Clinical standards for diagnosis, treatment and prevention of post-COVID-19 lung disease.

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice' care for the diagnosis, treatment and prevention of post-COVID-19 lung disease.METHODS: A panel of international experts representing scientific societies, associations and groups active in post-COVID-19 lung disease was identified; 45 completed a Delphi process. A 5-point Likert scale indicated level of agreement with the draft standards. The final version was approved by consensus (with 100% agreement).RESULTS: Four clinical standards were agreed for patients with a previous history of COVID-19: Standard 1, Patients with sequelae not explained by an alternative diagnosis should be evaluated for possible post-COVID-19 lung disease; Standard 2, Patients with lung function impairment, reduced exercise tolerance, reduced quality of life (QoL) or other relevant signs or ongoing symptoms ≥4 weeks after the onset of first symptoms should be evaluated for treatment and pulmonary rehabilitation (PR); Standard 3, The PR programme should be based on feasibility, effectiveness and cost-effectiveness criteria, organised according to local health services and tailored to an individual patient's needs; and Standard 4, Each patient undergoing and completing PR should be evaluated to determine its effectiveness and have access to a counselling/health education session.CONCLUSION: This is the first consensus-based set of clinical standards for the diagnosis, treatment and prevention of post-COVID-19 lung disease. Our aim is to improve patient care and QoL by guiding clinicians, programme managers and public health officers in planning and implementing a PR programme to manage post-COVID-19 lung disease.

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.

The role of climate on the geographic variability of asthma, allergic rhinitis and respiratory symptoms: results from the Italian study of asthma in young adults.

BACKGROUND: Variations in the prevalence of respiratory symptoms according to geo-climatic factors could provide important clues to the knowledge of the aetiology of asthma. METHODS: Geo-climatic variations in the prevalence of current asthma, allergic rhinitis and chronic cough, and phlegm were assessed on a random sample of 18 873 subjects (response rate = 72.7%) from different climatic regions of Italy. An ecological analysis, supported by robust statistical methods, was employed to investigate potential trends. RESULTS: The prevalence of all symptoms was significantly heterogeneous throughout the peninsula. Only asthma-like symptoms showed a north-south trend: the prevalence increased at a decreasing latitude [odds ratio (OR) varies from 0.92 to 0.96, P < 0.05], at a decreasing distance from the sea (OR: 0.90-0.93 for 30 km distance, P < 0.05), at higher annual mean temperatures (OR: 1.11-1.14, P < 0.05) and at smaller annual temperature ranges (OR: 0.94-0.95, P < 0.05). Of the geo-climatic variables considered, temperature range had the greatest influence on most asthma-like symptoms. No association was found between geo-climatic variables and allergic rhinitis or chronic cough and phlegm. CONCLUSIONS: Asthma prevalence seems to be significantly affected by climate as asthma-like symptoms were more common in central-southern Italy, with a Mediterranean climate, than in areas with a continental climate (northern Italy).

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.

Questionnaires, spirometry and PEF monitoring in epidemiological studies on elderly respiratory patients.

Questionnaires are the most used subjective instrument of measurement in respiratory epidemiology. The standardisation of the questionnaires aims to limit bias by maximising validity and reliability, and comparability. Within the European Union project BIOMED1, a compendium of respiratory standard questionnaires (CORSQ) was developed for adults covering 18 topics from general information to early life events, through environmental risk factors and respiratory symptoms and diseases. Reliable spirometry data needs a rigorous quality control programme, as in the "Salute Respiratoria nell'Anziano" (Sa.R.A.) project, Italian for "Respiratory Health in the Elderly". Reproducibility rates were 95.8% for forced expiratory volume in one second (FEV1). Male sex and age were independent risk factors for a poorer reproducibility, as well as cognitive and physical impairment (shorter 6-min walking distance) and lower educational level for a poorer acceptability. Reference values for people aged 65-85 yrs have been produced; these results suggest that the effect of aging should be corrected for physical and mental disability. A revision of interpretative strategies included in current guidelines is needed. Peak expiratory flow monitoring has several methodological problems: reliability and sensitivity of the measurement in order to detect changes in airway calibre; compliance with long-term monitoring; choice of the best variability index; difference between asthmatic and nonasthmatic subjects; age-related differences. Despite these methodological problems, peak expiratory flow monitoring has been successfully used in the evaluation of the effects of air pollution in normal and asthmatic subjects, and in the elderly.

Longitudinal changes of body mass index, spirometry and diffusion in a general population.

The aim of this study was to evaluate the effects of body mass index (BMI) changes over an 8-yr follow-up, on longitudinal changes of vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and carbon monoxide diffusing capacity of the lung (DL,CO) indices in a general population sample of North Italy. To avoid including weight changes possibly related to physical growth, only the 1,426 adults (>24 yrs, 46% males) with complete follow-up were selected. Median linear regression models were applied to estimate the medians of change (computed as follow-up minus baseline values) of VC, FVC, FEV1 and DL,CO indices, as functions of changes of BMI over the follow-up period, separately by sex, after considering several potential confounders and effect modifiers. The extent of lung function loss tended to be higher among those who, at baseline, reported greater BMI values. Males experienced larger losses than females (20 and 16 mL FEV1 median reduction for a BMI unit increase in males and females, respectively). Conversely, longitudinal changes of BMI caused a slight and nonsignificant increase in DL,CO values in both sexes. Over an 8-yr follow-up, the detrimental effect of gaining weight might be reversible for many adults as most of those who reduced their body mass index values also increased their lung function. Overweight patients with ventilatory impairment should be routinely encouraged to lose weight for improving their lung function.

The impact of climate and traffic-related NO2 on the prevalence of asthma and allergic rhinitis in Italy.

BACKGROUND: Environmental factors are likely to be involved in explaining the wide geographical variation in asthma and atopic diseases that has been documented in many recent epidemiological studies. AIM: To evaluate to what extent climate and outdoor NO2 pollution can explain the geographical variation in the prevalence of asthma and allergic rhinitis, and to estimate the relative risk for exposure to different levels of these two factors. METHODS: The impact of climate and long-term exposure to nitrogen dioxide (NO2) pollution on asthma and allergic rhinitis was assessed in a cross-sectional study, carried out during 1998 to 2000 on young adults aged 20 to 44 years (n = 18 873), living in 13 areas from two different Italian climatic regions (subcontinental and Mediterranean). RESULTS: Mediterranean areas had a significantly higher prevalence of asthma-like symptoms (P < 0.001), higher annual mean temperature (16.2 degrees C vs. 12.9 degrees C), lower temperature range (16.0 C degrees vs. 22.1 degrees C) and lower NO2 levels (31.46 microg/m3 vs. 57.99 microg/m3) than subcontinental ones. Mediterranean climate was associated with an increased risk of wheeze (OR = 1.23; 95% CI 1.13 to 1.35), tightness in the chest (OR = 1.21; 95% CI 1.11 to 1.33), shortness of breath (OR = 1.21; 95% CI 1.08 to 1.36) and asthma attacks (OR = 1.19; 95% CI 1.07 to 1.31). After adjusting for climate, an increase of 18.3 microg/m3 in NO2 levels moderately increased the risk of asthma attacks (OR = 1.13; 95% CI 0.98 to 1.32), tightness in the chest (OR = 1.11; 95% CI 0.98 to 1.26) and wheeze (OR = 1.11; 95% CI 0.96 to 1.28). When the levels of outdoor NO2 exposure rose, the prevalence of allergic rhinitis increased significantly in the Mediterranean region (OR = 1.38; 95% CI 1.12 to 1.69), but not in the subcontinental one (OR = 1.03; 95% CI 0.83 to 1.28). CONCLUSION: Our results show that the prevalence of asthma increases when annual mean temperature increases and temperature range decreases. Furthermore, climate interacts with NO2 outdoor exposure, increasing the risk for allergic rhinitis in people exposed to high stable temperatures. A long-term role for the effect of traffic pollution on asthma is also suggested.

The Po River Delta epidemiological survey: reference values of total serum IgE levels in a normal population sample of North Italy (8-78 yrs).

The aim of this paper was to define, for the first time in Italy, normal levels of total serum IgE in a general population sample of North Italy. Total serum IgE in 1905 subjects, living in Po Delta area (near Venice), were measured by PRIST method. Normal values were derived from 558 subjects without asthma and/or asthmatic/rhinitic symptoms, noncurrent smokers, skin prick-test negatives ('normals'). Cut-off values to differentiate 'normals' from the remaining part of the sample ('others'), from asthmatic, and from rhinitic subjects, were established with the IgE value midway between the upper limit of the 95% confidence intervals (CI) of the geometric mean for 'normals' and the lower limit for 'others', asthmatics, and rhinitics, respectively. Geometric mean of normal children-adolescents was 45 kU/L (SD: 2.6; 95% CI: 38-63). In normal adults geometric mean was 29 kU/L (SD: 3.3; 95% CI: 25-40) in males and 19 kU/L (SD: 3.8; 95% CI: 16-22) in females. The diagnostic sensitivity of IgE test was low, while the specificity was very high. A good positive predictive value in discriminating 'normals' from 'others' was found, on the contrary, we found a good negative predictive value in discriminating 'normals' from asthmatics or from rhinitics. In conclusion, our results confirm that it is necessary to provide separate total serum IgE reference values for what concerns age in children-adolescents and in adults, and gender, in adults. Low serum IgE are helpful to exclude allergic asthma or rhinitis level of total.