Single breath nitrogen test as predictor of lung function decline and COPD over an 8-year follow-up.

BACKGROUND: The single breath nitrogen (SBN2) test was proposed for early detection of "small airways disease" in the seventies. Few longitudinal studies have subsequently evaluated the relationships between SBN2 test measurements and lung function decline or COPD incidence. AIM: This study evaluates whether SBN2 test abnormalities may be significant predictors of lung function decline and COPD incidence over an 8-year follow-up. STUDY DESIGN AND METHODS: In this longitudinal study, 907 adults (20+ years old; 56% males) from the prospective Po River Delta epidemiological study underwent SBN2 test at baseline and spirometry testing at both baseline and follow-up 8-year apart. Multinomial and multiple regression models were used to assess associations of SBN2 indexes and rates of FEV1 decline or risk of COPD incidence over time, after adjusting for sex, height and baseline age, FEV1 and smoking status. COPD was defined according to either GOLD or ATS-ERS criteria. RESULTS: Among SBN2 indexes, only the slope of alveolar plateau (N2-slope) was significantly associated with rates of FEV1 decline (7.93 mL/year for a one-unit change in N2-slope, p<0.0001), and with an increased risk of developing COPD as defined by GOLD (RR 1.81, 95%CI 1.29-2.52, mild; RR 2.78, 95%CI 1.70-4.53, moderate or severe obstruction) and ATS-ERS criteria (RR 1.62, 95%CI 1.14-2.29, mild; RR 3.40, 95%CI 1.72-6.73, moderate or severe obstruction). CONCLUSION: In this population-based study, N2-slope from SBN2 test is a significant predictor of lung function decline and COPD incidence over an 8-year follow-up, confirming the role of the "small airways disease" in the natural history of COPD.

Venous Thromboembolism in Cancer: Frequently Asked Questions When Guidelines are Inconclusive.

Management of Venous thromboembolism (VTE) in cancer patients is difficult when guidelines are inconclusive. To share a reasonable and homogeneous behavior in such circumstances, four issues, which are felt as problematic by oncologists and surgeons, have been selected; all were uncovered or only partially covered by current guidelines. Results from the literature and author's specific experience in the field were utilized to suggest reasonable solutions to the raised questions. The reported experience is the first to provide real-world management guidance for VTE in cancer patients. The effort of putting together literature review and author's experience brought to the adoption of a common behavior.

Impact of long-term exposure to cigarette smoking on skin microvascular function.

In order to evaluate the impact of cigarettes smoking and smokers' clinical characteristics on skin microvascular function, we measured the skin forearm blood flux, basally and during post-occlusive reactive hyperaemia, in 100 current smokers (mean age 51±11 years; range: 18 to 86 years) and in 66 healthy never-smokers matched for age and sex, by using laser Doppler fluximetry (LDF). Basal and post-ischemic LDF tracings were analyzed in the frequency domain within 0.009-0.02 Hz, 0.021-0.06 Hz and 0.061-0.2 Hz ranges, related to endothelial-dependent, sympathetic-dependent and myogenic-dependent vasomotion, respectively, using an adapted version of the Fourier analysis. The post-ischemic percentage change from baseline of the area under the LDF curve (AUC%) was significantly lower in smokers than in never-smokers [162.5% (139.3-183.0) vs 190.1% (156.3-216.8); p=0.00016]. Compared to controls, smokers also showed a reduced basal power spectral density (PSD) in the myogenic-dependent vasomotion (p=0.0034) and a reduced post-ischemic percentage increase in PSD of the endothelial-dependent vasomotion (p=0.0010) and sympathetic-dependent vasomotion (p=0.0016). An inverse relationship was observed in smokers between AUC% and smoking exposure duration (r=0.23, p=0.018), pack-years (r=0.33, p=0.0007), age (r=0.26, p=0.008) and body mass index (r=0.21, p=0.037). In the multiple linear regression model, pack-years was the only variable independently associated with AUC% (r=0.21, p=0.03). This study confirms that smoking is associated with cutaneous microvascular dysfunction and shows that the severity of this impairment is independently related to the duration and intensity of the exposure to smoking.

Weight gain after smoking cessation.

Both overweight or obesity and cigarette smoking are relevant risk factors for public health. Cigarette smoking is associated with lower body weight while smoking cessation is associated with weight gain. Most smokers who quit experience a weight gain, particularly within one year, and it may persist up to 8 years after smoking cessation. However, only a minority of quitters gain excessive weight. Some individual characteristics have been found to be associated with excessive weight gain after smoking cessation while methodological problems may affect estimates of weight gain observed in different studies. Main mechanisms to explain weight gain after smoking cessation include increased energy intake, decreased resting metabolic rate, and decreased physical activity. The health benefits of smoking cessation far exceed any health risks that may result from smoking cessation-induced body weight gain. As weight gain may be a barrier against quitting smoking or a reason to restart smoking, behavioural and pharmacological methods have been evaluated to control weight gain after smoking cessation. Physicians should apply efficient strategies to promote smoking cessation on their weight-concerned smoking patient. This review briefly addresses some issues on the relationship between smoking cessation and weight gain, with regard to the size of the problem, mechanisms, health risks and control strategies.

Definition, epidemiology and natural history of COPD.

Chronic obstructive pulmonary disease (COPD) is the fifth cause of morbidity and mortality in the developed world and represents a substantial economic and social burden. Patients experience a progressive deterioration up to end-stage COPD, characterised by very severe airflow limitation, severely limited and declining performance status with chronic respiratory failure, advanced age, multiple comorbidities and severe systemic manifestations/complications. COPD is frequently underdiagnosed and under-treated. Today, COPD develops earlier in life and is less gender specific. Tobacco smoking is the major risk factor for COPD, followed by occupation and air pollution. Severe deficiency for alpha(1)-antitrypsin is rare; several phenotypes are being associated with elevated risk for COPD in the presence of risk factor exposure. Any patient presenting with cough, sputum production or dyspnoea should be assessed by standardised spirometry. Continued exposure to noxious agents promotes a more rapid decline in lung function and increases the risk for repeated exacerbations, eventually leading to end-stage disease. Without major efforts in prevention, there will be an increasing proportion of end-stage patients who can live longer through long-term oxygen therapy and assisted ventilation, but with elevated suffering and huge costs. Smoking prevention and smoking cessation are the most important epidemiological measurements to counteract chronic obstructive pulmonary disease epidemics.

Reported prevalence and co-morbidity of asthma, chronic bronchitis and emphysema: a pan-European estimation.

OBJECTIVE: Comparable population-based data exist at the European level for asthma but not for chronic obstructive pulmonary disease. Data from the World Health Organization's Large Analysis and Review of European Housing and Health Status Study conducted in random samples from eight European cities were used 1) to describe the prevalence of chronic bronchitis and emphysema (CBE) and asthma according to socio-demography, addictions, physical activities and body mass index; and 2) to identify the co-morbidities of these respiratory diseases. DESIGN: A total of 6915 adults filled out a standardised questionnaire on health outcomes, including major respiratory diseases and individual characteristics. RESULTS: Data showed that in the year preceding the survey, 3.3% of individuals had been diagnosed or treated for asthma and 6.2% for CBE. One per cent suffered simultaneously from both. Large variations were observed between cities. Physical activities and never smoking were inversely associated with CBE, independently of socio-cultural differences between the eight cities. Furthermore, both asthma and CBE were significantly related to several non-respiratory diseases, after adjustment for potential confounders. CONCLUSION: Population-based data from eight European cities show that there is a link between chronic respiratory diseases and various non-respiratory co-morbidities that needs further investigation.

Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy.

Smoking cessation is the one of the most important ways to improve the prognosis of patients with respiratory disease. The Task Force on guidelines for smoking cessation in patients with respiratory diseases was convened to provide evidence-based recommendations on smoking cessation interventions in respiratory patients. Based on the currently available evidence and the consensus of an expert panel, the following key recommendations were made. 1) Patients with respiratory disease have a greater and more urgent need to stop smoking than the average smoker, so respiratory physicians must take a proactive and continuing role with all smokers in motivating them to stop and in providing treatment to aid smoking cessation. 2) Smoking cessation treatment should be integrated into the management of the patient's respiratory condition. 3) Therapies should include pharmacological treatment (i.e. nicotine replacement therapy, bupropion or varenicline) combined with behavioural support. 4) Respiratory physicians should receive training to ensure that they have the knowledge, attitudes and skills necessary to deliver these interventions or to refer to an appropriate specialist. 5) Although the cost of implementing these recommendations will partly be offset by a reduction in attendance for exacerbations, etc., a budget should be established to enable implementation. Research is needed to establish optimum treatment strategies specifically for respiratory patients.

[Epidemiology of the chronic obstructive pulmonary disease: environmental and occupational risk]. / Epidemiologia della broncopneumopatia cronico-ostruttiva: fattori di rischio ambientali ed occupazionali.

FACTORS. Chronic Obstructive Pulmonary Disease (COPD) is a very important cause of morbidity and mortality in industrialized and developing countries. According to the World Health Organization (WHO), in 2020 COPD will become the third leading cause of death all over the world. To date, several risk factors for developing COPD have been studied. They can act either singly or interacting among themselves in a synergistic way. Smoking habits and aging are the most important factor for development and exacerbation of COPD, but environmental conditions, such as air pollution and work exposure, can be relevant factors. Recommendations for the prevention of COPD, beside the promotion of smoking cessation, may be air pollution abatement and control of professional exposure. In view of historical trend of risk factors exposure, further epidemiological studies are necessary for a better knowledge of COPD natural history.

Rhinitis is an independent risk factor for developing cough apart from colds among adults.

BACKGROUND: In cross-sectional clinical studies, rhinitis has been shown to be strongly associated with co-existing chronic cough. However, to date, this association has been poorly delineated from a prospective and epidemiological standpoint. METHODS: We used data from the 'Pisa Prospective Study', a population-based longitudinal cohort study composed of a baseline and a follow-up survey taken approximately 5 years apart from each other. Information on cough, rhinitis, and other risk factors was collected by standardized questionnaire. Cough apart from colds was defined as either 'chronic' (most days for at least 3 months for at least two consecutive years) or 'occasional' (if the three above temporal conditions were not met). 'Any' cough was defined as the presence of either occasional or chronic cough. RESULTS: Complete information was available for 1670 subjects who were > or =15 years old and had no positive history of cough apart from colds at the baseline survey. Among them, 299 (18%) had rhinitis at baseline. By the follow-up survey, 16% of the subjects with rhinitis had developed any cough apart from colds, as compared with only 10% of the subjects without rhinitis (OR 1.7, 95% CI 1.2-2.5, P < 0.005). After adjustment for age, gender, asthma status, smoking, and occupational exposure, rhinitis remained significantly associated with an increased risk both for any cough (OR 1.8, 95% CI 1.2-2.6) and for occasional and chronic cough separately (OR 2.2, 95% CI 1.1-4.5, and OR 1.7, 95% CI 1.1-2.6, respectively). CONCLUSIONS: Rhinitis is a significant and independent risk factor for developing cough among adults. Further research is needed to assess potential implications in terms of prevention.

Indoor air pollution and airway disease.

Scientific interest in indoor pollution has been increasing since the second half of the 1980s. Growing scientific evidence has shown that because people generally spend the majority of their time indoors, indoor pollution plays a significant role in affecting health and is thus an important health issue. Indoor environments include dwellings, workplaces, schools and day care centres, bars, discotheques and vehicles. Common indoor pollutants are environmental tobacco smoke, particulate matter, nitrogen dioxide, carbon monoxide, volatile organic compounds and biological allergens. In developing countries, relevant sources of indoor pollution include biomass and coal burning for cooking and heating. Concentrations of these pollutants can be many times higher indoors than outdoors. Indoor air pollution may increase the risk of irritation phenomena, allergic sensitisation, acute and chronic respiratory disorders and lung function impairment. Recent conservative estimates have shown that 1.5-2 million deaths per year worldwide could be attributed to indoor air pollution. Approximately 1 million of these deaths occur in children aged under 5 years due to acute respiratory infections, and significant proportions of deaths occur due to chronic obstructive pulmonary disease and lung cancer in women. Today, indoor air pollution ranks tenth among preventable risk factors contributing to the global burden of disease. Further research is necessary to better evaluate the respiratory health effects of indoor pollution and to implement protective programmes for public health.

Chronic cough and phlegm in young adults.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines underline that the presence of chronic cough and sputum production before airflow obstruction offers a unique opportunity to identify subjects at risk of chronic obstructive pulmonary disease for an early intervention. Current epidemiological data on these subjects are scant. Between 1998-2000, the authors evaluated the prevalence and characteristics of these symptoms by a multicentre cross-sectional survey of Italian people aged between 20-44 yrs from the general population (Italian Study on Asthma in Young Adults (ISAYA)). Besides the questions on asthma, more than 18,000 subjects answered the question: "Have you had cough and phlegm on most days for as much as 3 months per year and for at least two successive years?" The adjusted prevalence of subjects with chronic cough and phlegm was 11.9%, being 11.8% in males and 12.0% in females. From these subjects approximately 20% reported coexisting asthma and approximately 30%, predominately females, were nonsmokers. The survey showed that sex (female), smoking and low socioeconomic status were significantly and independently associated with chronic cough and phlegm, current smoking playing the major role. The prevalence of subjects with chronic cough and phlegm is startlingly high among young adults. Further follow-up studies are needed to establish how many of them will go on to develop chronic obstructive pulmonary disease.

Indoor air pollution and respiratory health in the elderly.

People spend about > or = 80-90%, of their daily time indoors, elderly people especially at home. Thus, it is important to investigate possible health effects of indoor air pollutants and to consider their contributions to the total human exposure. This report summarises current knowledge on health effects of three common indoor air pollutants, respirable suspended particles, nitrogen dioxide and environmental tobacco smoke, with focus on the adults and the elderly. Preliminary findings on exposure distributions and health effects of these pollutants in older subjects of two panel studies carried out in Italian general populations will also be reported. The two indoor pollution studies were performed in the Po Delta area in North Italy (428 subjects and 140 houses investigated) and in Pisa in Central Italy (761 subjects and 282 houses investigated). Individuals aged > or = 65 yrs spent a significantly larger number of hours at home than the other age groups both in winter and in summer. A trend of higher occurrence of acute respiratory symptoms in the presence of environmental tobacco smoke was shown in comparison to the unexposed elderly both in winter (31 versus 29%) and summer (33 versus 16%). The occurrence of acute respiratory symptoms was consistently higher in relation to the high respirable suspended particles-index exposure compared to low exposure (33 versus 27%, in winter, 27 versus 21% in summer). Both the presence of environmental tobacco smoke at home and exposure to the high respirable suspended particles-index were associated with a decrease in the mean daily peak expiratory flow.

Influence of bulla volume on postbullectomy outcome.

OBJECTIVE: To quantify the contribution of the resected volume and the presence of associated, functionally significant emphysema to the postoperative improvement of pulmonary function after resection of giant lung bullae. DESIGN: Patients undergoing elective surgery for giant bullae who had had complete pulmonary function and radiographic studies performed were reviewed retrospectively. SETTING: All 25 patients underwent surgery at the thoracic surgery unit of the University of Pisa, Pisa, Italy. METHODS: Pulmonary function was assessed before and 12 months after surgery. On the chest radiograph, the location of bullae, and the signs of compression and emphysema were evaluated. The radiographic total lung capacity (TLC(x-ray)) and the volume of bullae were measured according to the ellipse method. Postoperatively, functional and radiographic changes were analyzed. The percentage change in forced expiratory volume in 1 s (Delta FEV(1)%) after surgery was the main outcome measure. The influence of factors related to emphysema and bulla volume on the functional improvement postbullectomy was assessed by stepwise multiple regression. RESULTS: Before surgery, the TLC(x-ray) overestimated the TLC measured by nitrogen washout, with a mean difference between the two measurements of 1.095 L. A close relationship was found between the TLC(x-ray) and the plethysmographic TLC (n=6; r=0.95). After surgery, dyspnea lessened (P<0.05) and FEV(1) increased (P<0.01). Statistically, the radiographic bulla volume was the single most important factor determining the Delta FEV(1)% (r=0.80, P<0.0001). CONCLUSIONS: These findings suggest that the preoperative size of bullae is the most important contributor to the improvement in ventilatory capacity after bullectomy, and that it is possible to predict the expected increase of postoperative FEV(1) from preoperative bulla volume.

An 8-year follow-up of carbon monoxide diffusing capacity in a general population sample of northern italy.

STUDY OBJECTIVE: Diffusing capacity of the lung for carbon monoxide (DLCO) is frequently assessed as part of a thorough pulmonary function assessment in patients with pulmonary or cardiopulmonary diseases. However, little information regarding the longitudinal trends of DLCO is available. In this study, we examined the temporal trends in DLCO to determine the effects of smoking and changes in smoking habits. DESIGN: A longitudinal study was recently conducted in the Po River Delta area of northern Italy, in which DLCO measurements were taken approximately 8 years apart in the same subjects; this offered the unique opportunity to assess the temporal changes in DLCO. The longitudinal DLCO data were analyzed independently in two age groups (20 to 40 years, and > or = 40 years) using a repeated-measures analysis. RESULTS: Included were 928 subjects > 20 years old who had DLCO assessments both at baseline and follow-up. Male subjects had higher mean levels of DLCO than female subjects in the older age group (> or = 40 years). Continuous smokers had significantly lower DLCO levels than "never-smokers," but their changes in DLCO during follow-up were the same. This suggests that the lung damage due to smoking had occurred prior to DLCO testing. We also found that the annual decline in DLCO accelerated with age in adults > or = 40 years old. CONCLUSIONS: We conclude that in adults > or = 40 years of age from the general population, DLCO accelerates downwards regardless of gender, smoking, and initial FEV(1) level.

Smoking reduction in smokers compliant to a smoking cessation trial with nicotine patch.

The aim of this retrospective analysis was to assess the extent of smoking reduction in smokers who were compliant to a smoking cessation trial with nicotine patch, and failed to completely quit smoking. Out of 297 smokers in total, 237 participants received active treatment (60 received placebo). Eighty treated subjects attended all the scheduled visits and were classified as either abstainers (nonsmokers), regular smokers or occasional smokers. Compared to the remaining 157 participants, these 80 subjects had significantly lower mean baseline daily cigarette consumption (24 versus 30; p < 0.001), expired carbon monoxide levels (25 versus 33 ppm; p < 0.001), plasma nicotine and cotinine levels, and Fagerström Tolerance Questionnaire score (5.7 versus 7.0; p < 0.001). All subjects received active treatment for up to 18 weeks (full dose for 12 weeks plus tapering dose for 6 weeks), with follow-up visits scheduled up to 1 yr. A statistically significant reduction in cigarette consumption (versus baseline) was observed among both the occasional (-99%) and regular (-77%) smokers between week 1 and week 52 (p < 0.001). Concomitant smoking and patch use was well tolerated since adverse events were infrequent, mild and transient. Thus, in addition to those subjects who successfully quit smoking, a further group of subjects who attended all the follow-up visits during the smoking cessation trial significantly reduced their mean daily cigarette consumption.

Epidemiology of chronic obstructive pulmonary disease (COPD).

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality in the industrialized and the developing countries. During 1997, COPD has been estimated to be the number four cause of death after cardiovascular diseases, tumors and cerebrovascular diseases in the United States. In 2020 COPD will probably become the third leading cause of death all over the world, following the trend of increasing prevalence of lung cancer. The impact of this respiratory disease worldwide is expected to increase with a heavy economic burden on individuals and society. In the United States direct and indirect costs of COPD were estimated at about USD24 billion in 1993. Unfortunately, there are few data on health-care utilization despite the great interest in COPD among researchers. As all chronic diseases, the prevalence of COPD is strongly associated with age. Data collected in a general population sample (living in Italy) showed a progressive increase of the prevalence of chronic bronchitis and emphysema with age, both in males and in females. COPD is determined by the action of a number of various risk factors either singly or interacting among themselves in a synergistic way. Among these, the most important is cigarette smoking, ranking at the first level for developing chronic bronchitis and emphysema. Also air pollution and some occupational exposures represent risks for developing COPD. Many epidemiological studies have indicated an association between the prevalence of chronic bronchitis and a low socioeconomic status. Furthermore, in the etiology of COPD we must consider endogenous risk factors such as gender, genetic features, presence of respiratory troubles in childhood, and family history. To date, epidemiologic studies have been of great importance for the characterization of the disease at a population level, indicating possible causes and assessing its impact on the individual and on society as a whole. Unfortunately, international standards for the diagnosis of COPD are lacking, which complicates the organization of appropriate epidemiological surveys.

Characteristics of women exposed and unexposed to environmental tobacco smoke (ETS) in a general population sample of North Italy (Po River Delta epidemiological study).

To define qualitative and quantitative categories of exposure to environmental tobacco smoke (ETS) and to assess possible differences for life-style factors between exposed and unexposed women, we studied 867 nonsmoking women (8-73 aged), selected from a general population sample living in the Po Delta area (near Venice, North Italy). Information was collected by a standardized questionnaire. ETS exposure at home, at work or elsewhere was considered. There was a prevalence of ETS exposure of 46% in the whole sample; the rate had a negative association with age. Exposure to ETS occurred more frequently at home, either singly (56%) or in combination with school/work and other places (75%). Exposed women were significantly younger, taller and lighter than those unexposed. Logistic regression on 20+ aged women showed that single-separated-widowed, workers, women living in a rental house, and women with a central forced air heating were significantly more exposed to ETS. Crowding index (n inhabitants/n rooms of the house) was significantly higher in those exposed. These results indicate that ETS exposure is quite frequent in Italian women and that some life-style factors (e.g. marital status or occupational status or some home characteristics), should be considered in the study of relationship between passive smoking and respiratory health.

Smoking cessation as a therapeutic and preventive intervention: a meeting report.

In November 2000, a meeting took place on "Smoking cessation as a therapeutic and preventive intervention". The venue of the meeting was Venice, in the old Monastery of the Isola San Giorgio, and it was jointly organised by the Italian Association of Hospital Pulmonologists (AIPO) and the European Section of the Society for Research on Nicotine and Tobacco (SRNT--Europe). The meeting was also sponsored by the European Respiratory Society (ERS). The importance of the topic cannot be underestimated. According to the World Health Organisation (WHO) tobacco smoking is the most important cause of preventable death in the industrialised world. When tobacco smoking constitutes a repetitive and compulsive behaviour, for instance when a person continues smoking when suffering from a smoking related disease, it is due to tobacco dependence, which both WHO and the American Psychiatric Association classify as a disease. Tobacco smoking is not only a disease in itself but can also cause other diseases, such as chronic obstructive lung disease, lung cancer and cardiovascular disease, and can worsen pre-existent disease, e.g. asthma. In the WHO European region, according to WHO estimates, tobacco smoking causes at least 1,200,000 deaths each year (14% of all deaths). So far, a preventive strategy based on protection of children and adolescents from initiation has not worked in decreasing the prevalence among young generations. Even with the best educational programs success is partial and ephemeral. Smoking cessation with behavioural and pharmacological aid is a well established therapeutic intervention, supported by strong scientific evidence. But smoking cessation can also be a preventive intervention, because it can reduce the prevalence of smokers in a community. Obviously, smoking cessation is to be used together with all other interventions recognized as effective in tobacco control (cigarette and tobacco product pricing, regulatory approaches, smoking bans, health education).