Advances in respiratory medicine have presented a clear need for the continuous training and accreditation of health professionals, as well as of institutions providing and delivering care to respiratory patients. EBAP holds a central overarching position across Europe and overseas as an independent accreditor of training centres and educational activities with transferable and recognised CME/CPD points across countries https://bit.ly/3uZb5WT

Molds are often found in patients with pre-existing asthma, when they can be the cause of worsening asthma and even death. However, they can also represent a risk factor for the development of asthma in a previously healthy person. The most allergenic molds causing respiratory diseases are: Aspergillus, Alternaria, Penicillium and Cladosporium with an emphasis on Aspergillus in patients with asthma. In order to be inhaled their spores must be ≤5 µm in size. Germination of inhaled mold spores in the lungs is related to Th2 and Th17 pathways, as well as activation of the innate immune system, but also could promote sensitization to allergens of other mushrooms, as well as allergy to pollens and dust mites. Sensitization rates in asthma patients range from 5-50% of patients. Molds can act as internal or external sources of respiratory allergens depending on the climatic conditions. The diagnosis of fungal allergy is complicated by the fact that patients with mold allergy are often polysensitized to pollen as well. Therefore, a good allergic anamnesis and clinical picture play a key role. Regarding diagnostic procedures, the most important are serum fungal-specific IgE or precipitins, total IgE, IgG against suspected fungus, peripheral blood eosinophils and fungal-specific skin prick tests. The role of antifungal therapy in severe asthma remains unclear. Further research is needed to better define the potential utility of antifungal drugs in patients with asthma and mold sensitization or allergy to identify drugs and populations of patients who would benefit from such treatment. There is also insufficient evidence for the safety and efficacy of allergen immunotherapy in mold-sensitive patients. About 70% of patients with severe eosinophilic asthma with sensitization or allergy to Aspergillus and Penicillium could benefit with Mepolizumab therapy. On the other side, measures to avoid mold still remain key factor in therapy.

Introduction: There is limited knowledge on the sensitization patterns to peanut proteins and food allergy in the Middle East. The objective of this study is to analyze the relationship between sensitization patterns to peanut proteins and clinical symptoms in a group of patients with physician-diagnosed peanut allergy (PA) in Kuwait. Methods: PA patients were evaluated by the skin prick test (SPT), serum total IgE, peanut-specific IgE (sIgE), and sIgE against Ara h 1–3, 8, and 9, and clinical data were collected. Results: Sixty-nine patients were included. A positive correlation between peanut SPT and sIgE was detected for all 3 storage proteins (Ara h 1–3) in patients <6 years old and for Ara h 1 and 2 in older patients. ROC analysis of positive correlations showed that oral food challenge should be considered for definite diagnosis of PA only if the level of Ara h 2 is <22.25 KUA/L, with level of Ara h 2 ≥15.4 allowing the detection of systemic reactions with a sensitivity of 55.56%. Patients presenting with systemic reactions more frequently had positive Ara h 1 (88.9%) and Ara h 2 (83.3%), compared with 44.1% and 52.9% in those with local reaction (p = 0.0046 and p = 0.0378). The levels of Ara h 1 and 2 were also significantly higher in patients with systemic reactions compared to those with a local reaction, with those differences being especially relevant for Ara h 2 (15.9 vs. 0.4) (p = 0.0005). Conclusions: The pattern of sensitization to peanut proteins in the Middle East is similar to that of the Western world. Measurement of sIgE antibodies to Ara h 1, 2, and 3 is useful in the diagnosis of PA and in the investigation of reactions to raw and roasted peanuts.

BACKGROUND AND AIM   Skin prick test (SPT) with a wheal diameter of >3 mm, generally accepted as a positive, is most commonly use diagnostic tool for Allergic rhinitis. Aim was to validate wheal size of Skin Prick Test for the Bermuda grass, in desert environment, with positive Bermuda grass Nasal challenge in same environment. METHODS In 53 adults, mean age 33.43 ± 9.36 years, both gender (females: 33.96%), SPT positive on Bermuda grass with cut off wheal longest diameter of 3 mm, Bermuda grass nasal challenge test (bgNCT) was carried out. Response was assessed subjectively (scored) and objectively (PNIF). Safety profile was assessed by PEF measurement. RESULTS Mean weal size of SPT (mm) was bigger in bgNCT positive patients (n=47; 88.68%) 8 [4, 15] vs 5 [3, 6] (p<0.0001). ROC analysis showed Bermuda Grass SPT at the threshold of >6.5mm enabled identification of Bermuda challenge with sensitivity of 82.98% and specificity of 100.0% (area under the curve 0.9326, standard error 0.03528; 95% confidence interval (CI): 0.8635 to 1.002; p=0.0006203). CONCLUSIONS A SPT wheal size ≥6.5mm  might be considered as an appropriate wheal size for confirming Bermuda grass allergy in adults with SAR, avoiding the demanding, time consuming and often unavailable bgNCT, especially in patients eligible for allergen immunotherapy. In these patients, bgNCT is recommended if SPT wheal size is <6.5 mm.

Aim To analyse the resolution of chest X-ray findings in relation to laboratory parameters in patients infected with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a two- month followup. Analysis of chest X-ray findings in the first few months after the disease is the main goal of our work. Methods Out of the total of 343 patients chest X-ray findings were followed in 269 patients. Patients were divided into groups according to the severity of findings. D-dimer, inflammatory markers, blood cell count, neutrophil lymphocyte ratio (NLR) were analysed. Chest X-ray was analysed during the hospitalization on the day of admission, on the third, the seventh and the fourteenth day (scoring method was used). After discharge chest X-ray was performed in a two-week follow-up, then after one and two months, and after three months if necessary. Results Incomplete chest X-ray resolution was identified in 24 (39.34%) patients with severe, 27 (22.31 %) patients with moderate and in three (3.91%) patients with mild findings. Statistical significance was established in overall score by comparison between all groups (p<0.001), and in the moderate compared to the mild group (p=0.0051). The difference of NLR in the severe compared to the moderate group was observed (p=0.0021) and in the severe group compared to the mild group (p=0.00013). Conclusion Chest X-ray findings persisted mostly in the severe group followed by the moderate and mild ones. Long-term followup is necessary for the appropriate treatment and prevention of fibrosis, and reduction of symptoms.

Aim To identify laboratory tests for early detection and the development of more severe illness and death in COVID-19 hospitalized patients. Methods A prospective study was done on 66 hospitalized COVID-19 patients (males: 54.5%; mean age 70.1 ± 9.6 years) who were stratified into: moderate (n=36; 54.5%), severe (n=12; 18.2%), and critically ill (n=18; 27.3%). Besides clinical findings, a wide spectrum of laboratory parameters was monitored at admission and control during the first seven days of hospitalization and used to predict progression from non-severe to severe illness and to predict the final outcome. Results Critically ill patients showed a higher control value of white blood cell count, C-reactive protein, lactate dehydrogenase, ferritin, but lower lymphocyte count and O2 saturation. Patients with fatal outcome (23; 34.85%) showed a higher control value of neutrophil, lactate dehydrogenase, ferritin, and lower lymphocyte and O2 saturation. Progression from moderate to severe or critical illness was predicted by increasing lactate dehydrogenase (95% CI 0.5803 to 0.8397;p=0.003729), increase in ferritin (95% CI 0.5288 to 0.8221;p=0.03248), and by drop in O2 saturation (95% CI 0.5498 to 0.8179;p=0.01168). A fatal outcome was predicted by increase in ferritin (95% CI 0.5059 to 0.8195;p=0.04985), as well as by drop in O2 saturation (95% CI 0.5916 to 0.8803; p=0.001861). Conclusion Increase in ferritin, and drop in O2 saturation could be the most important prognostic parameters for the development of more severe clinical illness and death in COVID-19 hospitalized patients.

SUMMARY The prevalence of asthma in adults varies widely around the world, ranging from 0.2% to 21.0%. Population-based studies suggest that from 20% to 70% of people with asthma in the community remain undiagnosed. On the opposite side of the spectrum, 30–35% of adults and children diagnosed with asthma do not have current asthma. Overdiagnosis of current asthma can occur due to various reasons: 1. Physicians’ failure to confirm airflow limitation; 2. New signs and symptoms in patients with long-term clinical remission of previous asthma; 3. Alternative diagnoses that mimic signs and symptoms of asthma. The most common differential diagnosis of asthma in adults is vocal cord dysfunction, airflow obstruction (e.g. tumors and foreign bodies), congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic sinusitis and infection of upper airways. The consequences of the overdiagnosis of asthma are: 1. Not diagnosing and treating the actual disease; 2. Prolonged use of medication for asthma treatment in patients without asthma leads to the occurrence of adverse effects and complications caused by medication; 3. Unnecessary costs of treatment or increased insurance rates .

Background. Sensitization to Salsola kali (Sk) weed pollen allergen is the most common cause of seasonal allergic rhinitis (SAR) in Middle East countries. Aim. To identify Salsola kali skin prick test (SkSPT) wheal size cut-off, able to determine true allergy among adult patients with moderate to severe SAR, who are in need of Salsola kali allergen specific immunotherapy (SkAIT). Methods. In 151 adults with moderate to severe SAR, mean age 32.79 ± 10.79 years, of both gender (females: 43.05%), with a positive SkSPT, (i.e. cut off wheal longest diameter of 3 mm) and one or more other local weed pollens, Salsola kali nasal provocation test (SkNPT) was carried out. Response was assessed both subjectively, with scores, and objectively, by measuring peak nasal inspiratory flow (PNIF). Safety profile of SkNPT was assessed using peak expiratory flow rate (PEF) measurements. Results. SkNPT positive response was found in 125 patients (82.78%). Mean skin prick test (SPT) wheal size to Sk was bigger in the nasal provocatin test (NPT) positive group (9 mm) compared to the NPT negative patients (5 mm), p 7.5 mm enabled identification of SkNPT positivity with a sensitivity of 73.6% and specificity of 100.0% (area under the curve 0.9498, standard error 0.01808; 95% confidence interval (CI): 0.9144 to 0.9853; p 7.5 mm for Sk appears to distinguish individuals who develop disease from those who does not. Physicians should select the proper SPT wheal size value as an appropriate criterion according to the allergen than using a uniform cut off value in patients eligible for SkAIT.

Despite multistep efforts many asthma patients remain symptomatic. Anti-inflammatory activities of curcumin were shown. Aim was to analyse the add-on therapy with curcumin on inflammatory parameters, lung function, disease control and quality of life in asthma patients. 150 non-smokers with moderate partially controlled asthma were treated during 3 months with stable moderate dose of inhaled glucocorticoids and divided into three groups (n=50): curcumin group (receiving curcumin 500 mg per os twice daily), placebo and control group. Before study, sputum eosinophils (sEo), blood eosinophils (bEo), high sensitive C-reactive protein (hsCRP), predicted forced expiratory volume in first second (FEV1%), Asthma Control Test (ACT) and Asthma Quality of Life Questionnaire (AQLQ) were similar between groups. After study, FEV1%, ACT and AQLQ were improved in all groups, but these improvements were more prominent in curcumin group than in placebo and control. Additionally curcumin group only showed improvement in sEo, bEo and hsCRP. Furthermore, curcumin group showed also more frequent clinically significant improvement in ACT score (change>3) and in AQLQ score (change≥0.5) when compared to placebo and control. However, placebo and control showed similar distribution in FEV1%, ACT, AQLQ, hsCRP, sEo and bEo after study. This is the first placebo controlled and single-blind study to suggest that add-on therapy with curcumin could improve lung function, disease control and quality of life in moderate partially controlled asthma. Future studies may benefit from a larger sample size, longer study duration, double blind design, different dose of curcumin and/or improvements in oral bioavailability.

Sputum eosinophils might predict response to inhaled corticosteroids (ICS) in patients with advanced chronic obstructive pulmonary disease (COPD). Induction of sputum requires expertise and may not always be successful. Aim was to investigate correlation and predictive relationship between peripheral blood eosinophils (bEo) and sputum eosinophils (sEo), and impact of peripheral blood eosinophilia on outcome of COPD exacerbation. 120 current smokers with COPD (GOLD group C) (57.4 ± 0.92 years, M/F ratio 1.4), with no blood (≥7% or >0.43x109/L) nor sputum (≥3%) eosinophilia, were treated with moderate dose of ICS and long-acting bronchodilatator during stable disease, but systemic corticosteroids and antibiotics during exacerbation. According to sputum eosinophilia (≥4%) during exacerbation, patients were divided into eosinophilic (n=45) and non-eosinophilic group (n=75). In stable disease, bEo and sEo were similar in both groups (p>0.05). During exacerbation, bEo and sEo were significantly higher in eosinophilic group (eosinophilic vs. non-eosinophilic: blood: 1.42 ± 0.39 x109/l vs. 0.23 ± 0.02 x109/l, p<0.001; sputum: 8% (4, 19) vs. 1% (0, 3), p<0.0001), but bEo correlated with sEo in both groups (eosinophilic: r=0.52, p<0.001; non-eosinophilic: r=0.25, p<0.05). Relative bEo predicted sputum eosinophilia (area under the curve=0.71, standard error=0.05; 95% confidence interval [CI] =0.61-0.81; p<0.001) and enabled identification of the presence or absence of sputum eosinophilia in 82% of the cases at a threshold of ≥4% (specificity=83.56%, sensitivity=93.83%, positive likelihood ratio=3.67). Eosinophilic group during exacerbation showed less frequent hospitalisations and shorter exacerbation (eosinophilic vs. non-eosinophilic: hospitalisations: 26.7% vs. 60.0%, p<0.001; duration of exacerbation (days): 8.1±0.35 vs. 10.13±0.31, p<0.0001). In COPD exacerbation, relative peripheral blood eosinophils ≥4% might identify sputum eosinophilia. Blood eosinophilia indicate better outcome of COPD exacerbation. Further investigations are needed to predict eosinophilic exacerbation in COPD patients, with prior absence of sputum or blood eosinophilia.

The development of industry, agriculture, transport and urbanization has resulted in excessive emissions of heavy metals into the environment, which due to their bioaccumulative properties express negative effects on the environment and living organisms as a whole. In this work the presence of heavy metals in the soil samples of the urban area of Lukavac and Kalesija municipality and their effect on the health of the population were studied. Soil samples were collected in October 2017 at five locations in the urban area of Lukavac municipality and two urban locations in Kalesija municipality. Concentrations of chromium (Cr) copper (Cu), cobalt (Co), nickel (Ni), cadmium (Cd), lead (Pb), manganese (Mn), iron (Fe) and zinc (Zn) in the soil samples were determined. The results indicated that in some locations the concentration of heavy metals exceeded the maximum permissible concentration (MPC). MPC value for chromium was exceeded at four locations in the urban area of Lukavac, whereas MPC value for nickel and cadmium was exceeded at all locations. In Kalesija, MPC value was exceeded for chromium and nickel at one location, while cadmium MPC was exceeded at both locations. The negative impact of heavy metals on the health of the population is the cause of many malignant diseases. Statistical analysis of the number of patients with malignant diseases in the area of the Lukavac and Kalesija revealed significantly higher prevalence of malignant diseases of the lungs, breast, skin and cervix in the Lukavac (p<0,05) in comparisson to Kalesija municipality.