High paternal homocysteine causes ventricular septal defects in mouse offspring.

Maternal hyperhomocysteinemia is widely considered as an independent risk of congenital heart disease (CHD). However, whether high paternal homocysteine causes CHD remains unknown. Here, we showed that increased homocysteine levels of male mice caused decreased sperm count, sperm motility defect and ventricular septal defect of the offspring. Moreover, high levels of paternal homocysteine decrease sperm DNMT3A/3B, accompanied with changes in DNA methylation levels in the promoter regions of CHD-related genes. Folic acid supplement could decrease the occurrence of VSD in high homocysteine male mice. This study reveals that increased paternal homocysteine level increases VSD risk in the offspring, indicating that decreasing paternal homocysteine may be an intervening target of CHD.

Upregulation of miR-21-5p rescues the inhibition of cardiomyocyte proliferation induced by high glucose through negative regulation of Rhob.

Increasing evidence shows that maternal hyperglycemia inhibits cardiomyocyte (CM) proliferation and promotes cell apoptosis during fetal heart development, which leads to cardiac dysplasia. Accumulating evidence suggests that the overexpression of miR-21 in CMs has a protective role in cardiac function. Therefore, we investigated whether miR-21 can rescue CM injury caused by high glucose. First, we performed biological function analysis of miR-21-5p overexpression in H9c2 cells treated with high glucose. We found that the proliferation of H9c2 cells treated with high glucose decreased significantly and was rescued after overexpression of miR-21-5p. CCK-8 and EdU incorporation assays were performed to assess cell proliferation. The cell proliferation of the miR-21-5p mimic transfection group was improved compared with that of the NC mimic group (*p < 0.05, miR-21-5p mimics vs. NC mimics) when the proliferation of H9c2 cells was reduced by high glucose (****p < 0.0001, high glucose (HG) vs. normal glucose (NG)). Then, we verified the targeted and negative regulation of miR-21-5p on Rhob using a dual-luciferase activity assay and RT-qPCR, respectively. We further demonstrated that miR-21-5p regulates Rhob to rescue the inhibition of CM proliferation induced by high glucose. The CCK-8 results showed that the cell proliferation of the siRNA-Rhob group was higher than that of the NC mimic group (***p < 0.001) and that of the cotransfection group with Up-Rhob plasmids and miR-21-5p mimics was lower than that of the miR-21-5p mimic group (*p < 0.05). Conclusion: Overexpression of miR-21-5p rescues the inhibition of high glucose-induced CM proliferation through regulation of Rhob.

Maternal Obesity and Kawasaki Disease-like Vasculitis: A New Perspective on Cardiovascular Injury and Inflammatory Response in Offspring Male Mice.

Maternal obesity affects the risk of cardiovascular disease and inflammatory response in offspring. However, the impact of maternal obesity on offspring with Kawasaki disease (KD), the leading cause of childhood acquired heart disease, is still an understudied area. This study aimed to elucidate the impact of maternal obesity on offspring in KD-like vasculitis and the underlying mechanisms. Offspring of obese female mice and normal diet dams were randomly divided into two subgroups. The pups were injected intraperitoneally with either Candida albicans water-soluble fraction (CAWS) or phosphate buffered saline (PBS) to establish the obesity (OB)-CAWS group, OB group, wild type (WT)-CAWS group, and WT group. Their weight was monitored during the study. After four weeks, echocardiography was applied to obtain the alternation of cardiac structures. Mouse cytokine panel, Hematoxylin-Eosin (HE) staining, western blot, and real-time qPCR were used to study the pathological changes and protein and RNA expression alternations. Based on the study of pathology, serology and molecular biology, maternal obesity lead to more severe vasculitis and induced altered cardiac structure in the offspring mice and promoted the expression of pro-inflammatory cytokines through activating the NF-κB signaling pathway. Maternal obesity aggravated the inflammatory response of offspring mice in KD-like vasculitis.

Description of the medical services provided to children in Shanghai: a cross-sectional study of the characteristics and disparities of hospitals of different levels and types.

Background: The development of the pediatric care system is uneven in China. Limited research has been conducted on pediatric care in Shanghai, which is a well-developed region in China, in which the National Children's Medical Centers are located. Methods: In November 2021, under the commission of the Shanghai Center for Medical Quality Control, a city-wide questionnaire designed to examine the provision of medical services to children in Shanghai in 2020 was conducted at 86 hospitals providing pediatric care. The overall characteristics and disparities between the general hospitals and children's hospitals and suggestions for future developments were explored. Results: In 2020, there were 86 hospitals providing pediatric care, covering all 16 municipal districts of Shanghai, with an average distribution of 1.4 hospitals per 100 km2. The hospitals were mainly public (94.2%) and general (96.5%) hospitals. With a response rate of 90.7%, the questionnaire results revealed that there were 2,683 in-service pediatricians in Shanghai, with an average of 1.1 pediatrician per 1,000 children aged 0-14 years in Shanghai. The pediatricians were mainly women (71.8%), aged 40 years or younger (60.6%), who held a bachelor's degree or higher (99.5%). The total number of pediatric outpatient and emergency visits was approximately 8 million, with an average of 2,973 visits per pediatrician in 2020. There were >370,000 visits to fever clinics. The number of pediatric inpatient visits exceeded 160,000, with an average hospital stay length of 5.8 days. The uneven development between the children's hospitals and general hospitals represents a major challenge facing Shanghai's pediatric care system, and the close links between the 2 types of hospitals need to be further strengthened. Conclusions: Shanghai provides an overall superior medical service to children in China. The close link between the children's hospitals and general hospitals should be further strengthened to optimize the distribution of high-quality resources and greatly improve the overall provision of pediatric medical services.

Direct costs of community-acquired pneumonia for hospitalized children in Shanghai, China from 2018 to 2020: a cross-sectional analysis.

Background: Community-acquired pneumonia (CAP) is an acute respiratory infection with a high clinical and economic burden. Clarifying the burden is important for health policy making. However, there is inadequate data on the economic burden of childhood CAP in China. In this study, the direct disease burden of CAP in children was analyzed using city-level data. Methods: A cross-sectional study of the direct costs of CAP for hospitalized children aged 28 days to 18 years old in Shanghai from January 2018 to December 2020 was performed. Information, including the hospitalization costs from the first page of the children's hospitalized medical records, was obtained. The direct costs included medical services, diagnostics, medications, and medical supplies. The continuous variables with non-normal distributions are expressed as the median (interquartile range). Comparisons between groups were performed using the Kruskal-Wallis H test. The enumeration data are expressed as the number (percentage), and comparisons between groups were performed using the χ2 test. Results: A total of 59 hospitals and 63,614 hospitalized CAP patients were included in this study. Significantly fewer patients were discharged in 2020 than 2018 and 2019 (6,662, 27,943, and 29,009, respectively, P<0.001). Among the patients, 27,741 patients (43.6%) were covered by social medical insurance, 13,509 (21.2%) by commercial health insurance, and 22,364 (35.2%) were self-paying. The annual total direct costs for 2018, 2019, and 2020 were 118.553, 140.865, and 40.064 million Chinese Yuan (CNY), respectively. The average direct costs per hospital stay due to pediatric CAP in Shanghai was 4,707.83 CNY in 2018, a sum that accounted for 7.3% and 16.7% of the per capita disposable income in Shanghai and China in 2018, respectively. The total costs of the group aged <1 year were significantly higher than those of the other age groups (6,271.1 vs. 3,244.3~4,610.7 CNY, P<0.001). The total costs of severe cases were significantly higher than those of non-severe cases (5,200.6 vs. 3,170.4 CNY, P<0.001). The median duration of hospital stay was 6.0 days (5.0, 8.0). Conclusions: CAP hospitalization continues to represent a high clinical and economic burden in Shanghai, China. Specialized hospitals, severe cases, and the length of hospital stay were positively correlated with inpatient costs.

Association between High-Fat Diet during Pregnancy and Heart Weight of the Offspring: A Multivariate and Mediation Analysis.

Maternal nutrition and health status in the peri-pregnancy period are closely related to offspring health. Currently, population studies are unable to provide quantitative relationships and effective measures of peri-pregnancy high-fat diet and offspring myocardial remodeling due to the difficulty of obtaining human samples. This study aimed to establish the mouse models of maternal obesity and high-fat diet supplementation and deprivation during pregnancy. The effects of obesity, periconceptional high-fat diet window, fetal weight, sex, and placental weight on myocardial remodeling in the offspring were measured by single-factor and multiple-factor regression analyses. Moreover, the relationship between perinatal high-fat diet/fetal weight and offspring myocardial remodeling was explored using the mediation analysis model. The multivariate analysis showed that the heart weight to body weight (HW/BW) ratio of the offspring decreased by -1.6525 mg/g for every 1-g increase in fetal weight. The offspring HW/BW increased by 1.1967 mg/g if pregnant women were exposed to a high-fat diet throughout pregnancy. The mediation analysis model of a perinatal high-fat diet for the myocardial remodeling of offspring revealed that fetal weight had a suppression effect on the myocardial weight of offspring, accounting for 60.70%; also, it had a mediating effect on the HW/BW of offspring, accounting for 17.10%. Moreover, subgroup analysis showed an interaction between offspring sex and HW/BW in a maternal high-fat diet during pregnancy. Additionally, a quantitative real-time polymerase chain reaction experiment further proved that a perinatal high-fat diet could change the important indicators of myocardial remodeling in offspring. In conclusion, this study found that a high-fat diet in the periconceptional period influenced factors in offspring myocardial remodeling. Moreover, maternal high-fat diet deprivation attenuated the changes in offspring myocardial remodeling. In addition, the role of fetal weight in mediating maternal high-fat diet-mediated offspring myocardial remodeling was quantified. Our study showed that a sensible and healthy diet during the perinatal period, especially during pregnancy, played a positive role in the health of the offspring.

Size-segregated particle number concentrations and outpatient-department visits for pediatric respiratory diseases in Shanghai, China.

BACKGROUND: Few studies have simultaneously explored which size of particles has the greatest impact on the risk for pediatric asthma, bronchitis and upper respiratory tract infections (URTIs). OBJECTIVES: To investigate the short-term association between size-segregated particle number concentrations (PNCs) and outpatient-department visits (ODVs) for major pediatric respiratory diseases. METHODS: Daily counts of pediatric ODVs for asthma, bronchitis and URTIs were obtained from 66 hospitals in Shanghai, China, from 2016 to 2018. Pollutant effects were estimated using Poisson generalized additive models combined with polynomial distributed lag models. We also fitted co-pollutant cumulative effects models included six criteria air pollutants and conducted stratifying analyses by gender, age, season and geographic distances. RESULTS: We identified a total of 430,103 patients with asthma, 1,547,013 patients with bronchitis, and 2,155,738 patients with URTIs from the hospitals. Effect estimates increased with decreasing particle size. Ultrafine particle (UFP) and PNCs of 0.10-0.40 µm particles (PNC0.10-0.40) were associated with increased ODVs for asthma, bronchitis and URTIs at cumulative lags up to 3d. Associations tended to appear stable after adjusting for criteria air pollutants. At the cumulative lag 0-2d, each interquartile range increase in UFP was associated with increased ODVs due to asthma (relative risk 1.21, 95% CI: 1.07, 1.38), bronchitis (1.20, 95% CI: 1.07, 1.34) and URTI (1.17, 95% CI: 1.06, 1.30), whereas the associations for PNC0.10-0.40 remained significant but attenuated in magnitude. CONCLUSIONS: UFP may be a leading contributor to the adverse respiratory effects of particulate air pollution and the effects increased with decreasing particle size.

The functional verification and analysis of Fugu promoter of cardiac gene tnni1a in zebrafish.

Troponin I type 1b (Tnni1b) is thought to be a novel isoform that is expressed only in the zebrafish heart. Knocking down of tnni1b can lead to cardiac defects in zebrafish. Although both the zebrafish tnni1b and human troponin I1 (TNNI1) genes are thought to be closely associated with fatal cardiac development, the regulatory molecular mechanisms of these genes are poorly understood. Analyzing the functionally conserved sequence, especially in the noncoding regulatory region involved in gene expression, clarified these mechanisms. In this study, we isolated a 3 kb fragment upstream of Fugu tnni1a that can regulate green fluorescence protein (GFP) expression in a heart-specific manner, similar to the pattern of zebrafish homologue expression. Three evolutionarily conserved regions (ECRs) in the 5'-flanking sequence of Fugu tnni1a were identified by sequence alignment. Deletion analysis led to the identification of ECR2 as a core sequence that affects the heart-specific expression function of the Fugu tnni1a promoter. Interestingly, both the Fugu tnni1a promoter and ECR2 sequence were functionally conserved in zebrafish, although they shared no sequence similarity. Together, the findings of our study provided further evidence for the important role of tnni1a homologous in cardiac development and demonstrated that two functionally conserved sequences in the zebrafish and Fugu genomes may be ECRs, despite their lack of similarity.

Nicotinamide Mononucleotide Alleviates Cardiomyopathy Phenotypes Caused by Short-Chain Enoyl-Coa Hydratase 1 Deficiency.

Short-chain enoyl-CoA hydratase 1 (ECHS1) deficiency plays a role in cardiomyopathy. Whether ECHS1 deficiency causes or is only associated with cardiomyopathy remains unclear. By using Echs1 heterogeneous knockout (Echs1 +/-) mice, we found that ECHS1 deficiency caused cardiac dysfunction, as evidenced by diffuse myocardial fibrosis and upregulated fibrosis-related genes. Mechanistically, ECHS1 interacts with the p300 nuclear localization sequence, preventing its nuclear translocation in fibroblasts. ECHS1 deficiency promotes p300 nuclear translocation, leading to increased H3K9 acetylation, a known risk factor for cardiomyopathy. Nicotinamide mononucleotide-mediated acetylation targeting suppressed ECHS1 deficiency-induced cardiomyopathy phenotypes in Echs1 +/- mice. Thus, enhancing p300-mediated H3K9ac is a potential interventional approach for preventing ECHS1 deficiency-induced cardiomyopathy.

Melatonin alleviates vascular endothelial cell damage by regulating an autophagy-apoptosis axis in Kawasaki disease.

OBJECTIVES: Melatonin has been reported to be an appropriate candidate for mitigating various cardiovascular injuries, owing to its versatility. This study aimed to explore the role of melatonin in Kawasaki disease (KD)-associated vasculitis and its underlying mechanisms. MATERIAL AND METHODS: The role of melatonin was evaluated in human coronary artery endothelial cells (HCAECs), peripheral blood mononuclear cells from KD patients, human THP1 cell line in vitro, and a Candida albicans water-soluble fraction (CAWS)-induced KD mouse model in vivo. Cell proliferation assay, cell apoptosis assay, cell co-culture, RNA extraction, RNA sequencing, reverse transcription quantitative PCR, enzyme-linked immunosorbent assay (ELISA), transwell assay, western blot, dual-luciferase reporter assay, and autophagic flux assay were performed to investigate the function and regulatory mechanisms of melatonin in vitro, while haematoxylin and eosin staining, Verhoeff's van Gieson staining, ELISA, and immunohistochemical analysis were performed to detect the effect of melatonin in vivo. RESULTS: Melatonin suppressed cell apoptosis directly reduced the expression of endothelial cell damage markers in HCAECs, and alleviated vasculitis in the CAWS-induced KD mouse model. Mechanistically, melatonin promoted autophagy by activating the melatonin/ melatonin receptor (MT)/cAMP-response element binding protein (CREB) pathway and upregulating the expression of autophagy-related gene-3, thereby suppressing cell apoptosis in an autophagy-dependent manner. Additionally, melatonin decreased the production of pro-inflammatory cytokines in macrophages and indirectly reduced the immunopathological damage of HCAECs. CONCLUSIONS: This study revealed that melatonin protects vascular endothelial cells in KD, by suppressing cell apoptosis in an autophagy-dependent manner and reducing the immunopathological damage mediated by macrophages.

miR-29b-3p Inhibitor Alleviates Hypomethylation-Related Aberrations Through a Feedback Loop Between miR-29b-3p and DNA Methylation in Cardiomyocytes.

As a member of the miR-29 family, miR-29b regulates global DNA methylation through target DNA methyltransferases (DNMTs) and acts as both a target and a key effector in DNA methylation. In this study, we found that miR-29b-3p expression was inversely correlated with DNMT expression in the heart tissues of patients with congenital heart disease (CHD), but whether it interacts with DNMTs in cardiomyocytes remains unknown. Further results revealed a feedback loop between miR-29b-3p and DNMTs in cardiomyocytes. Moreover, miR-29b-3p inhibitor relieved the deformity of hypomethylated zebrafish and restored the DNA methylation patterns in cardiomyocytes, resulting in increased proliferation and renormalization of gene expression. These results suggest mutual regulation between miR-29b-3p and DNMTs in cardiomyocytes and support the epigenetic normalization of miRNA-based therapy in cardiomyocytes.

Effects of the Leptin-Mediated MAPK/ERK Signaling Pathway on Collagen II Expression in Knee Cartilage of Newborn Male Mice from Obese Maternal Offspring.

Epidemiological data suggest that various noncommunicable diseases develop as a result of altered maternal metabolic and physiological status due to exposure to several adverse factors during pregnancy. However, evidence for intrauterine exposure factors and mechanisms underlying the origin of early cartilage disease in chronic osteoarthritic disease is still lacking. In this study, we found that persistent overnutrition during pregnancy in obese mothers led to cartilage damage in neonatal male mice. This was mainly characterized by increased apoptosis with decreased expression of chondrocyte collagen II and low expression of Runx family transcription factor 2 (RUNX2) and SRY-box transcription factor 9 (SOX9). This reduction was also found to be associated with high leptin expression in newborn male mice of obese maternal offspring. Furthermore, the administration of leptin and mitogen-activated protein kinase (MAPK)-extracellular signal-regulated kinase (ERK) inhibitors in primary chondrocytes showed that leptin mediated MAPK/ERK signaling activation and thus affected the key regulators of cartilage matrix metallopeptidase 1 (MMP1) and tissue inhibitor of metalloproteinase 1 (TIMP1), thereby altering the expression of collagen II in mouse cartilage. Altogether, this study provided insights into the molecular mechanisms of cartilage-related disease development and also new clues and evidence for the fetogenetic origin of cartilage diseases.

Gestational Leucylation Suppresses Embryonic T-Box Transcription Factor 5 Signal and Causes Congenital Heart Disease.

Dysregulated maternal nutrition, such as vitamin deficiencies and excessive levels of glucose and fatty acids, increases the risk for congenital heart disease (CHD) in the offspring. However, the association between maternal amino-acid levels and CHD is unclear. Here, it is shown that increased leucine levels in maternal plasma during the first trimester are associated with elevated CHD risk in the offspring. High levels of maternal leucine increase embryonic lysine-leucylation (K-Leu), which is catalyzed by leucyl-tRNA synthetase (LARS). LARS preferentially binds to and catalyzes K-Leu modification of lysine 339 within T-box transcription factor TBX5, whereas SIRT3 removes K-Leu from TBX5. Reversible leucylation retains TBX5 in the cytoplasm and inhibits its transcriptional activity. Increasing embryonic K-Leu levels in high-leucine-diet fed or Sirt3 knockout mice causes CHD in the offspring. Targeting K-Leu using the leucine analogue leucinol can inhibit LARS activity, reverse TBX5 K-Leu modification, and decrease the occurrence of CHD in high-leucine-diet fed mice. This study reveals that increased maternal leucine levels increases CHD risk in the offspring through inhibition of embryonic TBX5 signaling, indicating that leucylation exerts teratogenic effects during heart development and may be an intervening target of CHD.

Protective effect of antioxidants on cardiac function in adult offspring exposed to prenatal overnutrition.

Maternal overnutrition-induced fetal programming predisposes offspring to cardiovascular health issues throughout life. Understanding how these adverse cardiovascular effects are regulated at the maternal-fetal crosstalk will provide insight into the mechanisms of these cardiovascular diseases, which will help in further identifying potential targets for intervention. Here, we uncover a role of oxidative stress caused by prenatal overnutrition in governing cardiac damage. Mice exposed to maternal obesity showed remarkable pathological cardiomyocyte hypertrophy (pmale < 0.001, Cohen's dmale = 1.77; pfemale < 0.001, Cohen's dfemale = 1.94), increased collagen content (pmale < 0.001, Cohen's dmale = 2.13; pfemale < 0.001, Cohen's dfemale = 2.71), and increased levels of transforming growth factor ß (TGF-ß) (pmale < 0.001, Cohen's dmale = 3.02; pfemale < 0.001, Cohen's dfemale = 4.52), as well as left ventricular dysfunction in adulthood. To cope with increased oxidative stress in the myocardial tissue of offspring from obese mothers, we sought to decrease the effect of oxidative stress and prevent the development of these cardiovascular conditions with use of the antioxidant N-acetylcysteine during pregnancy. As predicted, after treatment with the antioxidant, there was greatly mitigated cardiomyocyte hypertrophy (pmale < 0.001, Cohen's dmale = 1.31; pfemale < 0.001, Cohen's dfemale = 0.82) and cardiac fibrosis, including decreased composition of collagen fibers (pmale < 0.01, Cohen's dmale = 1.45; pfemale < 0.05, Cohen's dfemale = 1.23) and reduced levels of TGF-ß (pmale < 0.05, Cohen's dmale = 1.83; pfemale < 0.01, Cohen's dfemale = 3.81). We also observed improved left ventricle contractile function together with the alleviation of enhanced oxidative stress in the myocardial tissue of offspring. Collectively, these results established a crucial role of oxidative stress in prenatal overnutrition-associated ventricular remodeling and cardiac dysfunction. Our findings provided an important target for intervention of cardiovascular disease in overnutrition-related fetal programming.

Functional assessment of heart-specific enhancers by integrating ChIP-seq data.

BACKGROUND: Identification and functional annotations of regulatory sequences play a pivotal role in heart development and function. METHODS: To generate a map of human heart-specific enhancers, we performed an integrative analysis of 148 chromatin immunoprecipitation coupled to massively parallel sequencing (ChIP-seq) samples with enhancer-associated epigenetic marks from the heart, liver, brain, and kidney. Functional validation of heart-specific enhancer activity was then performed using cultured cells. RESULTS: A 144.6-Mb candidate heart-specific enhancer compendium was generated by integrating the analysis of 148 epigenomic data sets from human and mouse hearts and control tissues. To validate in vivo enhancer activity, we tested 12 of these sequences around 45 CHD-related genes in cultured cells and found that 8 (67%) have reproducible heart-specific enhancer activity. A functional analysis demonstrated that the identified human heart-specific enhancer wf1 regulates the FBN1 gene which is involved in heart disease. CONCLUSIONS: Our study provides an integrative analysis pipeline for ChIP-seq data and identified a comprehensive catalog of human heart-specific enhancers for clinical CHD-related studies. IMPACT: Establishing an efficient way to analyze regulatory regions in CHD is very important. A highly qualified heart-specific enhancer compendium was generated by integrating 148 online ChIP-seq samples. Sixty-seven percent of predicted regulatory sequences have reproducible heart-specific enhancer activity in vivo. Human heart-specific enhancer wf1 regulates the CHD-related FBN1 gene.

Characteristics of childhood allergic diseases in outpatient and emergency departments in Shanghai, China, 2016-2018: a multicenter, retrospective study.

BACKGROUND: The prevalence of allergic diseases (ADs), such as asthma and allergic rhinitis (AR), is increasing worldwide in both adults and children. Although ADs are common and frequently coexist in outpatient care, city-level data regarding the characteristics of childhood AD remain limited in China. This study aimed to assess the profile and characteristics of ADs in the city of Shanghai. METHODS: A multicenter retrospective study was designed to collect routine administrative data from outpatient and emergency departments from 66 hospitals in Shanghai, China, from 2016 to 2018. Children with asthma, AR, allergic conjunctivitis (AC), and allergic skin diseases were investigated. Demographic characteristics, patients visit pattern, spectrum of diagnosis, and comorbidities were analyzed. RESULTS: A total of 2,376,150 outpatient and emergency visits for ADs were included in the period from 2016 to 2018. Allergic skin diseases accounted for 38.9%, followed by asthma (34.8%), AR (22.9%), and AC (3.3%), with a male predominance in all four diseases. Asthma and allergic skin diseases were most frequent in the 1 to < 4 years of age group, while AR and AC were more common in the 4 to < 7 years of age group. Asthma accounted for the greatest number of annual and emergency visits. The most frequent comorbidity of asthma was lower respiratory tract infection (LRTI) (49.3%), followed by AR (20.5%) and upper respiratory tract infection (14.1%). The most common comorbidities of AR were otitis media (23.4%), adenoid hypertrophy/obstructive sleep apnea (22.1%), followed by LRTI (12.1%), asthma (9.4%) and chronic pharyngitis (8.9%). CONCLUSIONS: Asthma and allergic skin diseases were the most common ADs in outpatient and emergency departments in the study period. Respiratory tract infection was the most common comorbidity of asthma in children. More attention should be devoted to the treatment of comorbidities to improve childhood AD outcomes with a better understanding of the characteristics of ADs in outpatient care.