Anaphylaxis in children: Effect of age and atopic status.

BACKGROUND: Anaphylaxis is a life-threatening allergic reaction with rising incidence worldwide. Young children's limited ability to express symptoms adds unique diagnostic challenges. OBJECTIVE: To study on anaphylaxis in children, including triggers, symptoms, treatment, atopic status impact, and adrenaline injection time intervals. METHODS: In-patient medical records of children who were diagnosed with anaphylaxis during 2014-2021 were reviewed. RESULTS: One hundred thirty-three anaphylaxis events were identified. Food (47%) was the most common trigger, followed by drugs (31%), blood components (17%), insects (3%), and idiopathic causes (2%). Ten cases of refractory anaphylaxis, 2 cases of biphasic reactions, and 1 case of persistent anaphylaxis were found. There were no reported fatalities. The most common presentations involved the skin (94%), followed by the respiratory (73%), gastrointestinal (47%), and cardiovascular (42%) systems. In atopic patients, wheezing was more prominent than in those without atopy (p-value = 0.017). In the non-atopic patients, there was a higher incidence of cardiovascular symptoms, particularly hypotension (p-value = 0.001), compared to individuals with atopy. Children under 5 years old with mild-moderate anaphylaxis required more time to reach the hospital (147.0 vs. 45.0 minutes, p = 0.033) and to receive adrenaline injections (35.0 vs. 9.0 minutes, p-value = 0.017) than those with severe anaphylaxis. CONCLUSION: Childhood anaphylaxis is prevalent. Children with mild-moderate anaphylaxis experienced delays in hospital visits and adrenaline administration. Education on allergies is needed to improve the identification and prompt response to anaphylactic reactions, especially in young children.

Characterization of gut microbiome profile in children with confirmed wheat allergy.

BACKGROUND: Food allergies pose serious health risks, including life-threatening anaphylactic reactions, increased morbidity, and reduced quality of life. Wheat allergy is a common concern in Asia. There is growing interest in understanding the potential association between dysregulation of the gut microbiome and the development of food allergies. OBJECTIVE: This study aimed to explore the gut microbiome of Thai children with wheat allergy and its potential association with allergic responses. METHODS: Microbial abundance was assessed using Quantitative Insights into Microbial Ecology 2 (QIIME2) microbiome analysis based on 16S rDNA data. The correlation between microbial richness and relevant parameters was evaluated using the Spearman correlation analysis. Additionally, the microbial community functions were predicted using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt2). RESULTS: The gut microbiome analysis revealed significant differences between the two groups at the phylum and genus levels. Firmicutes (p = 0.012) and Verrucomicrobia (p < 0.001) were enriched in wheat-allergic children, whereas specific gut microbes such as Megamonas (p = 0.04), Romboutsia (p < 0.001), Fusobacterium (p < 0.001), Clostridium senso stricto1 (p < 0.001), and Turicibacter (p < 0.001) were more abundant in healthy children. Anaerostripes (p = 0.011), Erysipelatoclostridium (p < 0.001), Prevotella 2 (p < 0.001), Ruminiclostridium 5 (p < 0.001), and Clostridium innnocuum (p < 0.001) were enriched in children with a confirmed wheat allergy. Functional analysis indicated disparities in the pathways related to arginine and polyamine biosynthesis. CONCLUSION: These findings offer valuable insights into the gut microbiome of children with wheat allergy and its potential impact on symptom severity, laying the groundwork for further research and interventions aimed at addressing this health concern.

Cytomegalovirus-Specific T Cells in Pediatric Liver Transplant Recipients.

Cytomegalovirus (CMV) infection is a major opportunistic infection after liver transplantation (LT) that necessitates monitoring. Because of the lack of studies in children, we aimed to investigate CMV-specific T cell immune reconstitution among pediatric LT recipients. The recipients were monitored for CMV infection and CMV-specific T cells from the start of immunosuppressive therapy until 48 weeks after LT. Clinically significant CMV viremia (csCMV) requiring preemptive therapy was defined as a CMV load of >2000 IU/mL. Peripheral blood CMV-specific T cells were analyzed by flow cytometry based on IFNγ secretion upon stimulation with CMV antigens including immediate early protein 1 (IE1) Ag, phosphoprotein 65 (pp65) Ag, and whole CMV lysate (wCMV). Of the 41 patients who underwent LT, 20 (48.8%) had csCMV. Most (17/20 patients) were asymptomatic and characterized as experiencing CMV reactivation. The onset of csCMV occurred approximately 7 weeks after LT (interquartile range: 4-12.9); csCMV rarely recurred after preemptive therapy. Lower pp65-specific CD8+ T cell response was associated with the occurrence of csCMV (p = 0.01) and correlated with increased viral load at the time of csCMV diagnosis (ρ = -0.553, p = 0.02). Moreover, those with csCMV had lower percentages of IE1-specific CD4+ and wCMV-reactive CD4+ T cells at 12 weeks after LT (p = 0.03 and p = 0.01, respectively). Despite intense immunosuppressive therapy, CMV-specific T cell immune reconstitution occurred in pediatric patients post-LT, which could confer protection against CMV reactivation.

Benefits of mobile messenger application in caregivers of food allergy children.

BACKGROUND: Unintentional exposure is common in children with food allergies. OBJECTIVE: To assess the benefits of newly developed food allergy application. METHODS: Caregivers of children with confirmed immediate reactions to food were enrolled to use the "Kinchew" application for one month. Kinchew provides the detail of food allergens after typing the name of specific food in the chat box. Then, the app provides the product image and detail of food allergens. Kinchew also has a menu for recording food diaries and videos on managing food allergies. Kinchew users were asked to assess their confidence in dealing with food allergies assessed by the questionnaire using 5 points Likert scale. The number of patients who experienced allergic reactions from unintentional food exposure was recorded after using Kinchew. RESULTS: Seventy caregivers were enrolled. Wheat was the most common causative food in 67% of the participants. All participants used Kinchew with a total use of 1,754 times, classified as food items searching 1080 times (62%), and recorded their food diary 674 times (38%). The number of patients who experienced allergic reactions from unintentional exposure significantly decreased from 61 (87%) to 31 (44%), p < 0.001.The user's confidence in choosing food improved significantly compared to the baseline score. In the subgroup analysis of the type of causative food, a significant improvement in confidence in food choosing was demonstrated in wheat and multiple food allergy groups. CONCLUSIONS: Well-designed food allergy mobile applications could improve caregivers' confidence in dealing with food allergies and reduce unintentional food exposure.

Effect of Chronic Rhinitis Treatment in Children with Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: The purpose of this study is to examine the effect of chronic rhinitis treatment on attention-deficit/hyperactivity disorder (ADHD) symptoms in children with ADHD. METHODS: Children and adolescents with ADHD were screened for chronic rhinitis symptoms. Participants with positive chronic rhinitis screening underwent the skin prick test and received rhinitis treatment for 3 months. All participants were evaluated using the parent's and teacher's Vanderbilt ADHD rating scales, total nasal symptom score, and Quality of Life Questionnaire (OSA-18) for pediatric obstructive sleep apnea at pretreatment and posttreatment. RESULTS: Overall, 140 children and adolescents with ADHD were enrolled and screened for chronic rhinitis. Fifty-four children and adolescents with positive screening results underwent the skin prick test and received rhinitis treatment. After 3 months of treatment, inattentive, hyperactive/impulsive, and total ADHD symptom scores were significantly decreased as reported by parents ( p = 0.031 to <0.001) and teachers ( p = 0.001 to <0.001) compared with those before treatment. A subgroup analysis also showed improvement in ADHD symptoms as reported by parents and teachers in the allergic and nonallergic rhinitis groups. Pearson's correlation coefficient analyses showed positive correlations between improvement in the ADHD symptom scores reported by parents and improvement in the quality of life related to sleep problems from the OSA-18 questionnaire (r = 0.377-0.387). CONCLUSION: Treating chronic rhinitis can improve ADHD symptoms in children and adolescents with ADHD. Pediatricians should be aware of and treat chronic rhinitis to maximize ADHD symptom control.

Effect of dyslipidemia, obesity, and atopic status on exhaled and alveolar nitric oxide in asthmatic children.

BACKGROUND: Dyslipidemia and obesity contribute to a pro-inflammatory state. Eosinophilic airway inflammation can be indirectly measured by fractional exhaled nitric oxide (FeNO) produced in the airways of asthmatic subjects. OBJECTIVE: To compare exhaled nitric oxide (NO) and alveolar NO in asthmatic children with and without dyslipidemia. METHODS: Asthmatic children (5-18 years old) had fasting serum low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol (HDL-C) concentrations, and C-reactive protein (CRP) concentrations measured. FeNO was measured at constant flow rates of 20, 50, 100, and 300 ml/s by the chemiluminescence method. NO concentrations in tissue of the upper airways (CawNO) and the total flux of NO in the conducting airways (JawNO) were determined through FeNO at 20, 100, and 300 ml/s using a mathematical model. The atopic status was assessed using the skin prick test for aero-allergens. RESULTS: One hundred forty-one asthmatic children were enrolled with a mean (standard deviation) age of 11.82 (3.38) years. Sixty-four (45.4%) children had dyslipidemia and 20 (14.2%) were obese. Children with low HDL-C concentrations had significantly higher CawNO and JawNO than those with normal HDL-C concentrations (both p = 0.03). Asthmatic children with obesity had higher CRP concentrations than those with a normal weight (p < 0.001). Atopic children had a significantly higher FeNO, CawNO, and JawNO than non-atopic children (all p < 0.05). CONCLUSIONS: This study suggests an effect of HDL-C on CawNO and JawNO in asthmatic children. An intervention that normalizes HDL-C concentrations may be beneficial for airway inflammation in asthmatic children.

Skin prick test and serum specific IgE in predicting dust mite-induced allergic rhinitis diagnosed from nasal provocation test in chronic rhinitis children.

BACKGROUND: Allergen skin prick test (SPT) and serum specific immunoglobulin E (sIgE) are effective diagnostic tests in allergic rhinitis (AR), however, positive results may not always correlate with clinical allergies. A nasal provocation test (NPT) can identify the causative allergen for immunotherapy, but it's not routinely performed. OBJECTIVE: To establish the cutoff value for the house dust mite (HDM) SPT mean wheal diameter (MWD) and HDM sIgE level for identifying children with HDM-induced AR diagnosed from NPT. METHODS: Children aged 5 to 18 years old with chronic rhinitis were evaluated by HDM SPT, sIgE, and NPT. Children with positive NPT results indicated HDM-induced AR. The cutoff values of the HDM SPT and sIgE level for predicting positive NPT were determined using a receiver operating characteristic curve. RESULTS: A total of 245 children with a mean age of 9.53 ± 3 years were enrolled. HDM SPT results were positive (≥ 3 mm) in 160 (65.3%) children. HDM NPT results were positive in 176 (71.8%) children. Among children with positive HDM SPT (n = 160), 153 children (95.6%) were confirmed as having AR on NPT findings. The cutoff values for positive NPT responses were 6.6 mm for HDM SPT (yielding 100% specificity and 100% positive predictive value) and 17.0 kUA/L for sIgE (98.6% specificity and 99.2% positive predictive value). CONCLUSIONS: This study proposes HDM SPT and sIgE cutoff values for use in the diagnosis of HDM-induced AR based on NPT. These cutoff values can be used to identify HDM-induced AR children who might benefit from immunotherapy.

Regulatory T cell and cytokine changes in children undergoing 3 days rush venom immunotherapy.

BACKGROUND: Rush venom immunotherapy (VIT) is the recommended treatment for patients with Hymenoptera anaphylaxis. Specific data regarding regulatory T cell and cytokine changes in children receiving rush VIT are sparse. OBJECTIVE: To study the changing of CD4+CD25+FOXP3+ regulatory T cells (Treg) and serum cytokines in children undergoing 3 days rush VIT. METHODS: Children younger than 15 years with systemic reaction to Hymenoptera who had evidence of IgE sensitization to Hymenoptera were enrolled for 3 days rush VIT. Peripheral blood CD4+CD25+FOXP3+ Treg and serum IL-4, IL5, IL-13, IFN-γ, and IL-10 were measured at baseline before rush VIT, achieving maintenance dose, 6 months, and 12 months after reaching maintenance dose. Specific IgE to Hymenoptera was measured at baseline and 12 months after VIT. RESULTS: A total of 15 children (11 boys and 4 girls) aged 6-15 years (mean age, 10 years) were enrolled. Four children were allergic to bee and 11 children were allergic to Vespid. The levels of CD4+CD25+FOXP3+ Treg were significantly increased at 6 months after maintenance dose compared with baseline (6.58% VS 4.01%, p = 0.001). Serum IL-13, IFN-γ, and IL-10 levels did not change significantly from baseline. However, there was a significant reduction of IL-4 in the serum at 12 months after MN when compared to the baseline levels. The systemic reaction requiring epinephrine intramuscular injection occurred only in 1 case who was on Vespid venoms rush VIT. CONCLUSIONS: Three days rush VIT provide acceptable systemic reaction and able to increase the number of CD4+CD25+FOXP3+ Treg in children.

Spatial Estimation of PM2.5 Exposure and its Association with Asthma Exacerbation: A Prospective Study in Thai Children.

Background: The acceptable fine particulate matter (PM2.5) level in Thailand is double the recommendation of the World Health Organization. It is necessary to have an accurate measure of PM2.5 exposure and its association with health problems in vulnerable groups such as asthma exacerbation in Thai children to urge the Clean Air Act in Thailand, which is currently in the process of revision. Objective: To study the association between PM2.5 exposure and asthma exacerbation in children living in Bangkok Metropolitan Region and Chiang Mai Province. Methods: A pilot prospective observational study was conducted at the Chest and Allergy clinic at Ramathibodi Hospital, Mahidol University, Bangkok and at the Chest Clinic at Nakornping Hospital, Chiang Mai, Thailand, from June 2020 to February 2021. Children with asthma, aged 5-18 years old, were recruited. Respiratory symptoms, including cough, chest tightness, dyspnea or wheezing, peak expiratory flow rate, and asthma exacerbation, were recorded twice daily by caregivers. Estimated average daily PM2.5 exposure levels were calculated using ArcGIS® at exacerbation day, three days before exacerbation (lag day 3), and 7 days before exacerbation (lag day 7). Regression analysis was applied to examine the association between PM2.5 exposure and asthma exacerbation. Findings: Seventy asthmatic patients were enrolled. The median age was 9.7 (IQR 5-18) years old. There were 53 respiratory symptoms, 5 admissions, and 1 intensive care unit admission. Daily PM2.5 levels above 12 mcg/m3 (the US cut-off level for the sensitive group) has higher sensitivity to detect asthma exacerbation compared to Thai cut-off level for the sensitive group (37 mcg/m3) (sensitivity 98.2% vs 32.1%). The average daily PM2.5 level exposure at lag day 3 in the exacerbation vs the non-exacerbation group was 27.5 and 13.6 mcg/m3 (p < 0.01), respectively. The daily PM2.5 level at lag day 3 was also correlated with an acute asthmatic attack (r = 0.62, p < 0.01) with the 0.2 events increasing of asthmatic exacerbation every 10 mcg/m3 of increment of daily PM2.5 level. Conclusions: Our findings suggest that asthmatic children are sensitive to daily PM2.5 levels above 12 mcg/m3. Exposure to high daily PM2.5 levels can lead to asthma exacerbation within three days. Further participant recruitment is needed to emphasize this association and establish the national data.

Improvement of inattentive and hyperactive symptoms after real-life rhinitis treatment in school-aged children.

OBJECTIVES: Rhinitis treatment may improve attention-deficit/hyperactivity symptoms in children. The current study evaluated changes in inattentive and hyperactive symptoms after treatment in children with chronic rhinitis. METHODS: Children aged 5-18 years with chronic rhinitis were enrolled in a 3-month prospective study. The nasal provocation test for house dust mites (HDM) and evaluation of allergen sensitization, including the skin prick test and the Phadiatop test, were performed. The severity of rhinitis was assessed according to the ARIA guideline. The total nasal symptom score and the Vanderbilt ADHD Diagnostic Rating Scale (VADRS) score for assessing inattentive and hyperactive symptoms were recorded at baseline and at 1 and 3 months after rhinitis treatment. Children with rhinitis were classified into the following two groups: HDM-induced allergic rhinitis (AR group) and non-allergic rhinitis to HDM (NAR group) based on the NPT. RESULTS: Overall, 83 children completed the 3-month prospective study, and they had a mean age of 9.12 ± 2.89 years and 44.6% were boys. After rhinitis treatment, VADRS scores assessed by the parents and teachers were significantly decreased compared with those at baseline (p = 0.005). In subgroup analysis, 61 (73.49%) children had AR, and 22 (26.5%) children had NAR. No significant difference in the baseline VADRS score was found between the AR and NAR groups. After treatment, VADRS scores assessed by the parents and teachers were significantly decreased only in the AR group (p < 0.001). Forty-five (54.2%) children had moderate persistent rhinitis, 29 (34.9%) had mild persistent rhinitis, and 9 (10.8%) had mild intermittent symptoms. There were no differences in baseline VADRS scores assessed by the parents and teachers among children with mild intermittent, mild persistent, or moderate persistent symptoms. The total nasal symptom score and VADRS score were significantly decreased after treatment for all severities of rhinitis compared with those at baseline. A greater baseline VADRS score was associated with substantial improvement of inattentive and hyperactive symptoms after treatment. CONCLUSION: Early treatment for rhinitis may improve inattentive and hyperactive symptoms in school-aged children.

Immunologic changes after house dust mite modified rush subcutaneous immunotherapy in allergic rhinitis children.

BACKGROUND: House dust mites (HDM) are the major causative allergen for allergic rhinitis. The sole disease-modifying therapy for allergic rhinitis is allergen immunotherapy (AIT). Rush immunotherapy is the accelerated build-up schedules to reach the target maintenance dose. OBJECTIVE: To evaluate the kinetic changes of peripheral blood CD4+CD25+FOXP3+ regulatory T cells (Treg) and serum cytokines in children undergoing 2-day modified rush HDM AIT. METHODS: Children aged 5-15 years with allergic rhinitis were enrolled for a 2-day modified rush HDM AIT. Peripheral blood CD4+CD25+FOXP3+ Treg, serum interleukin (IL)-4, IL-13, interferon-γ, and IL-10 were measured at baseline, finishing rush, achieving maintenance dose, 6 months, and 12 months after reaching maintenance dose. Specific IgE (sIgE) to HDM was evaluated at baseline and 12 months after getting the maintenance dose. Rhinitis symptoms were assessed daily using a daily card. RESULTS: A total of 12 children with a mean age of 13 years were enrolled. Rhinitis symptom-free days per month increased significantly after reaching the maintenance dose compared to baseline (from 9.5 days to 19.5 days, p = 0.002), and the maximum improvement was seen at 1 year. The levels of Treg were significantly increased at 6 months after maintenance dose compared to baseline level (6.27%±1.63% vs. 3.83%±1.80%, p < 0.001). After treatment, there were significantly decreased serum IL-13 at 1 year after maintenance but no significant changes in sIgE to HDM. The systemic reaction during AIT occurred 7 episodes from 119 shots (5.9%). CONCLUSION: Two-day modified rush HDM AIT provides acceptable systemic reactions and increases the number of CD4+CD25+FOXP3+ Treg in children.

Association of Dyslipidemia and Respiratory Resistance Assessed by the Forced Oscillation Technique in Asthmatic Children.

PURPOSE: This study aimed to evaluate the associations between dyslipidemia and pulmonary function parameters assessed by spirometry and the forced oscillation technique in asthmatic children. METHODS: Asthmatic children (5-18 years old) had fasting serum lipid profiles including low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) concentrations, and C-reactive protein (CRP) measured. Pulmonary function tests were assessed by spirometry and the forced oscillation technique (FOT). RESULTS: One hundred forty-one asthmatic children were enrolled with a mean (SD) age of 11.82 (3.38) years. Eighty-eight (62.4%) children were boys, 64 (45.4%) had dyslipidemia, and 20 (14.2%) were obese. Among the children with dyslipidemia, a high LDL-C concentration (65.6%) was the most common form of dyslipidemia, followed by high TC (57.8%), high TG (35.9%), and low HDL-C concentrations (15.6%). Multivariable analysis showed significant associations between HDL-C concentrations and respiratory resistance at 5 Hz (R5) and respiratory resistance at 20 Hz (R20), and TC concentrations were modestly associated with reactance at 5 Hz (X5), the frequency of resonance (Fres), and the area of reactance (ALX). Asthmatic children who had high LDL-C concentrations had a significantly higher expiratory phase R5, whole breath R20, and expiratory phase R20 than those in children with normal LDL-C concentrations. CONCLUSION: This study suggests an association of blood cholesterol, especially HDL-C and LDL-C, and respiratory resistance measured by the FOT, irrespective of the obesity status. An intervention for improving LDL-C and HDL-C concentrations may be beneficial on lung function parameters in asthmatic children. CLINICAL TRIAL REGISTRATION: TCTR20200305005; date of registration: 03-04-2020 (retrospectively registered).

Zinc and vitamin C deficiencies associate with poor pulmonary function in children with persistent asthma.

BACKGROUND: One of the pathophysiologic mechanisms involved in asthma is the increase in oxidative stress. Zinc (Zn), vitamin C (VC), and vitamin E (VE) have antioxidant functions. However, the status of oxidative stress, Zn, VC, and VE in Thai asthmatic children have not been reported. OBJECTIVE: We aimed to evaluate the status of oxidative stress, Zn, VC, VE, pulmonary function tests, and airway inflammation in Thai asthmatic children with persistent asthma. METHODS: In this cross-sectional study, the data was collected from asthmatic children aged 7-17 years. The plasma PGF2α concentration as a marker of oxidative stress was measured using an ELISA kit. Plasma Zn concentration was measured through atomic absorption spectrophotometry. Plasma VC and VE concentrations were determined using HPLC. Pulmonary function tests were evaluated as forced expiratory volume in first second (FEV1) and forced vital capacity (FVC), using a spirometer. The status of airway inflammation was determined by measuring fractional exhaled nitric oxide. RESULTS: There were 76 asthmatic children in this study. Seventy-two participants had high oxidative stress. All participants had Zn deficiency. Nearly 40% of participants had VC deficiency. VC deficiency was associated with severe asthma and airway obstruction. Plasma Zn concentrations were positively correlated with FEV1 (r = 0.27) and FEV1/FVC ratio (r = 0.65). CONCLUSIONS: Deficiency of Zn and/or VC was related to severe asthma and decreased pulmonary function. Nutrition assessment and management should be considered to alleviate asthma burden.

Successful haploidentical hematopoietic stem cell transplantation with post-transplant cyclophosphamide in a child with X-linked chronic granulomatous disease: A first report in Asia.

BACKGROUND: HLA-matched hematopoietic stem cell transplantation (HSCT) is the curative treatment for chronic granulomatous disease (CGD). OBJECTIVE: To report a case of X-linked CGD with active infection successfully treated by haploidentical HSCT with post-transplant high dose cyclophosphamide (PTCY). METHODS: A 5-year-old Thai boy with CGD was undergone for haploidentical HSCT using PTCY with correction of the phagocytic function. He presented with Chromobacterium violaceum liver abscess at the age of 9 months and experienced recurrent perianal abscess and invasive pulmonary aspergillosis even receiving antimicrobial prophylaxis. PTCY was given on day 3 and 4, after CD34+ cells infusion. RESULTS: The peripheral blood-nucleated cell chimerism showed 100% on day 16 and remained 100%. Dihydrorhodamine (DHR) assay on day 108 and day 214 showed normal results. Currently at 22 months post HSCT, he does not receive antibiotic and anti-fungal prophylaxis. CONCLUSIONS: Haploidentical HSCT with PTCY could be an effective treatment option for children with CGD.

Effect of vitamin D on lung function assessed by forced oscillation technique in asthmatic children with vitamin D deficiency: A randomized double-blind placebo-controlled trial.

BACKGROUND: The role of vitamin D and asthma in pulmonary function changes showed conflicting result. OBJECTIVE: To evaluate if vitamin D treatment would improve lung function assessed by forced oscillation technique (FOT) in vitamin D deficient asthmatic children. METHODS: A randomized double-blind placebo-controlled trial was performed in children, aged 3-18 years with well controlled asthma. Serum total 25(OH)D and FOT parameters including respiratory resistance at 5 Hz (R5), at 20 Hz (R20), respiratory reactance at 5 Hz (X5) and area of reactance (ALX), resonance frequency (Fres) were evaluated at baseline, 1 month and 3 months. Vitamin D deficient patients (serum total 25(OH)D < 20 ng/ml) were randomized to receive treatment with vitamin D2 (tVDD) or placebo (pVDD). Non-vitamin D deficient patients (nVDD) received placebo as a control group. RESULTS: A total of 84 children were recruited, 43 patients in nVDD group, 20 in tVDD group and 21 in pVDD group. There were no significant differences in age, sex, height and weight among groups. There were no significant differences of FOT parameters among groups at all visits. There was a trend toward decrease in R5/R20 from baseline to 1 month and 3 months visit in all groups, but the statistically significant improvement was observed only in nVDD group. Serum 25(OH)D showed no correlation with % predicted of FOT measures. CONCLUSIONS: Vitamin D treatment in asthmatic children who had vitamin D deficiency may have no short term beneficial effect on pulmonary function assessed by FOT. Vitamin D supplementation in all asthmatic patient needs further study.

Efficacy of a newly developed cartoon video on dry powder inhaler technique: a multicenter study.

BACKGROUND: One of the factors associated with uncontrolled pediatric asthma is inadequate delivery of inhaled medication to the lungs. Incorrect inhaler technique has been reported. We developed a 2-minute cartoon video instruction aiming to improve dry powder inhaler (DPI) technique. OBJECTIVE: To assess the efficacy of video instruction in improvement of DPI technique in Thai children with asthma. METHODS: The prospective multicenter cohort study was conducted during March 2018 - February 2019. Children with asthma aged 6-15 years were recruited from the outpatient departments. Five videotapes demonstrated how the patients use DPI devices were recorded as the followings: before and after watching video (V1pre and V1post), at one-month (V2post), at three-month (V3post) after watching the video and at 5-month follow-up without watching the video (V4pre). Scoring of correct DPI steps were evaluated by two independent respiratory specialists. RESULTS: Of 57 patients recruited, 30 used Accuhaler™ while 27 used Easyhaler™. In Accuhaler™ group, the median age (range) of 10 (8, 11) year. The mean score of V1pre, V1post, V2post and V3post were 10.7, 12.3, 12.4, and 12.2 out of 14 respectively. In Easyhaler™ group, the median age (range) of 11 (9-12) year. The mean score of V1pre, V1post, V2post and V3post were 8.6, 10.4, 11.2 and 11.4 out of 12 respectively. At the five-month follow-up, without watching video, the V4pre score was still as high as 12.9 ± 1.3 in Accuhaler™ and 11.8 ± 0.4 in Easyhaler™. CONCLUSIONS: Our video instruction could improve Accuhaler± and Easyhaler± technique among Thai children with asthma.

Serum Periostin Predicts Wheezing Exacerbation: A Prospective Study in Preschool Children with Recurrent Wheezing.

INTRODUCTION: Wheezing is a common problem in preschool children. Currently, there are no reliable biomarkers that can predict subsequent wheezing in preschool children. This study aimed to compare serum periostin levels between preschool children with and without recurrent wheezing and investigate its utility for predicting acute wheezing exacerbation. METHODS: Children aged 2-5 years with recurrent wheezing and healthy control children were enrolled. They were evaluated for serum periostin level at enrollment and subsequently followed for wheezing episodes in a 1-year prospective study. RESULTS: A total of 122 children were enrolled. Children in the recurrent wheezing group (n = 80) had a greater median serum periostin level (1,122.32 pg/mL [<10-6,978.93]) than that of the healthy control group (n = 40) (<10 pg/mL [<10-2,116.69]), p value = 0.006. After 1-year follow-up, subjects who experienced subsequent wheezing exacerbation episodes had a greater median of periostin level (5,321 pg/mL) compared with those with no exacerbation (<10 pg/mL), p value = 0.014. ROC curve analysis revealed that the level of serum periostin >1,200 pg/mL, corresponding to 78.9% sensitivity and 64.6% specificity, with an AUC of 0.701, p value = 0.009, could be a predictor for acute wheezing exacerbation within 1 year. Besides, subjects with serum periostin >1,200 pg/mL had greater odds of subsequent wheezing episodes compared with those with lower levels of serum periostin (adjusted odds ratio 10.0, 95% confidence interval: 2.3-43.5). CONCLUSIONS: Preschool children with recurrent wheezing have a greater serum periostin level than healthy control. Serum periostin may be a valuable biomarker for predicting acute wheezing exacerbations in the following year.

Report of clinical presentations and two novel mutations in patients with Wiskott-Aldrich syndrome/X-linked Thrombocytopenia.

Wiskott-Aldrich syndrome (WAS)/X-linked thrombocytopenia (XLT) is a rare X-linked disease characterized by thrombocytopenia, eczema, and recurrent infection. In addition, WAS/XLT increases incidence of autoimmune diseases and malignancies. We reported 7 male patients, 2 with WAS and 5 with XLT, from 6 different families. Two novel mutations, p.Gly387GlufsTer58 and p.Ala134Asp, were identified in patients with WAS. Both patients had severe clinical phenotypes compatible with classic WAS and developed lethal outcomes with intracranial hemorrhage. Other than that, one patient with XLT developed pineoblastoma.