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Severe inherited alpha-1 antitrypsin deficiency (AATD) is an autosomal genetic condition linked to chronic obstructive pulmonary disease (COPD). The significance of heterozygous, milder deficiency variants (PiSZ, PiMZ, PiMS) is less clear. We studied AATD genotypes in 145 children (up to 72 months old) with assessed wheezing severity using the Pediatric Respiratory Assessment Measure (BCCH PRAM score). A control group of 74 children without airway obstruction was included. AAT concentration and Pi phenotype were determined from dry blood spot samples using nephelometry and real-time PCR; PiS and PiZ alleles were identified by isoelectrofocusing. Among the wheezers, the Pi*S allele incidence was 2.07% (3 cases) and the Pi*Z allele was 6.9% (10 cases). The Pi*Z allele frequency was higher in wheezers compared to controls (44.8% vs. 20.27%) and the general Lithuanian population (44.8% vs. 13.6%) and was similar to adult COPD patients in Lithuania: Pi*S 10.3% vs. 15.8% and Pi*Z 44.8% vs. 46.1%. No association was found between AAT genotypes and wheezing severity. Finding that wheezer children exhibit a frequency of Z* and S* alleles like that found in adults with COPD suggests a potential genetic predisposition that links early wheezing in children to the development of COPD in adulthood. Larger cohort studies are needed to confirm this finding.

Abstract Patient‐reported outcome measures (PROMs) are used to assess a patient's health status at a particular point in time. They are essential in the development of person‐centred care. This paper reviews studies performed on PROMs for assessing AR and asthma control, in particular VAS scales that are included in the app MASK‐air® (Mobile Airways Sentinel networK) for asthma and rhinitis. VASs were initially developed on paper and pencil and tested for their criterion validity, cut‐offs and responsiveness. Then, a multicentric, multinational, double‐blind, placebo‐controlled, randomised control trial (DB‐PC‐RCT) using an electronic VAS form was carried out. Finally, with the development of MASK‐air® in 2015, previously validated VAS questions were adapted to the digital format and further methodologic evaluations were performed. VAS for asthma, rhinitis, conjunctivitis, work and EQ‐5D are included in the app. Additionally, two control‐medication scores for allergic symptoms of asthma (e‐DASTHMA) were validated for their criterion validity, cut‐offs and responsiveness.

INTRODUCTION: The rising global epidemic of childhood obesity is a major public health challenge. Despite the urgency, there is a lack of data on the awareness and implementation of preventative measures. The aim of this study was to identify areas for improvement in the prevention and management of childhood obesity worldwide. METHODS: A cross-sectional electronic survey was distributed to 132 members of national pediatric societies of the International Pediatric Association. RESULTS: Twenty-eight (21.2%) participants, each from a different country across six World Health Organization (WHO) regions completed the survey. Most participants reported that national prevalence data of childhood obesity is available (78.6%), and the number increased during the Coronavirus disease-2019 pandemic (60.7%). In most countries (78.6%), the amount of sugar and salt in children's products is provided but only 42.9% enacted regulations on children-targeted advertising. Childhood obesity prevention programs from the government (64.3%) and schools (53.6%) are available with existing support from private or non-profit organizations (71.4%). Participants were aware of WHO's guidance concerning childhood obesity (78.6%), while fewer were aware of The United Nations International Children's Emergency Fund's (UNICEF) guidance (50%). Participants reported that WHO/UNICEF guidance acted as a reference to develop policies, regulations and national programs. However, progress was hindered by poor compliance. Lastly, participants provided suggestions on tackling obesity, with responses ranging from developing and reinforcing policies, involvement of schools, and prevention across all life stages. DISCUSSION AND CONCLUSION: There are different practices in implementing prevention measures to counter childhood obesity globally, particularly in statutory regulation on food advertising and national programs. While support and awareness was relatively high, implementation was hindered. This reflects the need for prompt, country-specific evaluation and interventions.

Abstract Rationale It is unclear how each individual asthma symptom is associated with asthma diagnosis or control. Objectives To assess the performance of individual asthma symptoms in the identification of patients with asthma and their association with asthma control. Methods In this cross‐sectional study, we assessed real‐world data using the MASK‐air® app. We compared the frequency of occurrence of five asthma symptoms (dyspnea, wheezing, chest tightness, fatigue and night symptoms, as assessed by the Control of Allergic Rhinitis and Asthma Test [CARAT] questionnaire) in patients with probable, possible or no current asthma. We calculated the sensitivity, specificity and predictive values of each symptom, and assessed the association between each symptom and asthma control (measured using the e‐DASTHMA score). Results were validated in a sample of patients with a physician‐established diagnosis of asthma. Measurement and Main Results We included 951 patients (2153 CARAT assessments), with 468 having probable asthma, 166 possible asthma and 317 no evidence of asthma. Wheezing displayed the highest specificity (90.5%) and positive predictive value (90.8%). In patients with probable asthma, dyspnea and chest tightness were more strongly associated with asthma control than other symptoms. Dyspnea was the symptom with the highest sensitivity (76.1%) and the one consistently associated with the control of asthma as assessed by e‐DASTHMA. Consistent results were observed when assessing patients with a physician‐made diagnosis of asthma. Conclusions Wheezing and chest tightness were the asthma symptoms with the highest specificity for asthma diagnosis, while dyspnea displayed the highest sensitivity and strongest association with asthma control.

In the North Atlantic and the Northern Ocean, from the second half of 2010 to 2014, satellite imagery data showed increased surface water temperatures (in the Icelandic Depression area in September–October 2010, it was 1.3 °C higher than in 2009). The peak of the annual sum of mean monthly ocean surface temperatures near the Icelandic Depression in 2010 (109.3 °C), as well as the negative values of the monthly averaged North Atlantic Oscillation (NAO) indices, estimated in the second half of 2010 and until March 2011, can be explained by the appearance of an additional film of oil origin on the water surface, formed after an oil spill accident at the Deepwater Horizon drilling rig in the Gulf of Mexico. Insufficient evaporative cooling of surface waters near the Icelandic Depression related to the formation of an additive film due to the influence of pollution of the North Sea by oil can explain the earlier peak in the annual sum of mean monthly ocean surface temperatures near the Icelandic Depression in 2003 (107.2 °C). Although global warming is usually ascribed to increased greenhouse gases in the atmosphere, ocean surface water pollution could increase the heat content of the ocean and explain the steady temperature stratification and desalination of these waters due to the melting of Greenland’s glaciers. Thus, when analyzing the concept of global warming, it is necessary to take into account the aspects of pollution of the ocean surface waters to assess the changes in their capacity to accumulate solar radiation, as well as the changes in the heat content of the ocean mixing zone (~200 m).

BackgroundIt has been reported that the disease-initiated and disease-mediated effects of aerosol pollutants can be related to concentration, site of deposition, duration of exposure, as well as the specific chemical composition of pollutants.ObjectivesTo investigate the microelemental composition of dust aggregates in primary schools of Vilnius and determine trace elements related to acute upper respiratory infections among 6-to 11-year-old children.MethodsMicroelemental analysis of aerosol pollution was performed using dust samples collected in the classrooms of 11 primary schools in Vilnius from 2016 to 2020. Sites included areas of its natural accumulation behind the radiator heaters and from the surface of high cupboards. The concentrations of heavy metals (Pb, W, Sb, Sn, Zr, Zn, Cu, Ni, Mn, Cr, V, and As) in dust samples were analyzed using a SPECTRO XEPOS spectrometer. The annual incidence rates of respiratory diseases in children of each school were calculated based on data from medical records.ResultsThe mean annual incidence of physician-diagnosed acute upper respiratory infections (J00-J06 according to ICD-10A) among younger school-age children was between 25.1 and 71.3% per school. A significant correlation was found between vanadium concentration and the number of episodes of acute upper respiratory infections during each study year from 2016 to 2020. The lowest was r = 0.67 (p = 0.024), and the highest was r = 0.82 (p = 0.002). The concentration of vanadium in the samples of dust aggregates varied from 12.7 to 52.1 parts per million (ppm). No significant correlations between the other trace elements and the incidence of upper respiratory infections were found, which could be caused by a small number of study schools and relatively low concentrations of other heavy metals found in the samples of indoor dust aggregates.ConclusionA significant and replicable correlation was found between the concentration of vanadium in the samples of natural dust aggregates collected in primary schools and the incidence of acute upper respiratory infections in children. Monitoring the concentration of heavy metals in the indoor environment can be an important instrument for the prevention and control of respiratory morbidity in children.

The advancement of technology and the increasing digitisation of healthcare systems have opened new opportunities to transform the delivery of child health services. The importance of interoperable electronic health data in enhancing healthcare systems and improving child health care is evident. Interoperability ensures seamless data exchange and communication among healthcare entities, providers, institutions, household and systems. Using standardised data formats, coding systems, and terminologies is crucial in achieving interoperability and overcoming the barriers of different systems, formats, and locations. Paediatricians and other child health stakeholders can effectively address data structure, coding, and terminology inconsistencies by promoting interoperability and improving data quality and accuracy of children and youth, according to guidelines of the World Health Organisation. Thus, ensure comprehensive health assessments and screenings for children, including timely follow-up and communication of results. And implement effective vaccination schedules and strategies, ensuring timely administration of vaccines and prompt response to any concerns or adverse events. Developmental milestones can be continuously monitored. This can improve care coordination, enhance decision-making, and optimise health outcomes for children. In conclusion, using interoperable electronic child health data holds great promise in advancing international child healthcare systems and enhancing the child's care and well-being. By promoting standardised data exchange, interoperability enables timely health assessments, accurate vaccination schedules, continuous monitoring of developmental milestones, coordination of care, and collaboration among child healthcare professionals and the individual or their caregiver. Embracing interoperability is essential for creating a person-centric and data-driven healthcare ecosystem where the potential of digitalisation and innovation can be fully realized.

Background and objectives: Respiratory distress syndrome (RDS) frequently necessitates respiratory support. While non-invasive methods are typically the preferred approach, mechanical ventilation becomes necessary for patients with insufficient response. Our study aimed to compare two common respiratory support modes, volume-targeted mechanical ventilation and non-invasive ventilation continuous positive airway pressure (CPAP) and high-flow nasal cannula (HFNC), using electrical impedance tomography. Materials and Methods: Infants with very low birth weight and gestational ages of less than 32 weeks were eligible for inclusion in the study. All enrolled infants were beyond the transitional period (>72 h of age). The infants were divided into two groups: infants receiving invasive respiratory support through an endotracheal tube and infants receiving non-invasive respiratory support. We used electrical impedance tomography to assess end-expiratory lung impedance (EELZ), DeltaZ, heterogeneity, and regional ventilation distribution. Patients were evaluated at 0, 30, and 60 min after assuming the supine position to examine potential time-related effects. Results: Our study initially enrolled 97 infants, and the final analysis included a cohort of 72 infants. Ventilated infants exhibited significantly larger EELZ compared to their non-invasive counterparts (p = 0.026). DeltaZ was also greater in the invasive respiratory support group (p < 0.001). Heterogeneity was higher in the non-invasive group and did not change significantly over time. The non-invasive group demonstrated significantly greater ventilation in the dependent lung areas compared to intubated patients (p = 0.005). Regional distribution in the left lung was lower than in the right lung in both groups; however, this difference was significantly more pronounced in intubated patients (p < 0.001). Conclusions: Our study revealed that volume-targeted mechanical ventilation results in higher EELZ and DeltaZ compared to spontaneously breathing infants receiving non-invasive respiratory support. However, lung heterogeneity was lower during mechanical ventilation. Our study also reaffirmed that spontaneous breathing promotes greater involvement of the dependent lung compared to mechanical ventilation.

The main objective of this study is to thoroughly evaluate the diversity and sources of heavy metals in the school environment. Specifically, this study examines the presence of heavy metals in the dust found and collected from 24 schools in Vilnius. Employing hierarchical cluster analysis, principal component analysis, and positive matrix factorization, we identified combustion-related activities as primary contributors to elevated metal concentrations, notably zinc, scandium, and copper, with PM2.5/PM10 ratios indicating a combustion source. They reveal significant differences in the levels of elements such as arsenic (4.55–69.96 mg/kg), copper (51.28–395.37 mg/kg), zinc, and lead, which are affected by both local environmental factors and human activities. Elevated pollution levels were found in certain school environments, indicating environmental degradation. Pollution assessment and specific element pairings’ strong positive correlations suggested shared origins or deposition processes. While this study primarily assesses non-carcinogenic risks to children based on a health risk assessment model, it acknowledges the well-documented carcinogenic potential of substances such as lead and arsenic. The research emphasizes the immediate necessity for efficient pollution management in educational environments, as indicated by the elevated hazard index for substances such as lead and arsenic, which present non-carcinogenic risks to children. This research offers important insights into the composition and origins of dust pollution in schools. It also promotes the need for broader geographic sampling and prolonged data collection to improve our understanding of pollution sources, alongside advocating for actionable strategies such as environmental management and policy reforms to effectively reduce exposure risks in educational settings. Furthermore, it aims to develop specific strategies to safeguard the health of students in Vilnius and similar urban areas.

Children and adolescents are no longer a priority in the most recent European Programme of Work (EPW) 2020–2025 of the World Health Organization (WHO) Regional Office for Europe. In this position statement we provide arguments for why we think this population should be explicitly addressed in this important and influential document. We firstly emphasize the persistent health problems and inequalities in access to care for children and adolescents that are challenging to solve, and thus require a continuous focus. Secondly, we urge the WHO to prioritize children and adolescents in their EPW due to the new and emerging health problems related to global issues. Finally, we explain why permanent prioritization of children and adolescents is essential for the future of children and of society.

BackgroundAntimicrobial resistance (AMR) is one of the leading causes of morbidity and mortality worldwide. Efforts to promote the judicious use of antibiotics and contain AMR are a priority of several medical organizations, including the WHO. One effective way to achieve this goal is the deployment of antibiotic stewardship programs (ASPs). This study aimed to survey the current situation of pediatric ASPs in European countries and establish a baseline for future attempts to harmonize pediatric ASPs and antibiotic use in Europe.MethodsA web-based survey was conducted among national delegates of the European Academy of Paediatrics (EAP). The survey assessed the presence of pediatric ASPs in the representatives’ countries in the inpatient and outpatient settings, the staff included in the programs, and their detailed activities regarding antibiotic use.ResultsOf the 41 EAP delegates surveyed, 27 (66%) responded. Inpatient pediatric ASPs were reported in 74% (20/27) countries, and outpatient programs in 48% (13/27), with considerable variability in their composition and activities. Guidelines for managing pediatric infectious diseases were available in nearly all countries (96%), with those for neonatal infections (96%), pneumonia (93%), urinary tract (89%), peri-operative (82%), and soft tissue (70%) infections being the most common. Pediatric ASPs were reported at the national (63%), institutional (41%), and regional/local (

Summary: Background: Validated questionnaires are used to assess asthma control over the past 1–4 weeks from reporting. However, they do not adequately capture asthma control in patients with fluctuating symptoms. Using the Mobile Airways Sentinel Network for airway diseases (MASK-air) app, we developed and validated an electronic daily asthma control score (e-DASTHMA). Methods: We used MASK-air data (freely available to users in 27 countries) to develop and assess different daily control scores for asthma. Data-driven control scores were developed based on asthma symptoms reported by a visual analogue scale (VAS) and self-reported asthma medication use. We included the daily monitoring data from all MASK-air users aged 16–90 years (or older than 13 years to 90 years in countries with a lower age of digital consent) who had used the app in at least 3 different calendar months and had reported at least 1 day of asthma medication use. For each score, we assessed construct validity, test–retest reliability, responsiveness, and accuracy. We used VASs on dyspnoea and work disturbance, EQ-5D-VAS, Control of Allergic Rhinitis and Asthma Test (CARAT), CARAT asthma, and Work Productivity and Activity Impairment: Allergy Specific (WPAI:AS) questionnaires as comparators. We performed an internal validation using MASK-air data from Jan 1 to Oct 12, 2022, and an external validation using a cohort of patients with physician-diagnosed asthma (the INSPIRERS cohort) who had had their diagnosis and control (Global Initiative for Asthma [GINA] classification) of asthma ascertained by a physician. Findings: We studied 135 635 days of MASK-air data from 1662 users from May 21, 2015, to Dec 31, 2021. The scores were strongly correlated with VAS dyspnoea (Spearman correlation coefficient range 0·68–0·82) and moderately correlated with work comparators and quality-of-life-related comparators (for WPAI:AS work, we observed Spearman correlation coefficients of 0·59–0·68). They also displayed high test–retest reliability (intraclass correlation coefficients range 0·79–0·95) and moderate-to-high responsiveness (correlation coefficient range 0·69–0·79; effect size measures range 0·57–0·99 in the comparison with VAS dyspnoea). The best-performing score displayed a strong correlation with the effect of asthma on work and school activities in the INSPIRERS cohort (Spearman correlation coefficients 0·70; 95% CI 0·61–0·78) and good accuracy for the identification of patients with uncontrolled or partly controlled asthma according to GINA (area under the receiver operating curve 0·73; 95% CI 0·68–0·78). Interpretation: e-DASTHMA is a good tool for the daily assessment of asthma control. This tool can be used as an endpoint in clinical trials as well as in clinical practice to assess fluctuations in asthma control and guide treatment optimisation. Funding: None.

Abstract MASK‐air®, a validated mHealth app (Medical Device regulation Class IIa) has enabled large observational implementation studies in over 58,000 people with allergic rhinitis and/or asthma. It can help to address unmet patient needs in rhinitis and asthma care. MASK‐air® is a Good Practice of DG Santé on digitally‐enabled, patient‐centred care. It is also a candidate Good Practice of OECD (Organisation for Economic Co‐operation and Development). MASK‐air® data has enabled novel phenotype discovery and characterisation, as well as novel insights into the management of allergic rhinitis. MASK‐air® data show that most rhinitis patients (i) are not adherent and do not follow guidelines, (ii) use as‐needed treatment, (iii) do not take medication when they are well, (iv) increase their treatment based on symptoms and (v) do not use the recommended treatment. The data also show that control (symptoms, work productivity, educational performance) is not always improved by medications. A combined symptom‐medication score (ARIA‐EAACI‐CSMS) has been validated for clinical practice and trials. The implications of the novel MASK‐air® results should lead to change management in rhinitis and asthma.

The number of children suffering from respiratory allergies and asthma has been increasing worldwide and, hence, it is crucial to understand the burden of inhalant biological particles present in school facilities, where children spend one third of their life. From the perspective of indoor air quality, while there are numerous studies on outdoor bioaerosol exposure, there are still uncertainties regarding the diversity and deposition of airborne pollen and fungi indoors. When it comes to schools, there is limited research as to the potential bioaerosol exposure. Here we studied the indoor environment of public schools aiming to reveal whether primary schools of different sizes and at localities of different levels of urbanization may exhibit a variability in the biodiversity and abundance of particles of biological origin, which could pose a risk to child health. To achieve this, 11 schools were selected, located in a variety of environments, from downtown, to city centre-periphery, and to the suburbs. Fungal and pollen samples were collected from various surfaces in school classrooms and corridors, using passive air sampling and swab sampling. We demonstrated that fungi and pollen are detected in school premises during and after the vegetation season. The highest diversity of bioaerosols was found on the top of cabinets and windowsills, with Penicillium, Cladosporium and Acremonium being the most abundant indoors. The levels of fungi were higher in schools with more students. The diversity and amount of pollen in the spring were significantly higher than in samples collected in autumn. Our findings complemented existing evidence that bioaerosol measurements in schools (including kindergartens or informal education facilities) are vital. Hence, we here suggest that, in addition to monitoring air quality and bacterial levels indoors, fungi and pollen measurements have to be integrated in the existing regular biomonitoring campaigns so as to prevent exposure, increase awareness and manage efficiently allergic symptomatology.

Abstract Digital health is an umbrella term which encompasses eHealth and benefits from areas such as advanced computer sciences. eHealth includes mHealth apps, which offer the potential to redesign aspects of healthcare delivery. The capacity of apps to collect large amounts of longitudinal, real‐time, real‐world data enables the progression of biomedical knowledge. Apps for rhinitis and rhinosinusitis were searched for in the Google Play and Apple App stores, via an automatic market research tool recently developed using JavaScript. Over 1500 apps for allergic rhinitis and rhinosinusitis were identified, some dealing with multimorbidity. However, only six apps for rhinitis (AirRater, AllergyMonitor, AllerSearch, Husteblume, MASK‐air and Pollen App) and one for rhinosinusitis (Galenus Health) have so far published results in the scientific literature. These apps were reviewed for their validation, discovery of novel allergy phenotypes, optimisation of identifying the pollen season, novel approaches in diagnosis and management (pharmacotherapy and allergen immunotherapy) as well as adherence to treatment. Published evidence demonstrates the potential of mobile health apps to advance in the characterisation, diagnosis and management of rhinitis and rhinosinusitis patients.

Studies and initiatives such as the “Choosing wisely” (CW) campaign emphasise evidence-based investigations and treatment to avoid overdiagnosis and overtreatment. The perception of the extent of medical overactivity among professionals and drivers behind are not well studied in the paediatric field.AimWe aimed to investigate the physicians‘ opinion and clarify the main drivers regarding medical overactivity in member countries of the European Academy of Paediatrics (EAP).MethodsIn this study, paediatricians, paediatric residents, primary care paediatricians, and family doctors treating children were surveyed in Norway, Lithuania, Ukraine, Italy, and Switzerland. Over-investigation was defined as “diagnostic work-up or referral that is unlikely to provide information which is relevant for a patient” and overtreatment was defined as “treatment that does not benefit or can harm more than benefit the patient.” The original questionnaire was developed in 2018 by a working group from the Norwegian Paediatric Association.ResultsOverall, 1,416 medical doctors participated in the survey, ranging from 144 in Lithuania to 337 in Switzerland. 83% stated that they experienced over-investigation/overtreatment, and 81% perceived this as a problem. The majority (83%) perceived expectations from family and patients as the most important driver for overtreatment in their country. Other drivers for overuse were use of national guidelines/recommendations, worry for reactions, and reduction of uncertainty.ConclusionThis is the first study investigating knowledge and attitude toward medical overactivity in European countries. Despite different cultural and economic environments, the patterns and drivers of increased investigations and medicalisation are similar.

Abstract Background MASK‐air® is an app whose aim is to reduce the global burden of allergic rhinitis (AR) and asthma. A transfer of innovative practices was performed to disseminate and implement MASK‐air® in European regions. The aim of the study was to examine the implementation of the MASK‐air® app in Lithuanian adults in order to investigate (i) the rate of acceptance in this population, (ii) the duration of app use and (iii) the evaluation of the app after its use. Methods In a longitudinal study, Lithuanian adults with AR and/or asthma were recruited by allergists. They were informed about how to use MASK‐air® and were followed closely. They were reviewed after one to 3 months to evaluate satisfaction and were asked to continue using the app. Results Among the 149 patients recruited (37.2 ± 10.4 years), 52.4% had rhinitis alone, 42.9% had rhinitis, asthma and/or conjunctivitis multimorbidity, and 2.7% isolated asthma. According to the MASK‐air® baseline questionnaire, 88.3% of patients considered that their symptoms were troublesome. Data were available for 102 (68.4%) patients. The duration of app usage in patients ranged from 1 to 680 days (median, 25–75 percentile: 54, 23.2–151 days). Forty‐two (41.1% of patients who were reviewed) patients agreed to share their opinion on MASK‐air®. Most users of the app were satisfied, from 46.5% thinking their allergy was treated more successfully to 90.4% recommending this app to other allergy sufferers. Discussion When recommended by physicians, MASK‐air® was used for a longer period of time.

In the face of the growing number of adolescents suffering from eating disorders (EDs) and access to psychiatric care limited by the epidemiological and demographic situation, the primary care pediatrician’s role in diagnosing and treating EDs is growing. The European Academy of Paediatrics (EAP) decided to summarize knowledge about EDs and formulate recommendations to support European pediatricians and improve care for adolescents with EDs.

Abstract Background Evidence regarding the effectiveness of allergen immunotherapy (AIT) on allergic rhinitis has been provided mostly by randomised controlled trials, with little data from real‐life studies. Objective To compare the reported control of allergic rhinitis symptoms in three groups of users of the MASK‐air® app: those receiving sublingual AIT (SLIT), those receiving subcutaneous AIT (SCIT), and those receiving no AIT. Methods We assessed the MASK‐air® data of European users with self‐reported grass pollen allergy, comparing the data reported by patients receiving SLIT, SCIT and no AIT. Outcome variables included the daily impact of allergy symptoms globally and on work (measured by visual analogue scales—VASs), and a combined symptom‐medication score (CSMS). We applied Bayesian mixed‐effects models, with clustering by patient, country and pollen season. Results We analysed a total of 42,756 days from 1,093 grass allergy patients, including 18,479 days of users under AIT. Compared to no AIT, SCIT was associated with similar VAS levels and CSMS. Compared to no AIT, SLIT‐tablet was associated with lower values of VAS global allergy symptoms (average difference = 7.5 units out of 100; 95% credible interval [95%CrI] = −12.1;−2.8), lower VAS Work (average difference = 5.0; 95%CrI = −8.5;−1.5), and a lower CSMS (average difference = 3.7; 95%CrI = −9.3;2.2). When compared to SCIT, SLIT‐tablet was associated with lower VAS global allergy symptoms (average difference = 10.2; 95%CrI = −17.2;−2.8), lower VAS Work (average difference = 7.8; 95%CrI = −15.1;0.2), and a lower CSMS (average difference = 9.3; 95%CrI = −18.5;0.2). Conclusion In patients with grass pollen allergy, SLIT‐tablet, when compared to no AIT and to SCIT, is associated with lower reported symptom severity. Future longitudinal studies following internationally‐harmonised standards for performing and reporting real‐world data in AIT are needed to better understand its ‘real‐world’ effectiveness.

Abstract Vaccination is a highly effective preventive measure against COVID‐19. However, complementary treatments are needed to better control the disease. Fermented vegetables and spices, agonists of the antioxidant transcription factor nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) and TRPA1/V1 channels (Transient Receptor Potential Ankyrin 1 and Vanillin 1), may help in the control of COVID‐19. Some preliminary clinical trials suggest that curcumin (spice) can prevent some of the COVID‐19 symptoms. Before any conclusion can be drawn and these treatments recommended for COVID‐19, the data warrant confirmation. In particular, the benefits of the foods need to be assessed in more patients, through research studies and large trials employing a double‐blind, placebo‐controlled design.

Abstract. Background. The growing public health concern caused by non-communicable diseases in urban surroundings cannot be solved by health care alone; therefore a multidisciplinary approach is mandatory. This study aimed to evaluate the airborne aerosol pollution level in primary schools as possible factor influencing origin and course of the diseases in children. Methods. Seasonal aerosol particle number concentration (PNC) and mass concentration (PMC) were studied in the randomly selected eleven primary schools in the Lithuanian capital, Vilnius, as model of a middle-size Eastern European city. Total PNC in the size range from 0.01 to >1.0 μm in diameter was measured using a condensation particle counter. Using an optical particle sizer, PNC was measured and PMC estimated for particles from 0.3 to 10.0 μm. A descriptive statistics was used to estimate the aerosol pollution levels. Results. During all seasons, local cafeterias in the absence of ventilation were the main sources of the elevated levels of indoor PMC and PNC (up to 97,500 particles/cm3). The other sources of airborne particulates were the children's activity during the lesson breaks with PMC up to 586 μg/m3. Soft furniture, carpets in the classrooms and corridors were responsible for PMC up to 200 μg/m3. Outdoor aerosol pollution (up to 18,170 particles/cm3) was higher for schools in city center. Elevated air pollution in classrooms also resulted from intermittent sources, such as construction work during classes (200–1000 μg/m3) and petrol-powered lawn trimmers (up to 66,400 particles/cm3). Conclusion. The results of our survey show that even in a relatively low polluted region of Eastern Europe there are big differences in aerosol pollution within middle-sized city. Additional efforts are needed to improve air quality in schools: more frequent wet cleaning, monitoring the operation of ventilation systems, a ban on construction works during school year, on a use of sandblasting mechanisms in the neighborhood of schools.

Abstract Reported COVID-19 deaths in Germany are relatively low as compared to many European countries. Among the several explanations proposed, an early and large testing of the population was put forward. Most current debates on COVID-19 focus on the differences among countries, but little attention has been given to regional differences and diet. The low-death rate European countries (e.g. Austria, Baltic States, Czech Republic, Finland, Norway, Poland, Slovakia) have used different quarantine and/or confinement times and methods and none have performed as many early tests as Germany. Among other factors that may be significant are the dietary habits. It seems that some foods largely used in these countries may reduce angiotensin-converting enzyme activity or are anti-oxidants. Among the many possible areas of research, it might be important to understand diet and angiotensin-converting enzyme-2 (ACE2) levels in populations with different COVID-19 death rates since dietary interventions may be of great benefit.

As the tobacco epidemic has waned, it has been followed by the advent of electronic nicotine delivery devices (ENDS) primarily manufactured by the tobacco industry to try to recruit replacements for deceased tobacco addicts. This document sets out the ten recommendations of the European Academy of Paediatrics (EAP) with regard to e-cigarettes and children and young people (CYP). The EAP notes that nicotine is itself a drug of addiction, with toxicity to the foetus, child and adult, and were ENDS only to contain nicotine, their use to create a new generation of addicts would be rigorously opposed. However, e-cigarettes include numerous unregulated chemicals, including known carcinogens, whose acute and long term toxicities are unknown. The EAP asserts that there is incontrovertible evidence that the acute toxicity of e-cigarettes is greater than that of “traditional” tobacco smoking, and a variety of acute pulmonary toxicities, including acute lung injuries, have been recorded due to e-cigarettes usage. The chronic toxicity of e-cigarettes is unknown, but given the greater acute toxicity compared to tobacco, the EAP cannot assume that e-cigarettes are safer in the long term. The high uptake of e-cigarettes by CYP, including under-age children, is partly fuelled by deceitful marketing and internet exposure, which is also unregulated. Although proposed as aids to smoking cessation, there is no evidence that e-cigarettes add anything to standard smoking cessation strategies. In summary, the EAP regards these devices and liquids as very dangerous, and ineluctably opposed to their use, and their direct or indirect marketing.

Background: During the COVID-19 pandemic, telemedicine use has increased within community pediatrics. This trend runs counter to reluctance to adaptation of the new mode of healthcare that existed prior to the pandemic. Little is known about what we can expect after the pandemic: if physicians will opt for telemedicine modalities and if tele-pediatrics will continue to be a significant mode of community pediatric care.Objective: The goal of this study was to survey primary pediatric care providers as to their experiences and clinical decision making with telemedicine modalities prior to and during the COVID-19 pandemic, as well as their projected use after the pandemic ends.Material and methods: Using the EAPRASnet database we surveyed pediatricians throughout Europe, using a web-based questionnaire. The survey was performed during the COVID-19 pandemic (June–July 2020), assessed telemedicine use for several modalities, prior to and during the pandemic as well as predicted use after the pandemic will have resolved. Participants were also surveyed regarding clinical decision making in two hypothetical clinical scenarios managed by telemedicine.Results: A total of 710 physicians participated, 76% were pediatricians. The percentage of respondents who reported daily use for at least 50% of all encounters via telemedicine modalities increased during the pandemic: phone calls (4% prior to the pandemic to 52% during the pandemic), emails (2–9%), text messages (1–6%), social media (3–11%), cell-phone pictures/video (1–9%), and video conferencing (1–7%) (p < 0.005). The predicted post-pandemic use of these modalities partially declined to 19, 4, 3, 6, 9, and 4%, respectively (p < 0.005), yet demonstrating a prospectively sustained use of pictures/videos after the pandemic. Reported high likelihood of remotely treating suspected pneumonia and acute otitis media with antibiotics decreased from 8 to 16% during the pandemic to an assumed 2 and 4% after the pandemic, respectively (p < 0.005).Conclusions: This study demonstrates an increased utilization of telemedicine by pediatric providers during the COVID-19 pandemic, as well as a partially sustained effect that will promote telemedicine use as part of a hybrid care provision after the pandemic will have resolved.

Abstract Background MASK‐air® is an app that supports allergic rhinitis patients in disease control. Users register daily allergy symptoms and their impact on activities using visual analog scales (VASs). We aimed to assess the concurrent validity, reliability, and responsiveness of these daily VASs. Methods Daily monitoring VAS data were assessed in MASK‐air® users with allergic rhinitis. Concurrent validity was assessed by correlating daily VAS values with those of the EuroQol‐5 Dimensions (EQ‐5D) VAS, the Control of Allergic Rhinitis and Asthma Test (CARAT) score, and the Work Productivity and Activity Impairment Allergic Specific (WPAI‐AS) Questionnaire (work and activity impairment scores). Intra‐rater reliability was assessed in users providing multiple daily VASs within the same day. Test–retest reliability was tested in clinically stable users, as defined by the EQ‐5D VAS, CARAT, or “VAS Work” (i.e., VAS assessing the impact of allergy on work). Responsiveness was determined in users with two consecutive measurements of EQ‐5D‐VAS or “VAS Work” indicating clinical change. Results A total of 17,780 MASK‐air® users, with 317,176 VAS days, were assessed. Concurrent validity was moderate–high (Spearman correlation coefficient range: 0.437–0.716). Intra‐rater reliability intraclass correlation coefficients (ICCs) ranged between 0.870 (VAS assessing global allergy symptoms) and 0.937 (VAS assessing allergy symptoms on sleep). Test–retest reliability ICCs ranged between 0.604 and 0.878—“VAS Work” and “VAS asthma” presented the highest ICCs. Moderate/large responsiveness effect sizes were observed—the sleep VAS was associated with lower responsiveness, while the global allergy symptoms VAS demonstrated higher responsiveness. Conclusion In MASK‐air®, daily monitoring VASs have high intra‐rater reliability and moderate–high validity, reliability, and responsiveness, pointing to a reliable measure of symptom loads.

An amendment to this paper has been published and can be accessed via the original article.

Abstract Background The Nature Step to Respiratory Health was the overarching theme of the 12th General Meeting of the Global Alliance against Chronic Respiratory Diseases (GARD) in Helsinki, August 2018. New approaches are needed to improve respiratory health and reduce premature mortality of chronic diseases by 30% till 2030 (UN Sustainable Development Goals, SDGs). Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends. Planetary health and human health are interconnected, and both need to be considered by individuals and governments while addressing several SDGs. Results The concept of the Nature Step has evolved from innovative research indicating, how changed lifestyle in urban surroundings reduces contact with biodiverse environments, impoverishes microbiota, affects immune regulation and increases risk of NCDs. The Nature Step calls for strengthening connections to nature. Physical activity in natural environments should be promoted, use of fresh vegetables, fruits and water increased, and consumption of sugary drinks, tobacco and alcohol restricted. Nature relatedness should be part of everyday life and especially emphasized in the care of children and the elderly. Taking “nature” to modern cities in a controlled way is possible but a challenge for urban planning, nature conservation, housing, traffic arrangements, energy production, and importantly for supplying and distributing food. Actions against the well-known respiratory risk factors, air pollution and smoking, should be taken simultaneously. Conclusions In Finland and elsewhere in Europe, successful programmes have been implemented to reduce the burden of respiratory disorders and other NCDs. Unhealthy behaviour can be changed by well-coordinated actions involving all stakeholders. The growing public health concern caused by NCDs in urban surroundings cannot be solved by health care alone; a multidisciplinary approach is mandatory.

Abstract Background In all societies, the burden and cost of allergic and chronic respiratory diseases are increasing rapidly. Most economies are struggling to deliver modern health care effectively. There is a need to support the transformation of the health care system into integrated care with organizational health literacy. Main body As an example for chronic disease care, MASK (Mobile Airways Sentinel NetworK), a new project of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, and POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure. Three aspects of care pathways are being developed: (i) Patient participation, health literacy and self-care through technology-assisted “patient activation”, (ii) Implementation of care pathways by pharmacists and (iii) Next-generation guidelines assessing the recommendations of GRADE guidelines in rhinitis and asthma using real-world evidence (RWE) obtained through mobile technology. The EU and global political agendas are of great importance in supporting the digital transformation of health and care, and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care. Conclusion In 20 years, ARIA has considerably evolved from the first multimorbidity guideline in respiratory diseases to the digital transformation of health and care with a strong political involvement.

COVID-19 is described in a clinical case involving a patient who proposed the hypothesis that Nuclear factor (erythroid-derived 2)-like 2 (Nrf2)-interacting nutrients may help to prevent severe COVID-19 symptoms. Capsules of broccoli seeds containing glucoraphanin were being taken before the onset of SARS-CoV-2 infection and were continued daily for over a month after the first COVID-19 symptoms. They were found to reduce many of the symptoms rapidly and for a duration of 6–12 h by repeated dosing. When the patient was stable but still suffering from cough and nasal obstruction when not taking the broccoli capsules, a double-blind induced cough challenge confirmed the speed of onset of the capsules (less than 10 min). A second clinical case with lower broccoli doses carried out during the cytokine storm confirmed the clinical benefits already observed. A third clinical case showed similar effects at the onset of symptoms. In the first clinical trial, we used a dose of under 600 μmol per day of glucoraphanin. However, such a high dose may induce pharmacologic effects that require careful examination before the performance of any study. It is likely that the fast onset of action is mediated through the TRPA1 channel. These experimental clinical cases represent a proof-of-concept confirming the hypothesis that Nrf2-interacting nutrients are effective in COVID-19. However, this cannot be used in practice before the availability of further safety data, and confirmation is necessary through proper trials on efficacy and safety.

Abstract On March 29, 2017, a European Summit on the Prevention and Self-Management of Chronic Respiratory Diseases (CRD) was organized by the European Forum for Research and Education in Allergy and Airway Diseases. The event took place in the European Parliament of Brussels and was hosted by MEP David Borrelli and MEP Sirpa Pietikainen. The aim of the Summit was to correspond to the needs of the European Commission and of patients suffering from CRD to join forces in Europe for the prevention and self-management. Delegates of the European Rhinologic Society, European Respiratory Society, European Academy of Allergy and Clinical Immunology, European Academy of Paediatrics, and European Patients Organization EFA all lectured on their vision and action plan to join forces in achieving adequate prevention and self-management of CRD in the context of Precision Medicine. Recent data highlight the preventive capacity of education on optimal care pathways for CRD. Self-management and patient empowerment can be achieved by novel educational on-line materials and by novel mobile health tools enabling patients and doctors to monitor and optimally treat CRDs based on the level of control. This report summarizes the contributions of the representatives of different European academic stakeholders in the field of CRD.