunotherapy developed a 42-question online survey, to evaluate real-life consequences of the COVID-19 pandemic in allergy practice.

RESULTS

The respondents in the survey were 618. About 80% of HCPs indicated being significantly affected in their allergy practice. A face-to-face visit reduction was reported by 93% of HCPs and about a quarter completely interrupted diagnostic challenges. Patients with severe uncontrolled asthma (59%) and anaphylaxis (47%) were prioritized for in-person care. About 81% maintained an unaltered prescription of inhaled corticosteroids (ICS) in asthmatics. About 90% did not modify intranasal corticosteroids (INCS) in patients with allergic rhinitis. Nearly half of respondents kept biological prescriptions unmodified for asthma. About 50% of respondents kept their allergen immunotherapy (AIT) prescription patterns unchanged for respiratory allergies; 60% for insect venom allergies. Oral immunotherapy (OIT) for food allergies was initiated by 27%. About 20% kept carrying out up-dosing without modifications and 14% changed to more prolonged intervals. Telemedicine practice was increased.

CONCLUSIONS

HCPs providing care to allergic patients were affected during the pandemic in diagnostic, management, and therapeutic approaches, including AIT for respiratory, insect-venom, and food allergies. Most HCPs maintained controller treatments for both asthma, and allergic rhinitis consistent with international recommendations, as well as biological agents in asthma. Remote tools are valuable in delivering allergy care.

Developments in pediatrics in 2020: choices in allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, ortopedics, respiratory tract illnesses and rheumatology

In this article, we describe the advances in the field of pediatrics that have been published in the Italian Journal of Pediatrics in 2020. We report progresses in understanding allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, orthopedics, respiratory tract illnesses, rheumatology in childhood.

Inhaled interferons beta and SARS-COV2 infection: a preliminary therapeutic perspective

Introduction

SARS-COV2 infection represents a therapeutic challenge due to the limited number of effective therapies available and due to the fact that it is not clear which host response in terms of inflammation pattern is the most predictive for an optimal (and rapid) recovery. Interferon β pathway is impaired in SARS-COV2 infection and this is associated with a bigger disease burden. Exogenous inhaled interferon might be beneficial in this setting.

Areas covered

Nebulized interferon-β is currently investigated as a potential therapy for SARS-COV2 because the available data from a phase II study demonstrate that this medication is able to accelerate the recovery from disease.

Expert opinion

Further clinical studies are needed in order to better document the efficacy of this therapy especially in severe forms of COVID-19, the optimal duration of therapy and if such a medication is appropriate for domiciliary use. Also combined regimens with antivirals or with compounds which are able to enhance the endogenous production of interferon might be of promise.

Chronic respiratory diseases other than asthma in children: the COVID-19 tsunami

Coronavirus disease 2019 (COVID-19) affects all components of the respiratory system, including the neuromuscular breathing apparatus, conducting and respiratory airways, pulmonary vascular endothelium, and pulmonary blood flow. In contrast to other respiratory viruses, children have less severe symptoms when infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A minority of children experience a post-infectious inflammatory syndrome, the pathology and long-term outcomes of which are poorly understood. The reason for the lower burden of symptomatic disease in children is not yet clear, but several pathophysiological characteristics are postulated. The SARS-CoV-2 pandemic has brought distinct challenges to the care of children globally. Proper recommendations have been proposed for a range of non-asthmatic respiratory disorders in children, including primary ciliary dyskinesia and cystic fibrosis. These recommendations involve the continuation of the treatment during this period and ways to maintain stability. School closures, loss of follow-up visit attendance, and loss of other protective systems for children are the indirect outcomes of measures to mitigate the COVID-19 pandemic. Moreover, COVID-19 has reshaped the delivery of respiratory care in children, with non-urgent and elective procedures being postponed, and distancing imperatives have led to rapid scaling of telemedicine. The pandemic has seen an unprecedented reorientation in clinical trial research towards COVID-19 and a disruption in other trials worldwide, which will have long-lasting effects on medical science. In this narrative review, we sought to outline the most recent findings on the direct and indirect effects of SARS-CoV-2 pandemic on pediatric respiratory chronic diseases other than asthma, by critically revising the most recent literature on the subject.

COVID-19 pandemic and allergen immunotherapy-an EAACI survey

BACKGROUND

As in many fields of medical care, the coronavirus disease 2019 (COVID-19) resulted in an increased uncertainty regarding the safety of allergen immunotherapy (AIT). Therefore, the European Academy of Allergy and Clinical Immunology (EAACI) aimed to analyze the situation in different countries and to systematically collect all information available regarding tolerability and possible amendments in daily practice of sublingual AIT (SLIT), subcutaneous AIT (SCIT) for inhalant allergies and venom AIT.

METHODS

Under the framework of the EAACI, a panel of experts in the field of AIT coordinated by the Immunotherapy Interest Group set-up a web-based retrospective survey (SurveyMonkey^® ) including 27 standardized questions on practical and safety aspects on AIT in worldwide clinical routine.

RESULTS

417 respondents providing AIT to their patients in daily routine answered the survey. For patients (without any current symptoms to suspect COVID-19), 60% of the respondents informed of not having initiated SCIT (40% venom AIT, 35% SLIT) whereas for the maintenance phase of AIT, SCIT was performed by 75% of the respondents (74% venom AIT, 89% SLIT). No tolerability concern arises from this preliminary analysis. 16 physicians reported having performed AIT despite (early) symptoms of COVID-19 and/or a positive test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

CONCLUSIONS

This first international retrospective survey in atopic diseases investigated practical aspects and tolerability of AIT during the COVID-19 pandemic and gave no concerns regarding reduced tolerability under real-life circumstances. However, the data indicate an undertreatment of AIT, which may be temporary, but could have a long-lasting negative impact on the clinical care of allergic patients.

The Impact of Coronavirus Disease 2019 on Pediatric Asthma in the United States

The coronavirus disease 2019 (COVID-19) pandemic has caused severe economic and health impacts in the United States, and the impact is disproportionately more in socially disadvantages areas. The available data, albeit limited in children, suggest that the initial concerns of the potential of serious impact of COVID-19 illness in children with asthma are unproven so far. The reduction in asthma morbidities is due to improved adherence, COVID-19 control measures, school closures, and decreased exposure to allergens and viral infections in children. During the pandemic, asthma guidelines were updated to guide physicians in asthma care. In the face of unprecedented time, it is important to be vigilant, adhere to treatment guidelines, and implement preventive measures to eradicate the virus and improve outcomes in children with asthma.

COVID-19 vaccination and allergen immunotherapy (AIT) - A position paper of the German Society for Applied Allergology (AeDA) and the German Society for Allergology and Clinical Immunology (DGAKI)

Background: Vaccinations against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) are intended to induce an immune response to protect against infection/disease. Allergen immunotherapy (AIT) is thought to induce a (different) immune response, e.g., to induce tolerance to allergens. In this position paper we clarify how to use AIT in temporal relation to COVID-19 vaccination. Four SARS-CoV-2 vaccines are currently approved in the EU, and their possible immunological interactions with AIT are described together with practical recommendations for use. Materials and methods: Based on the internationally published literature, this position paper provides specific recommendations for the use of AIT in temporal relation to a SARS-CoV-2 vaccination. Results: AIT is used in 1) allergic rhinitis, 2) allergic bronchial asthma, 3) insect venom allergy, 4) food allergy (peanut). Conclusion: For the continuation of an ongoing AIT, we recommend an interval of 1 week before and after vaccination for subcutaneous immunotherapy (SCIT). For sublingual immunotherapy (SLIT) and oral immunotherapy (OIT), we recommend taking them up to the day before vaccination and a break of 2 – 7 days after vaccination. Initiation of a new SCIT, SLIT, or OIT should be delayed until 1 week after the day of the second vaccination. For SCIT, we generally recommend an interval of ~ 1 week to COVID-19 vaccination.

Assessment of health equity consideration in masking/PPE policies to contain COVID-19 using PROGRESS-plus framework: a systematic review

INTRODUCTION

There is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. Policies and guidance for containing the infection and reducing the COVID-19 related deaths have proven to be effective, however the extent to which health inequity factors were considered in these policies is rather unknown. The aim of this study is to measure the extent to which COVID-19 related policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE).

METHODS

A systematic search for published documents on COVID-19 and masks/PPE was conducted across six databases: PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. Reviews, policy documents, briefs related to COVID-19 and masks/PPE were included in the review. To assess the extent of incorporation of equity in the policy documents, a guidance framework known as 'PROGRESS-Plus': Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, disability etc.) was utilized.

RESULTS

This review included 212 policy documents. Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component. Most of the policy documents (n = 163, 85.79%) focused on "occupation" component of the PROGRESS-plus followed by personal characteristics associated with discrimination (n = 4;2.11%), place of residence (n = 2;1.05%) and education (n = 1;0.53%). Subgroup analysis revealed that most of the policy documents (n = 176, 83.01%) were focused on "workers" such as healthcare workers, mortuary workers, school workers, transportation workers, essential workers etc. Of the remaining policy documents, most were targeted towards whole population (n = 30; 14.15%). Contrary to "worker focused" policy documents, most of the 'whole population focused' policy documents didn't have a PROGRESS-plus equity component rendering them equity limiting for the society.

CONCLUSION

Our review highlights even if policies considered health inequity during the design/implementation, this consideration was often one dimensional in nature. In addition, population wide policies should be carefully designed and implemented after identifying relevant equity related barriers in order to produce better outcomes for the whole society.

Pediatric health care professionals' vaccine knowledge, awareness and attitude: a survey within the Italian Society of Pediatric Allergy and Immunology

Background

Physicians play a key role in driving vaccine acceptance and their recommendations are crucial to address vaccine hesitancy. The aim of the study was to assess knowledge, awareness and attitude of Italian Pediatric Health Care Professionals (pHCPs) on vaccinations.

Methods

An anonymous on-line questionnaire was developed within the Vaccine Committee of Italian Society of Pediatric Allergy and Immunology (SIAIP) and spontaneously completed by 231 Pediatricians and Pediatric Nurses (PN).

Results

An accurate vaccine education was reported by 70% of pediatricians and 13% of PN but 11% of pediatricians versus 26% of PN consult social media instead of scientific sources for their vaccine update. The investigation on the pHCPs attitudes to vaccination in a personal and family setting highlights poor adherence to vaccinations. Only 63% of pediatricians versus 16% of PN (p < 0.0001) annually received the Flu vaccine. In their family setting 93% of pediatricians versus 51% of PN recommended all vaccinations (p < 0.0001). Anti-flu, anti-rotavirus, anti-zoster and anti-pneumococcal vaccines were not regularly recommended by all pHCPs due to doubts of uselessness (55% of pediatricians versus 40% of PN) and preference for “natural immunity” (44% of pediatricians versus 40% of PN).

Conclusions

Our results indicate that pHCPs’ attitude and confidence in regards to vaccines remain suboptimal. Current COVID-19 pandemic and the rapid development of vaccines could increase vaccine hesitancy. Due to the documented pHCPs’ influence in the parental decision, educational interventions are needed to improve their level of knowledge and counselling skills in order to address parental vaccine hesitancy and to maintain continuity of immunization services.

COVID-19 Vaccines in Children with Cow's Milk and Food Allergies

The COVID-19 pandemic is the most challenging global health crisis of our times. Vaccination against COVID-19 plays a key role to control the current pandemic situation. The risk of allergic reactions to new COVID-19 vaccines is low. However, there is a debate on the safety in allergic patients following post marketing findings by different agencies. Our aim is to understand from current experiences whether children with cow’s milk or food allergy are at higher risk than a general population for allergic reactions to COVID-19 vaccines. Current data indicate that patients with a history of allergy to cow’s milk or other foods, even if severe, should receive COVID-19 vaccine in a setting with availability of treatments for anaphylactic reactions and under medical supervision. Recipients should be discharged after a protracted observation period of 30 min if no reaction developed.

IgE-mediated fish allergy in children: is omega-3 supplementation useful?

The management of fish allergy relies on the elimination of all fish from the diet. Nevertheless, an exclusion diet can be problematic from a paediatric nutritional perspective. The issue of a substitute diet for children suffering from fish allergy seems to be not adequately addressed and the consequences of a fish exclusion diet in paediatric age are not known. Fish has an important nutritional value, it is rich in vitamins of group B, D and A, selenium, calcium and phosphorus, iron, zinc, magnesium, iodine and omega-3. While vitamins and iodine are normally present in the diet, omega-3 is present in few other foods, such as vegetable seed oils and nuts. Hence, the scientific research indicates a generic advice regarding a possible omega-3 supplementation in children with fish allergy. Given the knowledge about omega-3 supplementation having a potential good risk-benefit ratio and the absence of serious adverse events related to the omega-3 supplementation, this type of supplementation may seem advisable in children affected by fish allergy.

Is a strict cow's milk-free diet necessary to treat milk oral immunotherapy-related eosinophilic esophagitis?

We report the case of a 15-year-old boy who developed eosinophilic esophagitis (EoE) during cow’s milk oral immunotherapy (CM-OIT). In order to not completely invalidate OIT benefits, baked milk-containing foods were allowed instead of a strict CM-free diet. However, histological remission of EoE was reached only after a strict cow’s milk-free diet, not associated to pharmacological treatment. Nevertheless, given the limited data on real incidence of food OIT related EoE and potential beneficial treatment for this condition, we highlight the need of prospective studies aimed to evaluate if a strict CM free diet in OIT related EoE is always necessary to obtain remission of the disease or similarly to CM EoE, baked milk-containing foods” diet could be abeneficial treatment also in these patients. (www.actabiomedica.it)

Long-Term Pulmonary Damage From SARS-CoV-2 in an Infant With Brief Unexplained Resolved Events: A Case Report

A brief unexplained resolved event (BRUE) is an event observed in a child under 1 year of age in which the observer witnesses a sudden, brief but resolved episode of change in skin color, lack of breathing, weakness or poor responsiveness. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19). We report the case of a previously healthy, full-term infant infected with SARS-CoV-2 when he was 8 months old. Previous to this event, both his grandfather and great-uncle had died of severe pneumonia and his mother had developed respiratory symptoms and fever. Over the following month he was seen five times in the emergency room and was hospitalized twice for recurrent BRUE. At the first hospital admission, after the second emergency room visit, he twice tested positive for COVID-19 after nasopharyngeal swab tests. During his second hospital admission, after the fifth emergency room visit, chest computed tomography revealed typical SARS-CoV-2 pneumonia. During a follow-up examination 6 months later, mild respiratory distress required administration of inhaled oxygen (0.5 L/min) and chest computed tomography disclosed a slight improvement in pulmonary involvement. The clinical manifestation of pulmonary complications from COVID-19 infection was unusual. This is the first report of an infant at high-risk for BRUE, which was the only manifestation of long-term lung involvement due to SARS-CoV-2 pneumonia.

Novel therapeutic approaches targeting endotypes of severe airway disease

Introduction: Severe asthma and chronic rhinosinusitis (CRS), with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP), are heterogeneous diseases characterized by different mechanistic pathways (endotypes) and variable clinical presentations (phenotypes).Areas covered: This review provides the clinician with an overview of the prevalence and clinical impact of severe chronic upper and lower airways disease and suggests a novel therapeutic approach with biological agents with possible biomarkers. To select relevant literature for inclusion in this review, we conducted a literature search using the PubMed database, using terms 'severe airways disease' AND 'endotype' AND 'treatment.' The literature review was performed for publication years 2010-2020, restricting the articles to humans and English language publications.Expert opinion: The coronavirus disease (COVID-19) pandemic has brought forth many challenges for patients with severe airway disease and healthcare practitioners involved in care. These patients could have an increased risk of developing severe SARS-CoV-2 disease, although treatment with biologics is not associated with a worse prognosis. Eosinopenia on hospital admission plays a key role as a diagnostic and prognostic biomarker.

Sarcopenia as a predictor of mortality among the critically ill in an intensive care unit: a systematic review and meta-analysis

BACKGROUND

The evidence of sarcopenia based on CT-scan as an important prognostic factor for critically ill patients has not seen consistent results. To determine the impact of sarcopenia on mortality in critically ill patients, we performed a systematic review and meta-analysis to quantify the association between sarcopenia and mortality.

METHODS

We searched studies from the literature of PubMed, EMBASE, and Cochrane Library from database inception to June 15, 2020. All observational studies exploring the relationship between sarcopenia based on CT-scan and mortality in critically ill patients were included. The search and data analysis were independently conducted by two investigators. A meta-analysis was performed using STATA Version 14.0 software using a fixed-effects model.

RESULTS

Fourteen studies with a total of 3,249 participants were included in our meta-analysis. The pooled prevalence of sarcopenia among critically ill patients was 41 % (95 % CI:33-49 %). Critically ill patients with sarcopenia in the intensive care unit have an increased risk of mortality compared to critically ill patients without sarcopenia (OR = 2.28, 95 %CI: 1.83-2.83; P < 0.001; I² = 22.1 %). In addition, a subgroup analysis found that sarcopenia was associated with high risk of mortality when defining sarcopenia by total psoas muscle area (TPA, OR = 3.12,95 %CI:1.71-5.70), skeletal muscle index (SMI, OR = 2.16,95 %CI:1.60-2.90), skeletal muscle area (SMA, OR = 2.29, 95 %CI:1.37-3.83), and masseter muscle(OR = 2.08, 95 %CI:1.15-3.77). Furthermore, critically ill patients with sarcopenia have an increased risk of mortality regardless of mortality types such as in-hospital mortality (OR = 1.99, 95 %CI:1.45-2.73), 30-day mortality(OR = 2.08, 95 %CI:1.36-3.19), and 1-year mortality (OR = 3.23, 95 %CI:2.08 -5.00).

CONCLUSIONS

Sarcopenia increases the risk of mortality in critical illness. Identifying the risk factors of sarcopenia should be routine in clinical assessments and offering corresponding interventions may help medical staff achieve good patient outcomes in ICU departments.

Updates on Children with Allergic Rhinitis and Asthma during the COVID-19 Outbreak

BACKGROUND

During the lockdown period caused by the SARS-CoV-2 pandemic, we monitored via online survey the trend of allergic symptoms and the therapeutic compliance in patients followed at our center.

MATERIAL AND METHODS

In June 2020, we selected children followed at the Allergy and Immunology Service of Umberto I Hospital, aged between 6 and 16 years old, diagnosed with asthma and/or rhinitis and sensitized to grass pollen or dust mite. We sent an email with 12 multiple-choice questions investigating several areas: type of disease and sensitization, recurrence of symptoms, medication use during lockdown compared to the same period of the previous year.

RESULTS

The results of 82 questionnaires showed that 17.8% of patients suffered from asthma, 24.4% from rhinitis, and 57.8% from both. Within the group of asthmatic children, most of them presented an improvement of their symptoms. Likewise, with regard to allergic rhinitis, most of them reported better clinical conditions. Regarding treatment, we observed a global decrease in the use of on-demand therapies (salbutamol, nasal corticosteroid, and antihistamine) for both pathologies. In addition, there was a reduction in the use of basal therapy for asthma and rhinitis from 2019 (23.3%) to 2020 (15.5%).

CONCLUSIONS

Our data show a general trend of clinical improvement and a reduction in the use of on-demand and basal therapy in allergic children during the lockdown.

COVID-19 vaccination of patients with allergies and type-2 inflammation with concurrent antibody therapy (biologicals) - A Position Paper of the German Society of Allergology and Clinical Immunology (DGAKI) and the German Society for Applied Allergology (AeDA)

BACKGROUND

After the beginning and during the worldwide pandemic caused by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), patients with allergic and atopic diseases have felt and still feel insecure. Currently, four vaccines against SARS-CoV-2 have been approved by the Paul Ehrlich Institute in Germany, and vaccination campaigns have been started nationwide. In this respect, it is of utmost importance to give recommendations on possible immunological interactions and potential risks of immunomodulatory substances (monoclonal antibodies, biologicals) during concurrent vaccination with the approved vaccines.

MATERIALS AND METHODS

This position paper provides specific recommendations on the use of immunomodulatory drugs in the context of concurrent SARS-CoV-2 vaccinations based on current literature.

RESULTS

The recommendations are covering the following conditions in which biologicals are indicated and approved: 1) chronic inflammatory skin diseases (atopic dermatitis, chronic spontaneous urticaria), 2) bronchial asthma, and 3) chronic rhinosinusitis with nasal polyps (CRSwNP). Patients with atopic dermatitis or chronic spontaneous urticaria are not at increased risk for allergic reactions after COVID-19 vaccination. Nevertheless, vaccination may result in transient eczema exacerbation due to general immune stimulation. Vaccination in patients receiving systemic therapy with biologicals can be performed. Patients with severe asthma and concomitant treatment with biologicals also do not have an increased risk of allergic reaction following COVID-19 vaccination which is recommended in these patients. Patients with CRSwNP are also not known to be at increased risk for allergic vaccine reactions, and continuation or initiation of a treatment with biologicals is also recommended with concurrent COVID-19 vaccination. In general, COVID-19 vaccination should be given within the interval between two applications of the respective biological, that is, with a time-lag of at least 1 week after the previous or at least 1 week before the next biological treatment planned.

CONCLUSION

Biologicals for the treatment of atopic dermatitis, chronic spontaneous urticaria, bronchial asthma, and CRSwNP should be continued during the current COVID-19 vaccination campaigns. However, the intervals of biological treatment may need to be slightly adjusted (DGAKI/AeDA recommendations as of March 22, 2021).

Nutraceuticals in the Prevention of Viral Infections, including COVID-19, among the Pediatric Population: A Review of the Literature

In recent years, there has been a growth in scientific interest in nutraceuticals, which are those nutrients in foods that have beneficial effects on health. Nutraceuticals can be extracted, used for food supplements, or added to foods. There has long been interest in the antiviral properties of nutraceuticals, which are especially topical in the context of the ongoing COVID-19 pandemic. Therefore, the purpose of this review is to evaluate the main nutraceuticals to which antiviral roles have been attributed (either by direct action on viruses or by modulating the immune system), with a focus on the pediatric population. Furthermore, the possible applications of these substances against SARS-CoV-2 will be considered.

Childhood Obesity and Respiratory Diseases: Which Link?

Prevalence of childhood obesity is progressively increasing, reaching worldwide levels of 5.6% in girls and of 7.8% in boys. Several evidences showed that obesity is a major preventable risk factor and disease modifier of some respiratory conditions such as asthma and Obstructive Sleep Apnea Syndrome (OSAS). Co-occurrence of asthma and obesity may be due to common pathogenetic factors including exposure to air pollutants and tobacco smoking, Western diet, and low Vitamin D levels. Lung growth and dysanapsis phenomenon in asthmatic obese children play a role in impaired respiratory function which appears to be different than in adults. Genes involved in both asthma and obesity have been identified, though a gene-by-environment interaction has not been properly investigated yet. The identification of modifiable environmental factors influencing gene expression through epigenetic mechanisms may change the natural history of both diseases. Another important pediatric respiratory condition associated with obesity is Sleep-Disordered Breathing (SDB), especially Obstructive Sleep Apnea Syndrome (OSAS). OSAS and obesity are linked by a bidirectional causality, where the effects of one affect the other. The factors most involved in the association between OSAS and obesity are oxidative stress, systemic inflammation, and gut microbiota. In OSAS pathogenesis, obesity's role appears to be mainly due to mechanical factors leading to an increase of respiratory work at night-time. However, a causal link between obesity-related inflammatory state and OSAS pathogenesis still needs to be properly confirmed. To prevent obesity and its complications, family education and precocious lifestyle changes are critical. A healthy diet may lead to an improved quality of life in obese children suffering from respiratory diseases. The present review aimed to investigate the links between obesity, asthma and OSAS, focusing on the available evidence and looking for future research fields.

Component-Resolved Diagnosis of Hazelnut Allergy in Children

Hazelnuts commonly elicit allergic reactions starting from childhood and adolescence, with a rare resolution over time. The definite diagnosis of a hazelnut allergy relies on an oral food challenge. The role of component resolved diagnostics in reducing the need for oral food challenges in the diagnosis of hazelnut allergies is still debated. Therefore, three electronic databases were systematically searched for studies on the diagnostic accuracy of specific-IgE (sIgE) on hazelnut proteins for identifying children with a hazelnut allergy. Studies regarding IgE testing on at least one hazelnut allergen component in children whose final diagnosis was determined by oral food challenges or a suggestive history of serious symptoms due to a hazelnut allergy were included. Study quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Eight studies enrolling 757 children, were identified. Overall, sensitivity, specificity, area under the curve and diagnostic odd ratio of Cor a 1 sIgE were lower than those of Cor a 9 and Cor a 14 sIge. When the test results were positive, the post-test probability of a hazelnut allergy was 34% for Cor a 1 sIgE, 60% for Cor a9 sIgE and 73% for Cor a 14 sIgE. When the test results were negative, the post-test probability of a hazelnut allergy was 55% for Cor a 1 sIgE, 16% for Cor a9 sIgE and 14% for Cor a 14 sIgE. Measurement of IgE levels to Cor a 9 and Cor a 14 might have the potential to improve specificity in detecting clinically tolerant children among hazelnut-sensitized ones, reducing the need to perform oral food challenges.

Looking beyond pulmonary disease in COVID-19: A lesson from patients with cystic fibrosis

Coronavirus disease 2019 (COVID-19) caused more than 52.775.271 million confirmed cases, 1.293.106 deaths, globally, and afflicted 208 countries, areas, or territories; and almost three months have passed since the World Health Organisation (WHO) declared COVID-19 as a pandemic. Despite the dramatic and global impact of the Coronavirus, the knowledge about the SARS-CoV-2 infection has been improved remarkably. Herein, we provided the rationale for SARS-CoV-2 infection as endothelial dysfunction rather than respiratory disease. Accordingly, we strongly invited the researchers to look beyond pulmonary injury and shift their attention from respiratory disease to endothelial disorder. This strategy could be particularly relevant to identifying therapeutic weapons stabilizing the endothelium rather than the lungs.

An Overview of Asthma and COVID-19: Protective Factors Against SARS-COV-2 in Pediatric Patients

Coronavirus disease 2019 (COVID-19) is a pandemic infectious disease caused by severe acute respiratory syndrome coronavirus SARS-COV-2. Aberrant innate immunity response and cytokine storm are responsible for the syndrome. Apparently, in asthmatic patients, the inadequate antiviral immune response and the tendency for asthma exacerbation evoked by common respiratory viruses could explain increased susceptibility to SARS-COV-2 infection. However, asthma has not been suggested to be a risk factor in COVID-19 patients. Therefore, in asthmatic patients some potential protective mechanisms against SARS-COV-2 have been hypothesized, like type 2 immune response, number of eosinophils, overproduction of mucus, and asthma treatment, along with behavioral factors not strictly related to asthma, such as social distancing, hygiene measures and wearing facemasks, that contribute to reduce the individual susceptibility to SARS-COV-2 infection. In this mini-review, we will describe the current literature regarding potential protective factors against COVID-19 in children with asthma based on the evidence available so far.

Case Report: Self-Administration of Omalizumab in an Adolescent With Severe Asthma During SARS-CoV-2 Infection

Acute asthma remains one of the most frequent causes of children's access to healthcare. Asthma exacerbation is an essential defining characteristic of its severity, and respiratory infections entail increased risks of exacerbations with potential hospitalization. In the literature, contradictory findings have been reported about the risk and severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients affected by asthma, with several implications for its management. Anti-IgE monoclonal antibody therapy is meant for patients affected by severe persistent allergic asthma without adequate control with other treatments. Indeed, biological therapies, such as omalizumab, are used as add-on treatments (step 5 in the Global Initiative for Asthma report) for severe asthma with several benefits, including a reduction in the frequency of exacerbations. To the best of our knowledge, we hereby report the first case in which an adolescent with severe allergic asthma treated with omalizumab has switched to self-administration at home during SARS-CoV-2 infection. Based on our peculiar experience, physicians may consider switching to self-administration of omalizumab at home, even during the coronavirus disease 2019 pandemic. However, more extensive research data from future studies are needed to confirm these first findings.

Neumonía por COVID-19 en niños: De su etiología a su manejo

El COVID-19 es menos serio en niños que en adultos. Sin embargo, las afecciones respiratorias dominan el cuadro clínico de pacientes hospitalizados por COVID-19, aun en niños. En algunas series de casos, el deterioro del estado clínico, donde la disnea, la cianosis y el inicio del síndrome de dificultad respiratoria aguda (SDRA) emergieron ∼8–10 días después del inicio de la infección por SARS-CoV-2, pudo progresar rápidamente hasta la falla multiorgánica y la muerte. Esta revisión tiene como objetivo evaluar las características de la neumonía por COVID-19 en poblaciones pediátricas, comenzando con su etiología y sus mecanismos patológicos, para cerrar con su manejo clínico.