Chronic rhinosinusitis with nasal polyposis and biological agents: the ARIA-ITALY Survey.

Summary: Background. Chronic rhinosinusitis (CRS) is an inflammatory disease that affects the nasal mucosa and the paranasal sinuses. CRS can be associated by nasal polyposis (CRSwNP phenotype) in up to 30% of patients and it is frequently associated with bronchial asthma. CRSwNP shows predominantly an underlying activation of type 2 inflammatory pathways with the involvement of eosinophils, IgE, interleukin (IL)-4, IL-5 and IL-13. Biological drugs that target these inflammatory cytokines are currently a therapeutic option recognized by guidelines for the treatment of uncontrolled form of the disease. Methods. As part of the activity of the "ARIA-Italy" working group, a panel of 255 Italian Ear, Nose and Throat (ENT) specialists, pneumologists and immuno-allergologists actively participated in this national survey and answered a series of questions geared toward understanding the main criteria for patient characterization and therapeutic decision, highlighting multidisciplinarity, and the implementation of the management of CRSwNP patients, as a part of the precision medicine concept and the appropriate use of the biologicals. Results. Two hundred and fifty-five experts and specialists participated in the survey. Conclusions. The results of this survey obtained from an extensive number of active specialists throughout Italy allow some important concluding remarks to be drawn. The main points of agreement were that multidisciplinary care teams provide many benefits but that, once the team is established, meetings and communication between members must be coordinated. Finally, the dissemination of national disease registries and the continuous updating of guidelines and position papers related to CRSwNP and comorbidities should be encouraged.

A hierarchical cluster analysis of the psycological impact of the COVID-19 pandemic on Italian severe asthma patients.

INTRODUCTION: In the context of COVID-19 pandemic, a consistent medical concern raised among severe asthma patients, though the studies excluded an increased risk of severe disease as well as an increased susceptibility.The aim of the study was to apply the Psychological General Well-Being Index (PGWBI) questionnaire to severe asthmatics during the COVID-19 pandemic and to evaluate the data with a hierarchical cluster analysis. METHODS: 114 severe asthmatics were asked to respond anonymously to the PGWBI questionnaire. The patients underwent a lung functional test, fractional exhaled nitric oxide (FeNO) measurement, Asthma Control Test (ACT), and Asthma Control Questionnaire (ACQ6). A hierarchical cluster analysis was performed using an agglomerative approach and complete linkage to evaluate the results. RESULTS: The study population predominantly included female (60%), middle-aged patients, with normal lung function parameters, mild signs of airway, and satisfactory asthma control. The PGWBI score (82.46 ± 16.53) of the study population showed a good state of psychological well-being and was similar to that of a representative sample of healthy adult Italian subjects. Thus, Hierarchical cluster analysis identified 3 groups of patients: Cluster 1 (32%), Cluster 2 (64%), and Cluster 3 (4%). Whilst the Cluster 2 patients' PGWBI score fell within the normal range, the Cluster 1 patients had a significantly lower total score (68.57 ± 7.2; p < 0.05), suggesting moderate distress. The Cluster 3 patients presented a total score markedly low. CONCLUSION: Although the majority of the severe asthma patients studied demonstrated good mental well-being during the COVID-19 pandemic, some did indeed show moderate to severe psychological distress.

Allergic rhinitis and COVID-19: friends or foes?

Summary: Allergic rhinitis (AR) is a common disease affecting up to 40% of the general population worldwide. In the Coronavirus 2019 (COVID-19) pandemic era, many observational studies analysing the effect of asthma and chronic obstructive pulmonary disease on the risk of developing COVID-19 were conducted, while data on AR are limited.In this paper, we review the risk of developing SARS-Cov-2 infection carried by AR patients, the outcomes of those with COVID-19 disease, and the COVID-19 influence on the allergic and nasal symptoms and the psychological status of AR patients, in both adult and paediatric populations.AR patients seem to be protected from COVID 19 infection. Even if data about the influence of AR on the severity of COVID-19 disease are still not conclusive, it seems that being an AR patient does not increase the risk of poor COVID-19 prognoses. The clinical manifestation of AR can be distinguished by COVID-19 symptoms. Treating AR adequately is also strongly recommended, especially during pandemic.

Biologics and global burden of asthma: A worldwide portrait and a call for action.

Biologics for severe asthma can significantly impact on the burden of disease and also have the potential to reduce asthma mortality. By reviewing the literature and contacting the pharmaceutical companies, the present paper aims at providing a worldwide snapshot of biologic drugs availability, related with the trend of asthma mortality rate, as a marker of the burden of the disease. A decline in the global rate of annual asthma mortality was observed until the 1980s, but overall no further reduction occurred, and the current mortality estimation is 0.19 deaths per 100.000 people. A higher mortality rate has been registered in low and middle-income countries (LMICs), where poor socioeconomic conditions and lack of access to the medical resources are more relevant. The availability of monoclonal antibodies is mainly limited to the developed and high-income countries. Furthermore the overall "asthma management system" in LMICs suffers from a number of restrictions that hamper the widespread availability of biologics besides their costs. The availability of generic drugs in the field of biologics for severe asthma could contribute to facilitate their widespread accessibility. But before that, awareness and expertise regarding severe asthma, and proper tools to assess and manage it, deserve to be shared worldwide. Collaboration projects involving physicians from all the countries through the scientific Academies network and with the support of the Companies active in the field may provide an initial concrete opportunity.

The potential role of local pharmacies to assess asthma control: an Italian cross-sectional study.

BACKGROUND: Asthma control and monitoring still represents a challenge worldwide. Although the international guidelines suggest the interplay between secondary and primary care services as an effective strategy to control the disease, community pharmacies' are seldom involved in asthma control assessment. The present cross-sectional study aimed at providing a picture of the relationship between asthma severity and control in community pharmacies within the health district of the city of Verona (Veneto Region, North-Eastern Italy). METHODS: A call for participation was launched through the Pharmacists' Association of Verona. Patients referring to the participating pharmacies with an anti-asthmatic drug medical prescription and an asthma exemption code were asked to complete the Asthma Control Test (ACT) and a brief questionnaire collecting information on their age, sex, smoking status, aerobic physical exercise and usual asthma therapy, which also defined asthma severity. A multinomial logistic regression model was fitted to investigate the risk of uncontrolled as well as poorly controlled vs. controlled asthma (base). Results were expressed as relative risk ratios (RRR) with 95% confidence interval (95%CI). RESULTS: Fifty-seven community pharmacies accepted to participate and 584 asthmatic patients (54% females; mean-age: 51 ± 19 years) were consecutively recruited from 1st January to 30th June 2018 (6 months). Based upon ACT score 50.5% patients had a controlled asthma, 22.3% a poorly controlled and 27.2% uncontrolled. A variable proportion of patients with uncontrolled asthma were observed for every level of severity, although more frequently with mild persistent form of asthma. Most patients (92%) self-reported regular compliance with therapy. At multinomial regression analysis, patients under regular asthma treatment course (RRR = 0.33; 95%CI: 0.15; 0.77) were less likely to have an ACT< 16 compared to those not taking medications regularly. CONCLUSIONS: Overall, our findings highlighted an unsatisfactory asthma control in the general population, independently of the severity level of the disease. Community pharmacies could be a useful frontline interface between patients and the health care services, supporting an effective asthma management plan, from disease assessment and monitoring treatment compliance to referral of patients to specialist medical consultancies.

Relevance of TH2 Markers in the Assessment and Therapeutic Management of Severe Allergic Asthma: A Real-Life Perspective.

BACKGROUND: Although blood eosinophils are currently recognized as the main clinical marker of TH2-type inflammation, their relevance in identifying asthma severity remains a matter of debate. METHODS: Our retrospective real-life study on severe asthmatics included in the NEONet Italian database aimed to investigate the relevance of blood eosinophil count and fractional exhaled nitric oxide (FeNO) in the clinical assessment of severe asthma and their role as potential predictors of responsiveness to anti-IgE therapy. The cut-off values chosen were 300 eosinophils/mm3 and FeNO of 30 ppm. RESULTS: We evaluated 132 adult patients. No significant differences were observed between the groups (high and low baseline eosinophil counts) in terms of demographic data, total IgE, lung function, patient-reported outcomes, or nasal comorbidities. The Asthma Control Test score and Asthma Quality of Life Questionnaire scores were poorer in patients with FeNO ≥30 ppb than in patients with FeNO <30 ppb. In the high FeNO subgroup, more frequent hospital admissions and a higher number of working days lost in the previous year were registered. A combined score including both eosinophils and FeNO did not improve the accuracy of the individual parameters. In the high-eosinophil subgroup, the proportion of responders to omalizumab was greater and increased at each follow-up time point. CONCLUSIONS: Our findings show that blood eosinophil count is not an unequivocal marker of asthma severity, whereas a higher FeNO level is associated with more frequent hospital admissions and more working days lost. Blood eosinophils seem to act as a predictor of response to omalizumab.

Relevance of TH2 markers in the assessment and therapeutic management of severe allergic asthma: a real-life perspective

BACKGROUND: Although blood eosinophils are currently recognized as the main clinical marker of TH2-type inflammation, their relevance in identifying asthma severity remains a matter of debate. METHODS: Our retrospective real-life study on severe asthmatics included in the NEONet Italian database aimed to investigate the relevance of blood eosinophil count and fractional exhaled nitric oxide (FeNO) in the clinical assessment of severe asthma and their role as potential predictors of responsiveness to anti-IgE therapy. The cut-off values chosen were 300 eosinophils/mm3 and FeNO of 30 ppm. RESULTS: We evaluated 132 adult patients. No significant differences were observed between the groups (high and low baseline eosinophil counts) in terms of demographic data, total IgE, lung function, patient-reported outcomes, or nasal comorbidities. The Asthma Control Test score and Asthma Quality of Life Questionnaire scores were poorer in patients with FeNO ≥30 ppb than in patients with FeNO <30 ppb. In the high FeNO subgroup, more frequent hospital admissions and a higher number of working days lost in the previous year were registered. A combined score including both eosinophils and FeNO did not improve the accuracy of the individual parameters. In the high-eosinophil subgroup, the proportion of responders to omalizumab was greater and increased at each follow-up time point. CONCLUSIONS: Our findings show that blood eosinophil count is not an unequivocal marker of asthma severity, whereas a higher FeNO level is associated with more frequent hospital admissions and more working days lost. Blood eosinophils seem to act as a predictor of response to omalizumab

ANTECEDENTES: Aunque los eosinófilos en la sangre actualmente son reconocidos como el principal marcador clínico de la inflamación Th2, su relevancia en la identificación de la gravedad del asma sigue siendo un tema de debate. MÉTODOS: Nuestro estudio retrospectivo de la vida real sobre asmáticos graves, incluido en la base de datos italiana de NEONet, tuvo como objetivo investigar la relevancia del recuento de eosinófilos en sangre y el FeNO en la evaluación clínica del asma grave y su función como posible factor predictivo de la capacidad de respuesta al tratamiento con anti-IgE. Como valores de corte se eligieron 300 eosinófilos/mm3en sangre y 30 ppm para FeNO. RESULTADOS: En total se evaluaron 132 pacientes adultos. No se pudieron observar diferencias significativas entre los grupos de eosinófilos basales altos y bajos, en términos de datos demográficos, IgE total, función pulmonar, resultados informados por el paciente (PRO) o comorbilidades nasales. Los pacientes con ≥ FeNO 30 ppb mostraron una puntuación de ACT peor y una puntuación AQLQ más baja en comparación con los de FeNO <30 ppb. En el subgrupo de FeNO alto, se registraron ingresos hospitalarios con más frecuencia y un mayor número de días de trabajo perdidos en el último año. Una puntuación combinada que incluye tanto a los eosinófilos como el FeNO no mejoró la precisión de los parámetros individuales. En el subgrupo de eosinófilos altos, la proporción de pacientes que respondieron al tratamiento con omalizumab fue mayor y aumentó significativamente en cada punto de tiempo de seguimiento. CONCLUSIONES: De acuerdo con nuestros hallazgos, los eosinófilos en sangre no representan un marcador unívoco de la gravedad del asma, mientras que un nivel más alto de FeNO se asocia con más ingresos hospitalarios y más días de trabajo perdidos. Los eosinófilos de la sangre parecen actuar como predictores de la respuesta del tratamiento al omalizumab

Use of complementary medicine among patients with allergic rhinitis: an Italian nationwide survey.

BACKGROUND: A growing use of complementary alternative medicine (CAM) has been found in Europe as well in Italy for chronic diseases, including the allergic rhinitis. The study aims at investigating the prevalence and the pattern of use of CAM amongst patient with allergic rhinitis. METHODS: A 12-item questionnaire was developed by a panel of experts and administered to patients with moderate/severe allergic rhinitis consecutively referring during the study time-frame to seven allergy clinics placed all around Italy. The items covered several topics including reason for choosing CAM, its clinical efficacy, schedule of treatment, costs, type of therapy. RESULTS: Overall 359 questionnaires were analysed. 20% of patients declared CAM use. A significant correlation between the use of CAM and female sex (p < 0.01) and with a higher level of education (p < 0.01) was observed. CAM users were adults (36% in the range between 20 and 40 years and 32% between 41 and 60 years). Youngsters (< 20 years) (7%) and elderly (> 60) (25%) less frequently used CAM.The most used type of CAM was homoeopathy (77% of patients). 60% of users would recommend CAM despite a poor clinical efficacy according to 67% of them. CONCLUSIONS: Although no evidence supports CAM efficacy and safety, the number of patients who relies on it is not negligible. As allergic rhinitis is not a trivial disease, the use of CAM as the only treatment for it should be discouraged at any level, but by general practitioner and specialist in particular.

Influence of very short rest period lengths on repeated one maximun repetition bench press performance / Influencia del muy corto periodo de descanso en repetidos intentos de una repetición máxima en el press de banca / Influência do período de descanso muito curto em tentativas repetidas testes de uma repetição máxima em supino horizontal

Objective: The purpose of this investigation was to compare different rest period lengths between consecutive one maximum repetition bench press attempts on performance and ratings of perceived exertion. Method: Eighteen trained men (27.95 ± 4.25 years; 81.00 ± 9.21 kg; 174.62 ± 3.34 cm; bench press relative strength 1.33 ± 0.11 kg/kg of body mass) participated in three randomly ordered sessions that required two consecutive one maximum repetition bench press attempts with 20, 40, or 60-s rest between attempts. Results: The Cochran Q analysis showed no significant differences in the ability to successfully perform a second one maximum repetition attempt with 20, 40, or 60-s rest between attempts (p = 0.882). Specifically, no significant differences were found in the successful completion of the first and second attempts for the 20-s (p = 0.317), 40-s (p = 0.083), and 60-s (p = 0.157) trials, respectively. Briefly, for both 20 and 60-s rest conditions DELTA% = 88.88% of subjects successfully performed the second attempt and, for the 40-s protocol, only DELTA% = 83.33% completed. For the pre and post-set ratings of perceived exertion, the shorter rest period (20-s) promoted significantly higher values compared to the longer rest periods (pre-set ratings of perceived exertion, p = 0.04; post-set ratings of perceived exertion, p = 0.023). Conclusions: The results of this study can be applied to recreationally trained individuals with the intent of generating a time-efficient process for conducting a valid and reliable one maximum repetition bench press assessment

Objetivo: El objetivo de esta investigación fue comparar diferentes duraciones del periodo de descanso entre tentativas consecutivas de una repetición máxima de press de banca en el rendimiento y la percepción subjetiva del esfuerzo. Método: Dieciocho hombres entrenados (27.95 ± 4.25 años; 81.00 ± 9.21 kg; 174.62 ± 3.34 cm; fuerza relativa en el press de banca de 1.33 ± 0.11 kg/kg masa corporal) participaron en tres sesiones ordenadas al azar que requerían dos intentos consecutivos de una repetición máxima en el press de banca con 20, 40 y 60 segundos de descanso entre las tentativas. Resultados: La prueba Q de Cochran no mostró diferencias significativas en la habilidad de ejecutar la segunda tentativa de una repetición máxima de modo exitoso con 20, 40 o 60 segundos de descanso entre tentativas (p = 0.882). En concreto, no se encontró ninguna diferencia significativa en la conclusión satisfactoria entre la primera y la segunda tentativa para las pruebas de 20 segundos (p = 0.317), 40 segundos (p = 0.083) y 60 segundos (p = 0.157), respectivamente. En resumen, para las condiciones de descanso de 20 y 60 segundos DELTA% = 88.88% de los sujetos realizaron satisfactoriamente el segundo intento y, para el protocolo de 40 segundos, sólo DELTA% = 83.33%. Para antes y después de la prueba de percepción subjetiva del esfuerzo, el período de descanso más corto (20 segundos) promovió valores significativamente más altos en comparación con los períodos de descanso más largos (pre-prueba de percepción subjetiva del esfuerzo, p = 0.04; postprueba de percepción subjetiva del esfuerzo, p = 0.023). Conclusiones: Los resultados de este estudio pueden aplicarse a individuos entrenados de forma recreativa con la intención de generar un proceso eficiente en el tiempo para la realización de una evaluación válida y fiable de una repetición máxima del press de banca

Objetivo: O objetivo do estudo foi comparar diferentes tempos de intervalo (≤60 segundos) entre tentativas de uma repetição máxima, na execução do exercício de supino e percepção subjetiva de esforço. Métodos: Dezoito homens treinados (27.95 ± 4.25 anos; 81.00 ± 9.21 kg; 174.62 ± 3.34 cm; força relativa no supino 1.33 ± 0.11 kg/kg de massa corporal) participaram em três sessões ordenadas de forma aleatória e exigido dois séries consecutivas de supino uma repetição máxima com 20, 40, ou 60 segundos de descanso entre as tentativas. Resultados: A análise Q de Cochran não mostrou diferenças significativas na capacidade de executar com sucesso uma segunda tentativa de uma repetição máxima com 20, 40 ou 60 segundos de descanso entre as tentativas (p = 0.882). Especificamente, não foram encontradas diferenças significativas na conclusão bem-sucedida entre primeira e segunda tentativas de 20 segundos (p = 0.317), de 40 segundos (p = 0.083) e 60 segundos (p = 0.157) entre os ensaios, respectivamente. Em resumo, para os 20 e 60 segundos em condições de descanso, DELTA% = 88.88% dos sujeitos realizaram com sucesso a segunda tentaiva e, para o protocolo de 40 segundos, somente DELTA% = 83.33% concluíram. Para os dados da percepção subjetiva de esforço, durante o pré e o pós-teste, o intervalo mais curto (20 segundos) promoveu valores significativamente mais elevados em comparação com longos períodos de descanso (percepção subjetiva de esforço pré-teste, p = 0.04; percepção subjetiva de esforço pós-teste, p = 0.023). Conclusões: Independente do aumento da sensação de esforço observado pela percepção subjetiva de esforço no curto intervalo (20 segundos), os indivíduos têm sido bem-sucedidos no intervalo de dois séries consecutivas de uma repetição máxima no supino para qualquer intervalo testado

Teste de uma repetição máxima em exercício multi e monoarticulares em distintos protocolos de privação visual / Prueba de una repetición máxima para ejercicios multi y monoarticulares con diferentes protocolos con y sin deprivación visual / One repetition aximum tests for multi-joint exercise and single-joint exercise in different visual deprivation protocols

Objetivo. Verificar os valores do teste de uma repetição máxima nos exercícios multi e monoarticulares, com e sem privação visual. Método. Doze homens treinados (23.00±4.80 anos; 80.76±8.09kg; 1.76±0.05cm) realizaram 4 visitas (2 para cada exercício) constando de testes de uma repetição máxima para exercícios multi (agachamento na barra guiada) e monoarticulares (rosca bíceps), com ou sem privação visual. Resultados. O teste T não verificou diferenças importantes entre os métodos de privação visual para o exercício multiarticular, tanto para a força absoluta (Δ%=‐ 6.13%; p=0.422), quanto para a força relativa (p=0.397). O mesmo ocorreu para o exercício monoarticular, tanto para a força absoluta (Δ%=1.43%; p=0.220), como para a relativa (p=0.230). Adicionalmente, um pequeno tamanho do efeito foi verificado entre os testes de uma repetição máxima nos exercícios multi e monoarticulares, nos protocolos com e sem privação visual. Conclusão. De acordo com os resultados do estudo, podemos concluir que, para os exercícios multi e monoarticulares, o método de privação visual não promove diferenças importantes no deslocamento de cargas na execução do teste de uma repetição máxima (AU)

Objetivo. Determinar los valores del test de una repetición máxima en los ejercicios multi y monoarticulares con y sin deprivación visual. Método. Doce hombres entrenados (23.00±4.80 años; 80.76±8.09kg; 1.76±0.05m) realizaron 4 visitas (2 para cada ejercicio) que consiste en prueba de una repetición máxima para el ejercicio multiarticular (sentadilla con barra guiada) y el ejercicio de una sola articulación (flexión del codo), con y sin deprivación visual. Resultados. La prueba T no encontró diferencias significativas entre los métodos de deprivación visual para el ejercicio multiarticular, tanto en la fuerza absoluta (Δ%=‐ 6.13%; p=0.422) como fuerza relativa (p=0.397). Lo mismo ocurrió para el ejercicio monoarticular, para la fuerza absoluta (Δ%=1.43%; p=0.220) y la fuerza relativa (p=0.230). Además, se observó un tamaño de efecto pequeño entre las pruebas de una repetición máxima en los ejercicios multiarticulares y monoarticulares en ambos protocolos visuales. Conclusiones. De acuerdo con los resultados del estudio, se puede concluir que para los ejercicios multiarticulares y monoarticulares el protocolo de deprivación visual no causa diferencias significativas en el desplazamiento de cargas en la prueba de una repetición máxima (AU)

Objective. The aim of the study was to determine values of the 1RM test in multi and single‐joint exercises with and without visual deprivation. Method. Twelve trained men (23.00±4.80 years; 80.76±8.09kg; 1.76±0.05cm) performed four visits (two for each exercise) consisting in 1RM tests for multi‐joint exercise (guided bar squat) and single‐joint exercise (biceps curl), with or without visual deprivation. Results. The T test found no significant differences between the visual deprivation methods for multi‐joint exercise both in absolute strength (Δ%=‐ 6.13%; p=0.422) as for relative strength (p=0.397). The same occurred for the single‐joint exercise for absolute strength (Δ%=1.43%; p=0.220) and for relative strength (p=0.230). Additionally, a small effect size was observed between 1RM tests in multi and single‐joint exercises in both visual protocols. Conclusion. According to the study results, we can conclude that for multi and single‐joint exercises protocol visual deprivation do not cause significant differences in the displacement of loads in 1RM test execution (AU)

Thunderstorm asthma: a critical appraisal based on clinical practice

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Eosinophilic granulomatosis with polyangiitis and cardiac involvement: a case report

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Evaluation of asthma control in the pharmacy: an Italian cross-sectional study.

SUMMARY: Background. In Western countries a large proportion of asthmatic patients remain uncontrolled, despite the availability of effective drugs. An involvement of pharmacies / pharmacists in asthma management has been suggested in guidelines, since this could provide a relevant support. Objective. The present cross-sectional study aimed at assessing the level of asthma control, by using ACT questionnaire, in the community pharmacies in the County of Verona, North East of Italy. Methods. A call for participation was sent by Verona Pharmacists' Association to all the pharmacies located in the Verona municipality. Patients with a medical prescription and an asthma exemption code were recruited in pharmacies. They were asked to fill the ACT questionnaire and to answer some additional questions on asthma treatment, smoke habits and comorbidities. Results. Thirty-seven community pharmacies recruited 239 patients. According to the ACT score, more than 50% of patients had a controlled asthma but 20% of them were totally uncontrolled and 12% were using oral steroid. Only 2.9% of patients had received an asthma action plan. Asthma was intermittent in 17.6% of patients, mild persistent in 13.8%, moderate persistent in 63.1% and severe in 5.4%. Discordance was observed between the self-perceived asthma control and objective parameters, when available. Of note, in the severe asthma group, most patients had an ACT > 20. Conclusion. This is the first Italian pharmacy-based study on asthma control. A better asthma control was recorded in this study in comparison with other trials, but about 50% of patients were insufficiently controlled. The community pharmacies can play a relevant role in the preliminary assessment of asthma control by using easy and not time consuming tools, such as ACT.

Asthma management among allergists in Italy: results from a survey.

BACKGROUND: In Europe more than 50% of asthmatic treated patients have not well-controlled asthma. Asthma affects about 2.5 million of patients in Italy. AIMS AND OBJECTIVES: The present survey aims at investigating how Italian allergists approach asthmatic patients, in order to highlight pitfalls and unmet needs concerning real-life asthma management. METHODS: An anonymous 16 item web questionnaire was available (April-October 2015) to all allergists who visited the web site of SIAAIC (Società Italiana di Allergologia, Asma Immunologia Clinica). Those who wished to give their contribution had the opportunity to answer about epidemiology, risk factors, treatment approaches, and adherence to therapy. RESULTS: One hundred and seventy four allergists answered the survey. 54% of them reported up to 10 patient visits per week and 35.3% between 10 and 30. The most frequent reasons of follow up visits are routine check-up (56.5% of allergists), and worsening of symptoms (41% of allergists). Nocturnal apnoeas, gastro-esophageal reflux and obesity are the most important comorbidities/risk factors of poorly controlled asthma. Bronchial hyper-responsiveness, increased NO levels and reduced exercise tolerance are the most important indicators of asthma severity. Concerning therapy, ICS combined with LABA is the treatment of choice suitable for the majority of patients. A rapid onset of action and a flexible ICS dosage are indicated as the optimal characteristics for achieving the therapeutic goals. Poor adherence to therapy is an important reason for symptom worsening for the majority of allergists. Complex dosage regimens and economic aspects are considered the most important factors impacting on adherence. CONCLUSIONS: Allergists are involved in the management of asthma, regularly seeing their patients. Co-morbidities are frequent in asthmatic patients and may impact negatively on disease control, thus identifying patients who need a more careful and strict monitoring. Airway hyper-responsiveness to methacholine challenge test and nitric oxide are considered important indicators of asthma severity. The combination of LABA and inhaled steroids is considered the treatment of choice for most asthmatic patients, in keeping with broad evidence indicating that the combination therapy is more effective and rapid in gaining asthma control than inhaled corticosteroids alone. Adherence to medication regimens is considered of essence to achieve the therapeutic goals.

SANI-Severe Asthma Network in Italy: a way forward to monitor severe asthma.

Even if severe asthma (SA) accounts for 5-10% of all cases of the disease, it is currently a crucial unmet need, owing its difficult clinical management and its high social costs. For this reason several networks, focused on SA have been organized in some countries, in order to select these patients, to recognize their clinical features, to evaluate their adherence, to classify their biological/clinical phenotypes, to identify their eligibility to the new biologic therapies and to quantify the costs of the disease. Aim of the present paper is to describe the ongoing Italian Severe Asthma Network (SANI). Up today 49 centres have been selected, widespread on the national territory. Sharing the same diagnostic protocol, data regarding patients with SA will be collected and processed in a web platform. After their recruitment, SA patients will be followed in the long term in order to investigate the natural history of the disease. Besides clinical data, the cost/benefit evaluation of the new biologics will be verified as well as the search of peculiar biomarker(s) of the disease.

Periostin: The bone and beyond.

In recent years the relationship between bone, metabolism and many pathophysiologic mechanisms involving other organs and the immune system, was increasingly apparent. This observation concerns vitamin D, osteopontin and periostin (PO). PO is expressed in the periosteum of long bones but also in many other tissues and organs, including heart, kidney, skin and lungs, being enhanced by mechanical stress or injury. PO has a relevant physiological function in promoting injury repair in a large number of tissues. However, its overexpression was observed in different diseases characterized by inflammation, fibrosis and tumorigenesis. Here we review the current knowledge on the role of PO in physiologic and pathologic pathways of different diseases. A specific focus regards the correlation between the level of PO and lung diseases and the identification of PO also as an inflammatory key effector in asthma, strongly associated with airways eosinophilia. In fact PO seems to be a useful biomarker of "Th2-high" asthma compared to "Th2-low" asthma phenotype and a predictor of response to therapeutic agents. Currently, a growing number of studies suggests a possible role of PO as a new diagnostic marker and/or therapeutic target for different diseases and its usefulness in clinical practice should be supported and confirmed by further and larger studies.