Different greenness exposure in Europe and respiratory outcomes in youths. A systematic review and meta-analysis.

The existing evidence on the association between greenness and respiratory outcomes remains inconclusive. We aimed at systematically summarizing existing literature on greenness exposure and respiratory outcomes in European children and adolescents, with a preliminary attempt to qualify the distribution of dominant tree species across different geographical areas and bioclimatic regions. Overall, 4049 studies were firstly identified by searching PubMed/MEDLINE, EMBASE, Scopus, Web of Science, GreenFile and CAB direct, up to 29 August 2023. Eighteen primary studies were included in the systematic review and six were meta-analyzed. No overall significant association was observed between the Normalized Difference Vegetation Index, assessed within 500-m buffers (i.e. NDVI-500), and the odds of asthma for 0.3-increase in the exposure (OR: 0.97, 95% CI from 0.53 to 1.78). Similarly, an overall exposure to the NDVI-300 highest tertile, as compared to the lowest tertile, was not significantly associated with asthma (OR: 0.65, 95% CI from 0.22 to 1.91): heterogeneity among studies was significant (p = 0.021). We delineated some key elements that might have mostly contributed to the lack of scientific consensus on this topic, starting from the urgent need of harmonized approaches for the operational definition of greenness. Additionally, the complex interplay between greenness and respiratory health may vary across different geographical regions and climatic conditions. At last, the inconsistent findings may reflect the heterogeneity and complexity of this relationship, rather than a lack of scientific consensus itself. Future research should compare geographical areas with similar bioclimatic parameters and dominant or potentially present vegetation species, in order to achieve a higher inter-study comparability.

Relationship of long-term air pollution exposure with asthma and rhinitis in Italy: an innovative multipollutant approach.

BACKGROUND: air pollution is a complex mixture; novel multipollutant approaches could help understanding the health effects of multiple concomitant exposures to air pollutants. AIM: to assess the relationship of long-term air pollution exposure with the prevalence of respiratory/allergic symptoms and diseases in an Italian multicenter study using single and multipollutant approaches. METHODS: 14420 adults living in 6 Italian cities (Ancona, Pavia, Pisa, Sassari, Turin, Verona) were investigated in 2005-2011 within 11 different study cohorts. Questionnaire information about risk factors and health outcomes was collected. Machine learning derived mean annual concentrations of PM10, PM2.5, NO2 and mean summer concentrations of O3 (µg/m3) at residential level (1-km resolution) were used for the period 2013-2015. The associations between the four pollutants and respiratory/allergic symptoms/diseases were assessed using two approaches: a) logistic regression models (single-pollutant models), b) principal component logistic regression models (multipollutant models). All the models were adjusted for age, sex, education level, smoking habits, season of interview, climatic index and included a random intercept for cohorts. RESULTS: the three-year average (± standard deviation) pollutants concentrations at residential level were: 20.3 ± 6.8 µg/m3 for PM2.5, 29.2 ± 7.0 µg/m3 for PM10, 28.0 ± 11.2 µg/m3 for NO2, and 70.9 ± 4.3 µg/m3 for summer O3. Through the multipollutant models the following associations emerged: PM10 and PM2.5 were related to 14-25% increased odds of rhinitis, 23-34% of asthma and 30-33% of night awakening; NO2 was related to 6-9% increased odds of rhinitis, 7-8% of asthma and 12% of night awakening; O3 was associated with 37% increased odds of asthma attacks. Overall, the Odds Ratios estimated through the multipollutant models were attenuated when compared to those of the single-pollutant models. CONCLUSIONS: this study enabled to obtain new information about the health effects of air pollution on respiratory/allergic outcomes in adults, applying innovative methods for exposure assessment and multipollutant analyses.

Vitamin D and Healthcare Service Utilization in Children: Insights from a Machine Learning Approach.

Vitamin D deficiency and insufficiency is a global health issue: an association has been demonstrated between vitamin D deficiency and a myriad of acute and chronic illnesses. Data regarding vitamin D status among children hospitalized with non-critical illnesses are scanty. We aimed to: (1) identify profiles of children hospitalized due to non-critical illnesses, using vitamin D levels as the driving outcome; (2) assess the association between patient profiles and length of stay. The study included 854 patients (1−17 years old) who underwent blood tests for detecting vitamin D levels. A regression tree was used to stratify patients. The relationship between vitamin D levels and length of stay was explored using Poisson regression. The regression tree identified three subgroups. Group A (16%): African, North African, Hispanic, and Indian patients. Group B (62%): Caucasian and Asian patients hospitalized for respiratory, metabolic, ill-defined, infective, and genitourinary diseases. Group C (22%): Caucasian and Asian patients hospitalized for digestive, nervous, and musculoskeletal diseases, blood and skin diseases, and injuries. Mean serum vitamin D level (ng/mL) was 13.7 (SD = 9.4) in Group A, 20.5 (10.0) in Group B, and 26.2 (12.6) in Group C. Group B was associated with the highest BMI z-score (p < 0.001) and the highest frequency of preterm births (p = 0.041). Mean length of stay was longer in Group A than in the other groups (p < 0.001) and decreased significantly by 9.8% (p = 0.024) in Group A and by 5% (p = 0.029) in Group B per 10 ng/mL increase in vitamin D level. We identified three subgroups of hospitalized children, defined according to ethnicity and discharge diagnosis, and characterized by increasing vitamin D levels. Vitamin D levels were associated with length of hospitalization.

Might Dog Walking Reduce the Impact of COPD on Patients' Life?

Low levels of physical activity (PA) lead to a worsening of physical condition and contributes to multimorbidity in Chronic Obstructive Respiratory Disease (COPD). Unsupervised PA related to dog ownership may contribute to reducing sedentary behavior. We aimed to investigate the relationship between dog walking, patient-reported outcomes (PROs) and exacerbations in COPD. A pre-defined sample of 200 COPD patients (dog owners and non-dog owners) with symptomatic COPD was sourced from a database representative of the Italian population. A computer-assisted personal interview was used to assess health status impairment (CAT), fatigue (FACIT), health-related quality of life (HRQoL) (EQ-5D), and PA frequency. In the whole sample, PA was associated with better CAT, EQ-5D, VAS, FACIT scores and reduced number of exacerbation (p < 0.001). Under the same CAT scores, dog-walking duration was associated with a better HRQoL (EQ5D, p = 0.015) and less fatigue (FACIT, p = 0.017). In an adjusted regression model, walking dogs >30 min was associated with lower fatigue (FACIT) than having no dogs and walking dogs <15 min (p = 0.026 and p = 0.009, respectively). Motivation related to dog walking could modify patients' tendency to focus on symptoms during PA and, therefore, to perceive the fatigue. Dog walking may be effective for increasing and maintaining regular PA, reducing the subjective impact of COPD.

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

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

Addressing Exposome: An Innovative Approach to Environmental Determinants in Pediatric Respiratory Health.

Developmental age is particularly vulnerable to impacts of environmental exposures. Until recent years, the field of environment and child health has predominantly relied on the study of single exposure-health effect relationships. The exposome is an emerging concept in epidemiology, encompassing the totality of the exposures experienced by an individual throughout life and their changes over time. This innovative approach provides a risk profile instead of individual predictors. Exposome research may contribute to better understand the complex relationships between environmental exposures and childhood respiratory health, in order to implement prevention strategies and mitigate adverse health outcomes across the life span. Indeed, an accurate assessment of the exposome needs several measurements as well as different technologies. High-throughput "omics" technologies may be promising tools to integrate a wide range of exposures. However, analyzing large and complex datasets requires the development of advanced statistical tools. This narrative review summarizes the current knowledge on exposome-based approaches in pediatric respiratory health. Further, it explores practical implementation, associated evidence gaps, research limitations and future research perspectives.

Association between greenspace and lung function in Italian children-adolescents.

BACKGROUND: Few studies have examined the impact of urban greenspace exposure on lung function in children-adolescents, and the available evidence is still inconsistent. The aim of the current study was to verify the hypothesis that the effects of greenspace exposure vary with differing levels of lung function of children-adolescents. METHODS: Between November 2005 and May 2006, 2150 children-adolescents (age-range: 10-15 years) living in the city of Palermo were enrolled in a cross-sectional survey. Parents were interviewed through a modified version of the Italian Studies on Respiratory Disorders in Children and the Environment (SIDRIA) questionnaire. All children-adolescents performed spirometry and were tested for allergic sensitization. Exposures to greenspace and grey space at the home addresses were measured using the CORINE land-cover classes. Parametric quantile regression models were applied for assessing the association between greenspace exposure and spirometry parameters, accounting for possible confounders and effect modifiers. A p-value lower than 0.05 was considered statistically significant. RESULTS: From the 1st to the 21st percentile, children-adolescents living within greenspace had higher FEV1 than those living within grey space. In particular, the estimated effects were: 1st (ß = 0.238 L, p = 0.01), 5th (ß = 0.140 L, p = 0.01), 10th (ß = 0.097 L, p = 0.015), and 15th (ß = 0.073 L, p = 0.025). Similarly, from the 1st to the 29th percentile, children-adolescents living within greenspace had higher FVC than those living within grey space. In particular, the estimated effects were: 1st (ß = 0.367 L, p = 0.0003), 5th (ß = 0.215 L, p = 0.0003), 10th (ß = 0.150 L, p = 0.0004), and 15th (ß = 0.112 L, p = 0.001). No significant associations were found for FEV1/FVC, FEF25-75 and FEF25-75/FVC. CONCLUSION: Quantile regression techniques may provide new insights into the evaluation of the association between greenspace exposure and lung function in children-adolescents, showing substantially heterogeneous effects from lower to higher quantiles of spirometry parameters. These results may help implementing policies for planning sustainable housing and surrounding greenspaces.

Pharmacogenomics: A Step forward Precision Medicine in Childhood Asthma.

Personalized medicine, an approach to care in which individual characteristics are used for targeting interventions and maximizing health outcomes, is rapidly becoming a reality for many diseases. Childhood asthma is a heterogeneous disease and many children have uncontrolled symptoms. Therefore, an individualized approach is needed for improving asthma outcomes in children. The rapidly evolving fields of genomics and pharmacogenomics may provide a way to achieve asthma control and reduce future risks in children with asthma. In particular, pharmacogenomics can provide tools for identifying novel molecular mechanisms and biomarkers to guide treatment. Emergent high-throughput technologies, along with patient pheno-endotypization, will increase our knowledge of several molecular mechanisms involved in asthma pathophysiology and contribute to selecting and stratifying appropriate treatment for each patient.

The Effect of Outdoor Aeroallergens on Asthma Hospitalizations in Children in North-Western Tuscany, Italy.

Few data are currently available on the effects of aeroallergens in triggering respiratory symptoms in children. To evaluate the potential effects of daily outdoor aeroallergens loads on childhood admissions, in this case-crossover study, we analyzed data from 85 children hospitalized at the University Hospital of Pisa, Italy, for asthma or asthma-like symptoms without respiratory infection, between 2010 and 2019. Data were linked to outdoor allergens, temperature, nitrogen dioxide, and relative humidity observed during the same period. A 10-grains/m3 increase in the total aeroallergen concentration was associated with an increased risk of admission at lag 0 (OR = 1.054, 95% CI: 1.011-1.098), with a smaller effect at lag 1 (OR = 1.037, 95% CI: 1.008-1.067) and lag 2 (OR = 1.021, 95% CI: 1.003-1.039). Trends to larger effects were observed in children with sensitization to one or more aeroallergens (OR = 1.085, 95% CI: 1.004-1.173 at lag 0), in males (OR = 1.069, 95% CI: 1.009-1.132 at lag 0) and in older children (OR = 1.065, 95% CI: 1.007-1.127 at lag 0). Our study shows an association between increased outdoor allergens loads and asthma or asthma-like symptoms in children up to at least two days prior to hospitalization, suggesting that tracking aeroallergen counts may be useful to improve the management of respiratory allergic diseases.

Asthma-Related Knowledge and Practices among Mothers of Asthmatic Children: A Latent Class Analysis.

Mothers' knowledge about childhood asthma influences management practices and disease control, but validating knowledge/practice questionnaires is difficult due to the lack of a gold standard. We hypothesized that Latent Class Analysis (LCA) could help identify underlying mother profiles with similar knowledge/practices. A total of 438 mothers of asthmatic children answered a knowledge/practice questionnaire. Using answers to the knowledge/practice questionnaire as manifest variables, LCA identified two classes: Class 1, "poor knowledge" (33%); Class 2, "good knowledge" (67%). Classification accuracy was 0.96. Mothers in Class 2 were more likely to be aware of asthma-worsening factors and indicators of attacks. Mothers in Class 1 were more likely to prevent exposure to tobacco smoke (91.1% vs. 78.8%, p = 0.005). For attacks, mothers in Class 2 were more likely to go to the emergency department and follow the asthma action plan. Mothers in Class 2 more frequently had a high education level (79.5% vs. 65.2%, p = 0.004). Children in Class 2 more frequently had fully controlled asthma (36.7% vs. 25.9%, p = 0.015) and hospitalizations for attacks in the previous 12 months (24.2% vs. 10.7%, p = 0.003). LCA can help discover underlying mother profiles and plan targeted educational interventions.

Robotic-Assisted Neck Dissection: Our Experience

Abstract Introduction Robotic neck dissection surgery allows less invasiveness to significantly improve the aesthetic impact even though it does not compromise the principles of radical cancer procedure. Objective The aim of our work is to describe our personal experience with robotic neck dissection surgery. Methods A retrospective study was conducted by analyzing 10 patients subjected to a robotic neck dissection surgery. In the period from August 2012 to December 2018, these patients have been treated exclusively with robotic lateral-cervical dissection. Five of them were subjected to robotic-assisted transaxillary neck dissection (RATAND) and the other 5 treated with robotic-assisted retroauricular neck dissection (RARAND), then the surgical results have been compared with 5 similar dissections performed by open neck dissection (OND). Results The average surgical time of RATAND was estimated in 166 minutes, the average surgical time of RARAND was estimated in 153 minutes and the average surgical time of OND was estimated in 48 minutes. Both robotic techniques are valid from the oncological and aesthetic point of view, but in terms of surgical time, they are much longer than the open technique. Conclusions In terms of the post-operative decree, in our opinion, the retroauricular technique is more rapid for the purposes of recovery.

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

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

Cellular and Molecular Signatures of Oxidative Stress in Bronchial Epithelial Cell Models Injured by Cigarette Smoke Extract.

Exposure of the airways epithelium to environmental insults, including cigarette smoke, results in increased oxidative stress due to unbalance between oxidants and antioxidants in favor of oxidants. Oxidative stress is a feature of inflammation and promotes the progression of chronic lung diseases, including Chronic Obstructive Pulmonary Disease (COPD). Increased oxidative stress leads to exhaustion of antioxidant defenses, alterations in autophagy/mitophagy and cell survival regulatory mechanisms, thus promoting cell senescence. All these events are amplified by the increase of inflammation driven by oxidative stress. Several models of bronchial epithelial cells are used to study the molecular mechanisms and the cellular functions altered by cigarette smoke extract (CSE) exposure, and to test the efficacy of molecules with antioxidant properties. This review offers a comprehensive synthesis of human in-vitro and ex-vivo studies published from 2011 to 2021 describing the molecular and cellular mechanisms evoked by CSE exposure in bronchial epithelial cells, the most used experimental models and the mechanisms of action of cellular antioxidants systems as well as natural and synthetic antioxidant compounds.

Robotic-Assisted Neck Dissection: Our Experience.

Introduction Robotic neck dissection surgery allows less invasiveness to significantly improve the aesthetic impact even though it does not compromise the principles of radical cancer procedure. Objective The aim of our work is to describe our personal experience with robotic neck dissection surgery. Methods A retrospective study was conducted by analyzing 10 patients subjected to a robotic neck dissection surgery. In the period from August 2012 to December 2018, these patients have been treated exclusively with robotic lateral-cervical dissection. Five of them were subjected to robotic-assisted transaxillary neck dissection (RATAND) and the other 5 treated with robotic-assisted retroauricular neck dissection (RARAND), then the surgical results have been compared with 5 similar dissections performed by open neck dissection (OND). Results The average surgical time of RATAND was estimated in 166 minutes, the average surgical time of RARAND was estimated in 153 minutes and the average surgical time of OND was estimated in 48 minutes. Both robotic techniques are valid from the oncological and aesthetic point of view, but in terms of surgical time, they are much longer than the open technique. Conclusions In terms of the post-operative decree, in our opinion, the retroauricular technique is more rapid for the purposes of recovery.

Association between Asthma Control and Exposure to Greenness and Other Outdoor and Indoor Environmental Factors: A Longitudinal Study on a Cohort of Asthmatic Children.

Achieving and maintaining asthma control (AC) is the main goal of asthma management. Indoor and outdoor environmental factors may play an important role on AC. The aim of this longitudinal study was to evaluate the association between AC and exposure to greenness and other outdoor or indoor environmental factors in a cohort of asthmatic children. This study involved 179 asthmatic children (5-16 years). Parents were interviewed through a modified version of the SIDRIA questionnaire. AC was assessed at each visit. Exposure to greenness was measured using the normalized difference vegetation index (NDVI). A logistic regression model was applied for assessing risk factors for uncontrolled asthma (UA). Low NDVI exposure was a risk factor for UA (OR: 2.662, 95% CI (1.043-6.799)); children exposed to passive smoke during pregnancy had a higher risk of UA than those non-exposed to passive smoke during pregnancy (OR: 3.816, 95% CI (1.114-13.064)); and a unit increase in the crowding index was associated with an increased risk of UA (OR: 3.376, 95% CI (1.294-8.808)). In conclusion, the current study provided a comprehensive assessment of urban-related environmental exposures on asthma control in children, using multiple indicators of greenness and other outdoor or indoor environmental factors.

Endotyping allergic rhinitis in children: A machine learning approach.

INTRODUCTION: The diversity of allergic rhinitis (AR) phenotypes is particularly evident in childhood, suggesting the need to analyze and identify new approaches to capture such clinical heterogeneity. Nasal cytology (NC) is a very useful diagnostic tool for identifying and quantifying nasal inflammation. Data-driven approaches such as latent class analysis (LCA) assign subjects to classes based on their characteristics. We hypothesized that LCA based on NC, including the assessment of neutrophils, eosinophils, and mast cells, may be helpful for identifying AR endotypes in children. METHODS: A total of 168 children were enrolled. Sociodemographic characteristics and detailed medical history were obtained from their parents. All children performed NC and skin prick tests. LCA was applied for identifying AR endotypes based on NC, using the R package poLCA. All the statistical analyses were performed using R 4.0.5 software. Statistical significance was set at p ≤ .05. RESULTS: LCA identified two classes: Class 1 (n = 126, 75%): higher frequency of children with moderate/large number of neutrophils (31.45%); almost all the children in this class had no mast cells (91.27%) and Class 2 (n = 42, 25%): higher frequency of children with moderate/large number of eosinophils (45.24%) and moderate/large number of mast cells (50%). CONCLUSIONS: The present study used a machine learning approach for endotyping childhood AR, which may contribute to improve the diagnostic accuracy and to deliver personalized health care in the context of precision medicine.

Machine learning: A modern approach to pediatric asthma.

Among modern methods of statistical and computational analysis, the application of machine learning (ML) to healthcare data has been gaining recognition in helping us understand the heterogeneity of asthma and predicting its progression. In pediatric research, ML approaches may provide rapid advances in uncovering asthma phenotypes with potential translational impact in clinical practice. Also, several accurate models to predict asthma and its progression have been developed using ML. Here, we provide a brief overview of ML approaches recently proposed to characterize pediatric asthma.

Rhinitis and Asthma Patient Perspective (RAPP): Clinical Utility and Predictive Value.

BACKGROUND: RhinAsthma Patient Perspective (RAPP) is the only validated tool for assessing of health-related quality of life (HRQoL) related to asthma and rhinitis in individual patients. OBJECTIVE: To compare the HRQoL burden among countries and explore the usefulness of RAPP as a complementary measure in disease management. METHODS: In this post hoc analysis of the RAPP International Study, the enrolled population was clustered into patients with controlled rhinitis and controlled asthma (CA/CR), uncontrolled rhinitis and controlled asthma (CA/UR), controlled rhinitis and uncontrolled asthma (UA/CR), and uncontrolled rhinitis and uncontrolled asthma (UA/UR). RESULTS: We recruited 575 adult patients. Significant differences among countries were observed in the mean RAPP score (from 15.7 in Spain to 18.7 in the Philippines) although the percentage of subjects with an optimal HRQoL (RAPP <15) was not significantly different. Compared with patients with AR and asthma disease control, those with UR/CA, CR/UA, and UR/UA had significantly higher RAPP scores (4.7, 5, and 9.8, respectively). The best cutoffs for detecting uncontrolled diseases were RAPP of 15 or greater (SE = 75%; specificity = 69%; and area under the receiver operating characteristic curve [AUC] = 0.78) for AR; RAPP of 16 or greater (SE = 78%; specificity = 76%; and AUC = 0.83) for asthma; and RAPP of 18 or greater (SE = 86%; specificity = 87%; and AUC = 0.92) for both AR and asthma. CONCLUSIONS: These findings provide a better understanding of the individual burden of HRQoL related to asthma and rhinitis in daily practice. In addition, the RAPP estimates how much of the risk for uncontrolled disease depends on uncontrolled AR and asthma, allowing its use as a clinical support tool in clinical management.