Severe Asthma Network Italy Definition of Clinical Remission in Severe Asthma: A Delphi Consensus.

Severe asthma affects about 10% of the population with asthma and is characterized by low lung function and a high count of blood leukocytes, mainly eosinophils. Various definitions are used in clinical practice and in the literature to identify asthma remission: clinical remission, inflammatory remission, and complete remission. This work highlights a consensus for asthma remission using a Delphi method. In the context of the Severe Asthma Network Italy, which accounts for 57 severe asthma centers and more than 2,200 patients, a board of six experts drafted a list of candidate statements in a questionnaire, which has been revised to minimize redundancies and ensure clear and consistent wording for the first round (R1) of the analysis. Thirty-two statements were included in the R1 questionnaire and then submitted to a panel of 80 experts, which used a 5-point Likert scale to measure agreement regarding each statement. Then, an interim analysis of R1 data was performed, and items were discussed and considered to produce a consistent questionnaire for round 2 (R2) of the analysis. Then, the board set the R2 questionnaire, which included only important topics. Panelists were asked to vote on the statements in the R2 questionnaire afterward. During R2, the criteria of complete clinical remission (the absence of the need for oral corticosteroids, symptoms, exacerbations or attacks, and pulmonary function stability) and those of partial clinical remission (the absence of the need for oral corticosteroids, and two of three criteria: the absence of symptoms, exacerbations or attacks, and pulmonary stability) were confirmed. This Severe Asthma Network Italy Delphi analysis defined a valuable and independent tool that is easy to use, to test the efficacy of different treatments in patients with severe asthma enrolled into the SANI registry.

Different co-sensitizations could determine different risk assessment in peach allergy? Evaluation of an anaphylactic biomarker in Pru p 3 positive patients.

BACKGROUND: In Italy, the nsLTP (Pru p 3) has been identified as the most frequent cause of food allergy and anaphylaxis. In order to estimate the risk assessment in peach allergy, we investigated the presence of correlations between the levels of sIgE to Pru p 3 with the severity of the clinical symptoms in two Pru p 3 positive populations from two different areas of Italy. METHODS: 133 consecutively Pru p 3 positive patients were recruited from South Italy, where the prevalence of PR-10 and profilin sensitization is low, and from North-East Italy, where the sensitization to pathogenesis related protein -10 (PR-10) and profilin is higher. Skin prick test (SPT) to peach extract and sIgE to peach panallergens were performed. RESULTS: All 133 patients were positive to SPT to peach extract and to sIgE to Pru p 3. The North-East population was simultaneously positive to Pru p 1 (42.8 %) and Pru p 4 (12.7 %), while no Southern patients were positive to PR-10 or to profilin. A significant difference in the levels of sIgE to Pru p 3 was found only in South Italy Pru p 3 + patients vs. asymptomatic patients (p = 0.01) and in mild reactions vs. severe reactions (p = 0.0008). In South Italy patients, it was also found a significant correlation between the severity of the clinical reaction and the levels of sIgE to Pru p 3 (p = 0.001). CONCLUSION: Level of sIgE to Pru p 3 indicates the possibility of development a severe food allergic reaction. Pru p 3 positive patients from different geographical areas and with different co-sensitizations to Pru p 1 and/or Pru p 4 could have a different risk assessment in peach allergy.

Association of reduced total lung capacity with mortality and use of health services.

BACKGROUND: Pulmonary restriction is associated with increased mortality in adults, especially those who are elderly. Previous studies, however, have used the FVC as a surrogate for the total lung capacity (TLC). We evaluated the association between a reduced TLC, mortality, and health-care resources use and compared this association with a reduced FVC. METHODS: Seven hundred fifty-two patients > 60 years old and undergoing spirometry were recruited. The main analyses were performed in patients without bronchial obstruction (n = 405). Data on mortality and admission to acute care hospitals were derived. Pulmonary restriction was alternatively defined as a TLC or an FVC below the lower limit of normal (LLN). The unadjusted relative risk of mortality associated with pulmonary restriction and adjusted incidence rate ratios (IRRs) were determined. Survival analysis was repeated using time to first hospital admission as the dependent variable. RESULTS: Overall mortality was significantly higher in the group with reduced TLC compared with the group with lower FVC (10.2 per 100 patients vs 4.27 per 100 patients, respectively), with mortality rate ratios of 6.87 (95% CI, 2.54-18.24) and 2.73 (95% CI, 1.04-7.66), respectively. After adjustment, the hazard ratio (HR) for mortality associated with pulmonary restriction in patients who received diagnoses using the FVC was reduced to 2.05 (95% CI, 0.70-6.02). Reduced TLC remained strongly associated with mortality (HR, 4.52; 95% CI, 1.32-15.51). No association was found between restriction (diagnosed using either parameter) and risk for hospitalization. CONCLUSIONS: Reduced TLC is strongly associated with mortality in adults who are elderly. Reduction of the FVC is a weaker risk factor for mortality.

Pitfalls in respiratory allergy management: alexithymia and its impact on patient-reported outcomes.

OBJECTIVES: Alexithymia is a personality trait characterized by a limited ability to identify and express emotions and it represents a possible risk factor for disease development and management. The objective of the study is to evaluate alexithymia in patients with persistent asthma and comorbid rhinitis and its relation with patient-reported outcomes (PROs). METHODS: Alexithymia, quality of life, illness perception, and stress were assessed, as well as rhinitis symptoms and asthma control in out-patients classified according to GINA and ARIA guidelines. RESULTS: Out of 115 patients, 19% turned out to be alexithymic (TAS-20 ≥ 61). Concerning alexithymia level, no difference was detected between males and females (χ(2) = 0.317) and among GINA levels (χ(2) = 0.22). Alexithymics had significantly lower Asthma Control Test scores when compared with non-alexithymics (15.86 vs. 19; p = .02). Alexithymics had a worse quality of life (p< .001) and, concerning illness perception, they ascribed to respiratory allergy symptoms that are not strictly disease related and referred to asthma and rhinitis more serious negative consequences (p < .001) and emotional representations (p < .035). Moreover, they had lower illness coherence (p < .001) and lived their disease as a cyclical rather than a chronic disorder (p < .035). As regards stress, alexithymics reported less energy (p < .001), higher levels of tension (p < .001), depression (p < .001), confusion (p > .001), and inertia (p < .001). CONCLUSION: Alexithymia is present in a relevant percentage of subjects and, as it can modulate illness perception, quality of life, and stress, it should be considered in disease management.

Accuracy of spirometry in diagnosing pulmonary restriction in elderly people.

OBJECTIVES: To compare the accuracy of a diagnosis of pulmonary restriction made using forced vital capacity (FVC) less than the lower limit of normal (LLN) with the criterion standard diagnosis made using total lung capacity (TLC) less than the LLN in an elderly population. DESIGN: Retrospective analysis. SETTING: A teaching hospital. PARTICIPANTS: Five hundred sixty-four ambulatory and acute care hospital patients aged 65 to 96 underwent complete pulmonary function evaluation. MEASUREMENTS: Sensitivity, specificity, positive and negative predictive values (PPV, NPV) of diagnosis of pulmonary restriction defined as FVC less than the LLN were calculated in the overall sample and after stratification according to bronchial obstruction. Expected PPV and NPV at different background prevalence of true pulmonary restriction (5% and 15%) were calculated using the Bayes theorem. RESULTS: Low sensitivity (0.32) and high specificity (0.95) were found, with an area under the receiver operating characteristic curve (AUC) of 0.89. In participants without bronchial obstruction, specificity was even higher, although sensitivity decreased to 0.28 (AUC=0.92). The PPV was good (0.81), whereas with a low to moderate a priori probability (prevalence from 5% to 15%) the NPV was fair (> or =0.89). CONCLUSION: A reduction in FVC below LLN cannot reliably identify true pulmonary restriction in elderly people, confirming previous findings in the adult population. Normal FVC, instead, can effectively exclude pulmonary restriction regardless of the presence of bronchial obstruction when the a priori probability is low or moderately high.

Mechanisms of atherothrombosis in chronic obstructive pulmonary disease.

Patients affected by chronic obstructive pulmonary disease (COPD) have an increased risk of atherothrombotic acute events, independent of smoking and other cardiovascular risk factors. As a consequence, myocardial ischemia is a relevant cause of death in these patients. We reviewed studies concerning the potential mechanisms of atherothrombosis in COPD. Bronchial inflammation spreads to the systemic circulation and is known to play a key role in plaque formation and rupture. In fact, C-reactive protein blood levels increase in COPD and provide independent prognostic information. Systemic inflammation is the first cause of the hypercoagulable state commonly observed in COPD. Furthermore, hypoxia is supposed to activate platelets, thus accounting for the increased urinary excretion of platelet-derived thromboxane in COPD. The potential metabolic risk in COPD is still debated, in that recent studies do not support an association between COPD and diabetes mellitus. Finally, oxidative stress contributes to the pathogenesis of COPD and may promote oxidation of low-density-lipoproteins with foam cells formation. Retrospective observations suggest that inhaled corticosteroids may reduce atherothrombotic mortality by attenuating systemic inflammation, but this benefit needs confirmation in ongoing randomized controlled trials. Physicians approaching COPD patients should always be aware of the systemic vascular implications of this disease.

[Epidemiological, clinical and therapeutical aspects of HIV/HCV coinfection in a series of HIV seropositive Umbrian patients]. / Epidemiologia, clinica e terapia della coinfezione HIV-HCV in una casistica di pazienti umbri.

Because hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share common transmission pathways, HIV-HCV co-infection is frequent, involving about 40% of seropositive subjects particularly injection drug users and patients with hemophilia. We performed a retrospective analysis on clinical, epidemiological and therapeutical aspects in a population of HIV-HCV coinfected patients, observed in our Department during the period 2001-2003. Forty per cent of 404 observed patients had a co-infection; 90% of those were drug addicts and most (90.2%) were on HAART treatment. Seventy-three per cent of co-infected patients showed transaminases alterations, and 85% had detectable viremia. Prevalent genotypes were 1 (44.6%) and 3 (36.4%). The association PEG-IFN and ribavirine obtained sustained responses in 55% of 9 treated patients.