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Schuler CL, Kercsmar C, Mansour M, McDowell KM, Huang G, Hossain MM, Robinette ED, Beck AF. Identifying asthma-related risks during hospitalization using the child asthma risk assessment tool. J Asthma 2023; 60:2189-2197. [PMID: 37345884 DOI: 10.1080/02770903.2023.2228897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/20/2023] [Indexed: 06/23/2023]
Abstract
Objective: The Child Asthma Risk Assessment Tool (CARAT) identifies risk factors for asthma morbidity. We hypothesized that CARAT-identified risk factors (using a CARAT adapted for inpatient use) would be associated with future healthcare utilization and would identify areas for intervention.Methods: We reviewed CARAT data collected during pediatric asthma admissions from 2010-2015, assessing for risk factors in environmental, medical, and social domains and providing prompts for inpatient (specialist consultation or social services engagement) and post-discharge interventions (home care visit or home environmental assessment). Confirmatory factor analysis identified groups of CARAT-identified risk factors with similar effects on healthcare utilization (latent factors). Structural equation models then evaluated relationships between latent factors and future utilization.Results: There were 2731 unique patients admitted for asthma exacerbations; 1015 (37%) had complete CARAT assessments and were included in analyses. Those with incomplete CARAT assessments were more often younger and privately-insured. CARAT-identified risk factors across domains were common in children hospitalized for exacerbations. Risks in the environmental domain were most common. Inpatient asthma consults by pulmonologists or allergists and home care referrals were the most frequent interventions indicated (62%, 628/1015, and 50%, 510/1015, respectively). Two latent factors were positively associated with healthcare utilization in the year after index stay - social stressors and known/suspected allergies (both p < 0.05). Stratified analyses analyzing data just from those children with prior healthcare utilization also indicated known/suspected allergies to be positively associated with future utilization.Conclusions: Inpatient interventions to address social stressors and allergic profiles may be warranted to reduce subsequent asthma morbidity.
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Affiliation(s)
- Christine L Schuler
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carolyn Kercsmar
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mona Mansour
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karen M McDowell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Guixia Huang
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Md Monir Hossain
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric D Robinette
- Division of Infectious Disease, Akron Children's Hospital, Akron, OH, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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2
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Phelan KJ, Dill-McFarland KA, Kothari A, Segnitz RM, Burkle J, Grashel B, Jenkins S, Spagna D, Martin LJ, Haslam DB, Biagini JM, Kalra M, McCoy KS, Ross KR, Jackson DJ, Mersha TB, Altman MC, Khurana Hershey GK. Airway transcriptome networks identify susceptibility to frequent asthma exacerbations in children. J Allergy Clin Immunol 2023; 152:73-83. [PMID: 36918038 PMCID: PMC10395049 DOI: 10.1016/j.jaci.2023.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/11/2023] [Accepted: 02/01/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Frequent asthma exacerbators, defined as those experiencing more than 1 hospitalization in a year for an asthma exacerbation, represent an important subgroup of individuals with asthma. However, this group remains poorly defined and understudied in children. OBJECTIVE Our aim was to determine the molecular mechanisms underlying asthma pathogenesis and exacerbation frequency. METHODS We performed RNA sequencing of upper airway cells from both frequent and nonfrequent exacerbators enrolled in the Ohio Pediatric Asthma Repository. RESULTS Through molecular network analysis, we found that nonfrequent exacerbators display an increase in modules enriched for immune system processes, including type 2 inflammation and response to infection. In contrast, frequent exacerbators showed expression of modules enriched for nervous system processes, such as synaptic formation and axonal outgrowth. CONCLUSION These data suggest that the upper airway of frequent exacerbators undergoes peripheral nervous system remodeling, representing a novel mechanism underlying pediatric asthma exacerbation.
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Affiliation(s)
- Kieran J Phelan
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Arjun Kothari
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - R Max Segnitz
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Wash
| | - Jeff Burkle
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brittany Grashel
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Seth Jenkins
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Daniel Spagna
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David B Haslam
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jocelyn M Biagini
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maninder Kalra
- Department of Pediatrics, Dayton Children's Hospital, Dayton, Ohio
| | - Karen S McCoy
- Division of Pediatric Pulmonology, Nationwide Children's Hospital, Columbus; Ohio
| | - Kristie R Ross
- Department of Pediatrics-Pulmonary, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Tesfaye B Mersha
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew C Altman
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Wash; Systems Immunology Program, Benaroya Research Institute, Seattle, Wash
| | - Gurjit K Khurana Hershey
- Divison of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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3
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Obesity affects pulmonary function in Japanese adult patients with asthma, but not those without asthma. Sci Rep 2022; 12:16457. [PMID: 36180514 PMCID: PMC9525285 DOI: 10.1038/s41598-022-20924-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022] Open
Abstract
Obesity is associated with the severity of asthma, which is characterized by airway obstruction. Pulmonary function testing is one of the important examinations for evaluating airway obstruction. However, the impact of obesity on pulmonary function in patients with asthma is not fully understood. A total of 193 patients with asthma and 2159 patients without asthma who visited Saga University Hospital were investigated retrospectively. Obesity was defined as a body mass index (BMI) greater than 25 kg/m2. Pulmonary functions including forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were compared between patients with and without asthma, focusing especially on obesity. FVC percent predicted and FEV1 percent predicted were significantly lower in patients with asthma than in those without asthma (p = 0.03, < 0.01 respectively). In patients with asthma, FVC percent predicted and FEV1 percent predicted were significantly lower in patients with obesity than in those without obesity (all p < 0.01). In addition, BMI was negatively correlated with FEV1 (r =- 0.21, p = 0.003) and FVC (r = - 0.15, p = 0.04), along with the percent predicted. On multivariate analysis in patients with asthma, FVC (β [95% confidence interval] 0.12 [0.02-0.22], p = 0.02) and FEV1 (0.13 [0.05-0.22], p < 0.01) were still significantly different between patients with and without obesity. However, these obesity-associated differences were not observed in patients without asthma. Obesity reduces pulmonary function, including FVC and FEV1, in patients with asthma, but not in those without asthma.
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4
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Meng Z, Chen H, Deng C, Meng S. Potential cellular endocrinology mechanisms underlying the effects of Chinese herbal medicine therapy on asthma. Front Endocrinol (Lausanne) 2022; 13:916328. [PMID: 36051395 PMCID: PMC9424672 DOI: 10.3389/fendo.2022.916328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022] Open
Abstract
Asthma is a complex syndrome with polygenetic tendency and multiple phenotypes, which has variable expiratory airflow limitation and respiratory symptoms that vary over time and in intensity. In recent years, continuous industrial development has seriously impacted the climate and air quality at a global scale. It has been verified that climate change can induce asthma in predisposed individuals and that atmospheric pollution can exacerbate asthma severity. At present, a subset of patients is resistant to the drug therapy for asthma. Hence, it is urgent to find new ideas for asthma prevention and treatment. In this review, we discuss the prescription, composition, formulation, and mechanism of traditional Chinese medicine monomer, traditional Chinese medicine monomer complex, single herbs, and traditional Chinese patent medicine in the treatment of asthma. We also discuss the effects of Chinese herbal medicine on asthma from the perspective of cellular endocrinology in the past decade, emphasizing on the roles as intracellular and extracellular messengers of three substances-hormones, substances secreted by pulmonary neuroendocrine cells, and neuroendocrine-related signaling protein-which provide the theoretical basis for clinical application and new drug development.
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Affiliation(s)
- Zeyu Meng
- The Second Clinical Medical College, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Huize Chen
- Department of Traditional Chinese Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Chujun Deng
- Department of Traditional Chinese Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Shengxi Meng
- Department of Traditional Chinese Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Shengxi Meng,
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Ricciardolo FLM, Sprio AE, Baroso A, Gallo F, Riccardi E, Bertolini F, Carriero V, Arrigo E, Ciprandi G. Characterization of T2-Low and T2-High Asthma Phenotypes in Real-Life. Biomedicines 2021; 9:biomedicines9111684. [PMID: 34829913 PMCID: PMC8615363 DOI: 10.3390/biomedicines9111684] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Asthma is a heterogeneous and complex condition characterized by chronic airway inflammation, which may be clinically stratified into three main phenotypes: type 2 (T2) low, T2-high allergic, and T2-high non-allergic asthma. This real-world study investigated whether phenotyping patients with asthma using non-invasive parameters could be feasible to characterize the T2-low and T2-high asthma phenotypes in clinical practice. This cross-sectional observational study involved asthmatic outpatients (n = 503) referring to the Severe Asthma Centre of the San Luigi Gonzaga University Hospital. Participants were stratified according to the patterns of T2 inflammation and atopic sensitization. Among outpatients, 98 (19.5%) patients had T2-low asthma, 127 (25.2%) T2-high non-allergic, and 278 (55.3%) had T2-high allergic phenotype. In comparison to T2-low, allergic patients were younger (OR 0.945, p < 0.001) and thinner (OR 0.913, p < 0.001), had lower smoke exposure (OR 0.975, p < 0.001) and RV/TLC% (OR 0.950, p < 0.001), higher prevalence of asthma severity grade 5 (OR 2.236, p < 0.05), more frequent rhinitis (OR 3.491, p < 0.001) and chronic rhinosinusitis with (OR 2.650, p < 0.001) or without (OR 1.919, p < 0.05) nasal polyps, but less common arterial hypertension (OR 0.331, p < 0.001). T2-high non-allergic patients had intermediate characteristics. Non-invasive phenotyping of asthmatic patients is possible in clinical practice. Identifying characteristics in the three main asthma phenotypes could pave the way for further investigations on useful biomarkers for precision medicine.
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Affiliation(s)
- Fabio Luigi Massimo Ricciardolo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
- Correspondence:
| | - Andrea Elio Sprio
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
- Department of Research, ASOMI College of Sciences, 19112 Marsa, Malta
| | - Andrea Baroso
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
| | - Fabio Gallo
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Elisa Riccardi
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
| | - Francesca Bertolini
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
| | - Vitina Carriero
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
| | - Elisa Arrigo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy; (A.E.S.); (A.B.); (E.R.); (F.B.); (V.C.); (E.A.)
| | - Giorgio Ciprandi
- Allergy Clinic, Casa di Cura Villa Montallegro, 16145 Genoa, Italy;
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6
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Luo G, Stone BL, Sheng X, He S, Koebnick C, Nkoy FL. Using Computational Methods to Improve Integrated Disease Management for Asthma and Chronic Obstructive Pulmonary Disease: Protocol for a Secondary Analysis. JMIR Res Protoc 2021; 10:e27065. [PMID: 34003134 PMCID: PMC8170556 DOI: 10.2196/27065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 12/05/2022] Open
Abstract
Background Asthma and chronic obstructive pulmonary disease (COPD) impose a heavy burden on health care. Approximately one-fourth of patients with asthma and patients with COPD are prone to exacerbations, which can be greatly reduced by preventive care via integrated disease management that has a limited service capacity. To do this well, a predictive model for proneness to exacerbation is required, but no such model exists. It would be suboptimal to build such models using the current model building approach for asthma and COPD, which has 2 gaps due to rarely factoring in temporal features showing early health changes and general directions. First, existing models for other asthma and COPD outcomes rarely use more advanced temporal features, such as the slope of the number of days to albuterol refill, and are inaccurate. Second, existing models seldom show the reason a patient is deemed high risk and the potential interventions to reduce the risk, making already occupied clinicians expend more time on chart review and overlook suitable interventions. Regular automatic explanation methods cannot deal with temporal data and address this issue well. Objective To enable more patients with asthma and patients with COPD to obtain suitable and timely care to avoid exacerbations, we aim to implement comprehensible computational methods to accurately predict proneness to exacerbation and recommend customized interventions. Methods We will use temporal features to accurately predict proneness to exacerbation, automatically find modifiable temporal risk factors for every high-risk patient, and assess the impact of actionable warnings on clinicians’ decisions to use integrated disease management to prevent proneness to exacerbation. Results We have obtained most of the clinical and administrative data of patients with asthma from 3 prominent American health care systems. We are retrieving other clinical and administrative data, mostly of patients with COPD, needed for the study. We intend to complete the study in 6 years. Conclusions Our results will help make asthma and COPD care more proactive, effective, and efficient, improving outcomes and saving resources. International Registered Report Identifier (IRRID) PRR1-10.2196/27065
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Xiaoming Sheng
- College of Nursing, University of Utah, Salt Lake City, UT, United States
| | - Shan He
- Care Transformation and Information Systems, Intermountain Healthcare, West Valley City, UT, United States
| | - Corinna Koebnick
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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7
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Tiotiu A, Novakova P, Baiardini I, Bikov A, Chong-Neto H, de-Sousa JC, Emelyanov A, Heffler E, Fogelbach GG, Kowal K, Labor M, Mihaicuta S, Nedeva D, Novakova S, Steiropoulos P, Ansotegui IJ, Bernstein JA, Boulet LP, Canonica GW, Dubuske L, Nunes C, Ivancevich JC, Santus P, Rosario N, Perazzo T, Braido F. Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document. J Asthma 2021; 59:639-654. [PMID: 33492196 DOI: 10.1080/02770903.2021.1879130] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD). METHODS Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members. RESULTS The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life. CONCLUSIONS Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.
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Affiliation(s)
- Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France.,EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control, University of Lorraine, Nancy, France
| | - Plamena Novakova
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Ilaria Baiardini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Andras Bikov
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Herberto Chong-Neto
- Division of Allergy and Immunology, Department of Pediatrics, Federal University of Paraná, Curitiba, Brazil
| | - Jaime Correia- de-Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University named after I.I.Mechnikov, St-Petersburg, Russia
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
| | - Guillermo Guidos Fogelbach
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria.,Instituto Politécnico Nacional, Escuela Nacional de Medicina y Homeopatía, Laboratorio de Bioquímica Estructural, Ciudad de México, México
| | - Krzysztof Kowal
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | | | - Stefan Mihaicuta
- Pulmonology Department, Cardio Prevent Foundation, University of Medicine and Pharmacy "Dr Victor Babes", Timisoara, Romania
| | - Denislava Nedeva
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Sylvia Novakova
- Allergy Unit of Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section University of Cincinnati, Cincinnati, OH, USA
| | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
| | - Lawrence Dubuske
- Division of Allergy and Immunology, Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Carlos Nunes
- Centro de ImmunoAlergologia de Algarve, Porto, Portugal
| | - Juan Carlos Ivancevich
- Immunology Department, Faculty of Medicine, del Salvador University, Buenos Aires, Argentina
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences, University of Milan, Division of Respiratory Diseases "L. Sacco" Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Tommaso Perazzo
- Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Fulvio Braido
- Department of Internal Medicine, University of Genoa, Genova, Italy.,Respiratory Unit for Continuity of Care IRCCS, Ospedale Policlinico San Martino, Genova, Italy
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