Publications by authors named "Pierachille Santus"

119 Publications

Characteristics and outcomes in hospitalized COVID-19 patients during the first 28 days of the spring and autumn pandemic waves in Milan: An observational prospective study.

Respir Med 2021 03 30;178:106323. Epub 2021 Jan 30.

Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milano, Italy; Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi di Milano, Division of Respiratory Diseases, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milano, Italy. Electronic address:

Background: The therapeutic approach to COVID-19 and healthcare system preparedness improved during 2020. We compared characteristics and outcomes of hospitalized COVID-19 patients during the first 28 days of the March and October pandemic waves in Milan, Italy.

Material And Methods: A prospective, observational study enrolling adult patients hospitalized with COVID-19 pneumonia during March 7-April 4 (1st period) and October 15-November 12 (2nd period). During the 1st period hydroxychloroquine, lopinavir/ritonavir and therapeutic enoxaparin when thrombosis was confirmed were administered; systemic corticosteroids were given in case of severe pneumonia. During the 2nd period dexamethasone, methylprednisolone, remdesivir, thromboprophylaxis or anticoagulation were administered according to international recommendations. Patients with respiratory distress on oxygen masks initiated CPAP. Outcomes were: length of hospital stay, all-cause in-hospital mortality and need for intubation.

Results: We included 70 patients (75% males) during the 1st and 76 patients (51% males, p = 0.522) during the 2nd period. Prevalence of severe respiratory failure (30% vs. 12%, p = 0.006), and D-dimer >3000 FEU (34% vs. 15%, P = 0.012) were reduced during the 2nd period, while anticoagulation and corticosteroids were more frequently administered (both p < 0.01). Mortality and time to referral were also reduced (39.4% vs. 22.4%, p = 0.019 and 6 vs. 5 days, p = 0.014), while need for intubation didn't change. Hospitalization length was comparable, but the proportion of patients discharged home was higher during the 2nd period (28.2% vs. 55.4%, p = 0.001).

Conclusions: Changing treatment paradigms and early referral might have reduced mortality in COVID-19 patients. The effects of specific therapeutic regimens needs further confirmation in future clinical studies.
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http://dx.doi.org/10.1016/j.rmed.2021.106323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847282PMC
March 2021

Mask-induced Koebner phenomenon and its clinical phenotypes: A multicenter, real-life study focusing on 873 dermatological consultations during COVID-19 pandemics.

Dermatol Ther 2021 Feb 2:e14823. Epub 2021 Feb 2.

Department of Health Sciences, University of Eastern Piedmont, Novara, Italy.

During COVID-19 pandemic, wearing masks for prevention became mandatory but evidence suggest that is also detrimental for skin. Although facial dermatoses due to masks increase in both healthcare workers and general population, a pathogenetic hypothesis remains still elusive. We aimed to evaluate the prevalence of dermatological consultations due to Koebner triggered dermatoses In this prospective, multicenter, real life study carried out in Italy from March 11th to December 11th 2020 during COVID-19 pandemics, dermatological consultations (in-person and telemedicine) to study the prevalence of Koebner (KB) phenomenon due to masks were evaluated. Boyd and Nelder classification was adopted for Koebner phenomenon and Bizzozero's for KB intensity. A total of 229/873 (26.2%) dermatological consultations were KB triggered dermatoses and lesions were located in mask-covered ear area (76 [33.2%]), malar area (73 [31.8%]), perioral area (53 [23.1%]), and nose (27 [11.8%]). The first KB category grouped 142 patients (psoriasis, vitiligo, maskne, and mask rosacea), the second one 24 (warts, molluscum contagiosum, and impetigo), the third one 46 (atopic dermatitis), and the fourth one 17 (eczema). Among previously KB negative psoriatic patients that became KB positive, 9/13 (69.2%) had discontinued or modified the prescribed antipsoriatic treatment. Mask-related Koebner phenomenon is an important clinical sign to orient clinician's therapeutic protocols during COVID-19 pandemic, especially in patients with psoriasis.
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http://dx.doi.org/10.1111/dth.14823DOI Listing
February 2021

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document.

J Asthma 2021 Mar 5:1-16. Epub 2021 Mar 5.

Department of Internal Medicine, University of Genoa, Genova, Italy.

Objective: The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

Methods: Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

Results: The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

Conclusions: Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.
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http://dx.doi.org/10.1080/02770903.2021.1879130DOI Listing
March 2021

Suggestions for lung function testing in the context of COVID-19.

Respir Med 2020 Dec 31;177:106292. Epub 2020 Dec 31.

Department of Internal Medicine and Medical Therapy, University of Pavia, Italy. Electronic address:

The 2019 coronavirus disease (COVID-19) pandemic is currently a challenge worldwide. Due to the characteristics of lung function tests, the risk of cross infection may be high between health care workers and patients. The role of lung function testing is well defined for the diagnosis of various diseases and conditions. Lung function tests are also indispensable in evaluating the response to medical treatment, in monitoring patient respiratory and systemic pathologies, and in evaluating preoperative risk in cardiothoracic and major abdominal surgeries. However, lung function testing represents a potential route for COVID-19 transmission, due to the aerosol generated during the procedures and the concentration of patients with pulmonary diseases in lung function laboratories. Currently, the opportunities for COVID-19 transmission remain partially unknown, and data are continuously evolving. This review provides useful information on the risks and recommendations for lung function testing, which have varied according to the phase of the pandemic. This information may support national and regional boards and the health authorities to which they belong. There is a need for rapid re-opening of lung function laboratories, but maximum safety is required in the COVID-19 era.
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http://dx.doi.org/10.1016/j.rmed.2020.106292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773526PMC
December 2020

Tetracyclines in COVID-19 patients quarantined at home: Literature evidence supporting real-world data from a multicenter observational study targeting inflammatory and infectious dermatoses.

Dermatol Ther 2021 Jan 29;34(1):e14694. Epub 2020 Dec 29.

Department of Health Sciences, University of Eastern Piedmont, Novara, Italy.

Tetracyclines (TetraC) are widely used in dermatology for both inflammatory and infectious dermatoses; recently both in vivo and in vitro studies started to suggest also a potential antiviral effect. During COVID-19 outbreak, several dermatological patients contracted SARS-CoV-2 experiencing only mild symptoms, but no protocol were approved. A multicenter prospective observational study that enrolled COVID-19 patients visited with teledermatology and undergoing TetraC was performed. About 38 adult outpatients (M/F: 20/18, age 42.6 years [21-67]) were enrolled. During the TetraC treatment, symptoms resolved in all patients within 10 days. Remarkably, ageusia and anosmia disappeared in the first week of TetraC treatment. TetraC seem a promising drug to treat COVID-19 outpatients with mild symptoms.
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http://dx.doi.org/10.1111/dth.14694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883087PMC
January 2021

Prevalence and influence of gastroesophageal reflux symptoms on sleep apnea and sleepiness.

Eur J Intern Med 2021 Feb 3;84:115-117. Epub 2020 Dec 3.

Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milano, Italy; Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ejim.2020.11.022DOI Listing
February 2021

Preliminary observations on IGRA testing for TB infection in patients with severe COVID-19 eligible for immunosuppressive therapy.

Respir Med 2020 12 6;175:106204. Epub 2020 Nov 6.

Regional TB Reference Centre and Laboratory, Villa Marelli Institute/ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Stop TB Italia ONLUS, Milan, Italy.

COVID-19, the novel coronavirus pandemic, has already spread around the globe affecting more than 18 million people. As previously observed with other coronaviruses, SARS-CoV-2 deeply dysregulate the immune system eliciting respiratory failure and a state of systemic hyperinflammation in severely ill individuals. Immunotherapy is often used to downgrade the detrimental effects of the disease sustained by high-level of cytokines. Those treatments, however, are known to undermine patients' ability to contain tuberculosis (TB) infection. This study aims to describe interferon-γ release assay (IGRA) results in severe COVID-19 patients eligible for immunosuppressive treatment. Aggregate data were gathered from five hospitals in Milan, Italy, from March 1 to May 15, 2020 and retrospectively analyses. Results were summarized using absolute frequencies and percentages and compared using a two-sided Chi-squared test. Overall, 462 COVID-19 patients were eligible for immunosuppressive therapy, among which 335 were tested using IGRA testing. More than one-third of them (122/335; 36.4%) had an indeterminate IGRA result because of insufficient immune response to mitogen control, 19 (5.7%) tested positive and 194 (57.9) negative. The majority of patients with lymphocytopenia (i.e., total lymphocyte count [TLC] below 1000 cells/mm) had indeterminate IGRAs (81/155; 52.3%). The proportion becomes even higher in patients with severe lymphocytopenia (i.e., TLC<500 cells/mm) (36/57; 63%). Our results suggest a possible negative impact of COVID-19 related immune dysregulation on TB infection assessment and management. Close monitoring of individuals with or without retesting of individuals with indeterminate IGRAs and further basic science investigations should to be sought to better comprehend their implication on TB epidemiology.
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http://dx.doi.org/10.1016/j.rmed.2020.106204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645275PMC
December 2020

Changes in quality of life and dyspnoea after hospitalization in COVID-19 patients discharged at home.

Multidiscip Respir Med 2020 Jan 13;15(1):713. Epub 2020 Oct 13.

Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan.

Background: To date, the effects of COVID-19 pneumonia on health-related quality of life (HRQoL) and dyspnoea are unknown.

Methods: In a real-life observational study, 20 patients with COVID-19-related pneumonia received usual care plus erdosteine (300 mg twice daily) for 15 days after hospital discharge following local standard operating procedures. At discharge (T0) and on Day 15 (T1), participants completed the St George's Respiratory Questionnaire (SGRQ), the modified Medical Research Council (mMRC) scale of dyspnoea during daily activity, the BORG scale for dyspnoea during exertion, and Visual Analogue Scale (VAS) for dyspnoea at rest. Paired t-tests compared scores at T0 and T1.

Results: The mean (SD) SGRQ total score decreased from 25.5 (15.5) at T0 to 16.9 (13.2) at T1 (p<0.01); 65% of patients achieved a clinically important change of ≥4 points. SGRQ domain scores (symptoms, activity, and impact) were also significantly reduced (all p<0.01). The mean (SD) VAS score decreased from 1.6 (1.7) to 1.4 (2.5); p<0.01. The mean mMRC score decreased significantly (p=0.031) and 30% of patients achieved a clinically important change of ≥1 point. The mean (SD) Borg score increased from 12.8 (4.2) to 14.3 (2.4); p<0.01.

Conclusion: The present proof of concept study is the first to report HRQoL in patients with COVID-19. During 15 days after hospital discharge, patients reported significant improvements in HRQoL and dyspnoea at rest and during daily activities.
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http://dx.doi.org/10.4081/mrm.2020.713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7582021PMC
January 2020

Mepolizumab Effectiveness and Allergic Status in Real Life.

Int Arch Allergy Immunol 2020 Oct 28:1-8. Epub 2020 Oct 28.

Experimental Medicine and Systems, "PhD Program" Department of Systems Medicine University of Rome "Tor Vergata", Rome, Italy.

Background: It is not clear whether mepolizumab is differently effective in allergic and nonallergic severe eosinophilic asthmatics (SEA) in real life.

Objective: We tested mepolizumab effectiveness in allergic/nonallergic SEA in real life. A strict criterion to identify the 2 phenotypes was used.

Method: We retrospectively considered 134 consecutive patients divided into allergic, with a positivity to at least 1 allergen to prick tests and/or IgE values ≥100 UI/mL (severe allergic eosinophilic asthma [SAEA]; n: 97-72.4%), and nonallergic, with no prick test results and normal IgE levels <100 UI/mL (severe nonallergic eosinophilic asthma [SNAEA]; n: 37-27.6%). They had taken mepolizumab for at least 6 months.

Results: After 10.9 ± 3.7 months, improvements in FEV1%, FEF25-75%, exacerbation numbers, blood eosinophil (BE) counts, fractional exhaled nitric oxide (FENO) (ppb), percentages of patients that stopped/reduced short-acting β2-agonists (SABAs) or oral corticosteroid (OC), observed after treatment, were similar in both groups. Only Asthma Control Test (ACT) increases were higher in SNAEA (8 [5-9]) than in SAEA (5 [2.5-8.5]; p = 0.016). However, no differences were found after treatment in percentages of subjects with ACT ≥20, as well as with FEV1 >80%, FEF25-75 >65%, exacerbations ≤2, BE <300 cells/µL, and FENO <25 ppb between SAEA and SNAEA. Besides, no significant relationships were found, comparing SNAEA with SAEA, for FEV1% (β = -0.110; p = 0.266), FEF25-75% (β = -0.228; p = 0.06), BE counts (β = -0.012; p = 0.918), FENO (β = 0.234; p = 0.085), ACT (β = 0.046; p = 0.660), and exacerbations (β = -0.070; p = 0.437). No different associations between lung function and SNAEA occurrence when compared to SAEA condition (FEV1 >80%: OR = 1.04 [95% CI: 0.43-2.55], p = 0.923; FEF25-75 >65%: OR = 0.41 [95% CI: 0.08-2.03], p = 0.272) were detected. Neither all other parameters, such as ACT >20 (OR = 0.73 [95% CI: 0.32-1.63], p = 0.440), presence of exacerbations (OR = 1.35 [95% CI: 0.55-3.27], p = 0.512), SABA discontinuation (OR = 1.16 [95% CI: 0.40-3.39], p = 0.790), and OC cessation/reduction (OR = 3.44 [95% CI: 0.40-29.27], p = 0.258), were differently associated with 1 or the other phenotype.

Conclusion: Mepolizumab can be considered as a valid therapeutic choice for either allergic or nonallergic SEA in real life.
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http://dx.doi.org/10.1159/000511147DOI Listing
October 2020

Prolonged Low-Dose Methylprednisolone in Patients With Severe COVID-19 Pneumonia.

Open Forum Infect Dis 2020 Oct 12;7(10):ofaa421. Epub 2020 Sep 12.

Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy.

Background: In hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia, progression to acute respiratory failure requiring invasive mechanical ventilation (MV) is associated with significant morbidity and mortality. Severe dysregulated systemic inflammation is the putative mechanism. We hypothesize that early prolonged methylprednisolone (MP) treatment could accelerate disease resolution, decreasing the need for intensive care unit (ICU) admission and mortality.

Methods: We conducted a multicenter observational study to explore the association between exposure to prolonged, low-dose MP treatment and need for ICU referral, intubation, or death within 28 days (composite primary end point) in patients with severe COVID-19 pneumonia admitted to Italian respiratory high-dependency units. Secondary outcomes were invasive MV-free days and changes in C-reactive protein (CRP) levels.

Results: Findings are reported as MP (n = 83) vs control (n = 90). The composite primary end point was met by 19 vs 40 (adjusted hazard ratio [aHR], 0.41; 95% CI, 0.24-0.72). Transfer to ICU and invasive MV were necessary in 15 vs 27 ( = .07) and 14 vs 26 ( = .10), respectively. By day 28, the MP group had fewer deaths (6 vs 21; aHR, 0.29; 95% CI, 0.12-0.73) and more days off invasive MV (24.0 ± 9.0 vs 17.5 ± 12.8;  = .001). Study treatment was associated with rapid improvement in PaO:FiO and CRP levels. The complication rate was similar for the 2 groups ( = .84).

Conclusion: In patients with severe COVID-19 pneumonia, early administration of prolonged MP treatment was associated with a significantly lower hazard of death (71%) and decreased ventilator dependence. Treatment was safe and did not impact viral clearance. A large randomized controlled trial (RECOVERY trial) has been performed that validates these findings. ClinicalTrials.gov NCT04323592.
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http://dx.doi.org/10.1093/ofid/ofaa421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543560PMC
October 2020

Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study.

BMJ Open 2020 10 10;10(10):e043651. Epub 2020 Oct 10.

Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali. Via Padre Manzella, 4-07100, Università degli Studi di Sassari, Sassari, Italy.

Objectives: COVID-19 causes lung parenchymal and endothelial damage that lead to hypoxic acute respiratory failure (hARF). The influence of hARF severity on patients' outcomes is still poorly understood.

Design: Observational, prospective, multicentre study.

Setting: Three academic hospitals in Milan (Italy) involving three respiratory high dependency units and three general wards.

Participants: Consecutive adult hospitalised patients with a virologically confirmed diagnosis of COVID-19. Patients aged <18 years or unable to provide informed consent were excluded.

Interventions: Anthropometrical, clinical characteristics and blood biomarkers were assessed within the first 24 hours from admission. hARF was graded as follows: severe (partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) <100 mm Hg); moderate (PaO2/FiO2 101-200 mm Hg); mild (PaO2/FiO2 201-300 mm Hg) and normal (PaO2/FiO2 >300 mm Hg).

Primary And Secondary Outcome Measures: The primary outcome was the assessment of clinical characteristics and in-hospital mortality based on the severity of respiratory failure. Secondary outcomes were intubation rate and application of continuous positive airway pressure during hospital stay.

Results: 412 patients were enrolled (280 males, 68%). Median (IQR) age was 66 (55-76) years with a PaO2/FiO2 at admission of 262 (140-343) mm Hg. 50.2% had a cardiovascular disease. Prevalence of mild, moderate and severe hARF was 24.4%, 21.9% and 15.5%, respectively. In-hospital mortality proportionally increased with increasing impairment of gas exchange (p<0.001). The only independent risk factors for mortality were age ≥65 years (HR 3.41; 95% CI 2.00 to 5.78, p<0.0001), PaO2/FiO2 ratio ≤200 mm Hg (HR 3.57; 95% CI 2.20 to 5.77, p<0.0001) and respiratory failure at admission (HR 3.58; 95% CI 1.05 to 12.18, p=0.04).

Conclusions: A moderate-to-severe impairment in PaO2/FiO2 was independently associated with a threefold increase in risk of in-hospital mortality. Severity of respiratory failure is useful to identify patients at higher risk of mortality.

Trial Registration Number: NCT04307459.
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http://dx.doi.org/10.1136/bmjopen-2020-043651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549463PMC
October 2020

Oral CorticoSteroid sparing with biologics in severe asthma: A remark of the ().

World Allergy Organ J 2020 Oct 20;13(10):100464. Epub 2020 Sep 20.

Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy.

According to the data derived from several national and international registries, including SANI (Severe Asthma Network Italy), and considering the strong impact that frequent or regular use of oral corticosteroid has on quality of life (QoL) of severe asthmatics, as well as on the costs for managing corticosteroid-related diseases, oral corticosteroid sparing up to withdrawal should be considered a primary outcome in the management of severe asthma. New biologics have clearly demonstrated that this effect is possible, with concomitant reduction in the rate of exacerbations and in symptom control. Then, there is no reason for using so frequently oral corticosteroid before having explored all alternatives currently available for a large part of severe asthmatics.
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http://dx.doi.org/10.1016/j.waojou.2020.100464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509464PMC
October 2020

Efficacy of Benralizumab in severe asthma in real life and focus on nasal polyposis.

Respir Med 2020 09 3;171:106080. Epub 2020 Jul 3.

Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Department of Internal Medicine (DIMI), Genoa, Italy.

Introduction: Severe asthma occurs in 5-10% of asthmatic patients, with nasal polyposis as one of the most frequent comorbidity. Benralizumab was recently marketed, thus we could analyse its effects in real-life in severe asthma, and compare the effects of the drug in patients with and without polyposis.

Methods: Patients with severe asthma, receiving Benralizumab were enrolled in Italian asthma centres. The efficacy criteria for asthma (exacerbation rate, oral corticosteroid intake, hospitalizations, pulmonary function, exhaled nitric oxide) were evaluated at baseline and after 24 weeks of treatment. Patients were then sub-analysed according to the presence/absence of nasal polyposis.

Results: Fifty-nine patients with severe uncontrolled asthma (21 males, age range 32-78) and treated with benralizumab for at least 24 weeks has been evaluated, showing significant improvements in asthma-related outcomes, except for pulmonary function and exhaled nitric oxide. This included a reduction in the sino-nasal outcome-22 score versus baseline of 13.7 points (p = .0037) in the 34 patients with nasal polyposis. Anosmia disappeared in 31% patients (p = .0034). When comparing the groups with and without nasal polyposis, a similar reduction of exacerbations was seen, with a greater reduction of the steroid dependence in patients with polyposis (-72% vs -53%; p < .0001), whereas lung function was significantly more improved (12% vs 34%, p = .0064) without polyposis patients.

Conclusions: Benralizumab, after 6 months of treatment, confirmed its efficacy in severe asthma, and also in nasal polyposis, which is the most frequent comorbidity. The efficacy of Benralizumab in reducing steroid dependence was even higher in patients with polyposis.
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http://dx.doi.org/10.1016/j.rmed.2020.106080DOI Listing
September 2020

Sleep, sleep apneas, and headache in general population.

Neurol Sci 2020 12;41(Suppl 2):455-456

Headache Center, Neurology Unit, Luigi Sacco University Hospital, Milan, Italy.

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http://dx.doi.org/10.1007/s10072-020-04657-2DOI Listing
December 2020

Sleep, headache and sleep breathing disturbances: a polisomnographic study.

Neurol Sci 2020 12;41(Suppl 2):473-474

"Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.

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http://dx.doi.org/10.1007/s10072-020-04663-4DOI Listing
December 2020

Beliefs and preferences regarding biological treatments for severe asthma.

World Allergy Organ J 2020 Jul 31;13(7):100441. Epub 2020 Jul 31.

Università di Genova, Dipartimento di Medicina Interna (DiMI), Italy.

Background: Severe asthma is a serious condition with a significant burden on patients' morbidity, mortality, and quality of life. Some biological therapies targeting the IgE and interleukin-5 (IL5) mediated pathways are now available. Due to the lack of direct comparison studies, the choice of which medication to use varies. We aimed to explore the beliefs and practices in the use of biological therapies in severe asthma, hypothesizing that differences will occur depending on the prescribers' specialty and experience.

Methods: We conducted an online survey composed of 35 questions in English. The survey was circulated via the INterasma Scientific Network (INESNET) platform as well as through social media. Responses from allergists and pulmonologists, both those with experience of prescribing omalizumab with (OMA/IL5) and without (OMA) experience with anti-IL5 drugs, were compared.

Results: Two hundred eighty-five (285) valid questionnaires from 37 countries were analyzed. Seventy-on percent (71%) of respondents prescribed biologics instead of oral glucocorticoids and believed that their side effects are inferior to those of Prednisone 5 mg daily. Agreement with ATS/ERS guidelines for identifying severe asthma patients was less than 50%. Specifically, significant differences were found comparing responses between allergists and pulmonologists (Chi-square test, p < 0.05) and between OMA/IL5 and OMA groups (p < 0.05).

Conclusions: Uncertainties and inconsistencies regarding the use of biological medications have been shown. The accuracy of prescribers to correctly identify asthma severity, according to guidelines criteria, is quite poor. Although a substantial majority of prescribers believe that biological drugs are safer than low dose long-term treatment with oral steroids, and that they must be used instead of oral steroids, every effort should be made to further increase awareness. Efficacy as disease modifiers, biomarkers for selecting responsive patients, timing for outcomes evaluation, and checks need to be addressed by further research. Practices and beliefs regarding the use of asthma biologics differ between the prescriber's specialty and experience; however, the latter seems more significant in determining beliefs and behavior. Tailored educational measures are needed to ensure research results are better integrated in daily practice.
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http://dx.doi.org/10.1016/j.waojou.2020.100441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7396819PMC
July 2020

The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians.

J Clin Med 2020 Jul 27;9(8). Epub 2020 Jul 27.

Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V 0A6, Canada.

Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the "International Course on Severe Asthma" that took place in Palermo, Italy, on May 10-11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient's needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.
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http://dx.doi.org/10.3390/jcm9082397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463666PMC
July 2020

Sublobar resection: functional evaluation and pathophysiological considerations.

J Thorac Dis 2020 Jun;12(6):3363-3368

Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy.

To date, pulmonary function tests (PFTs) are part of consolidated standard operating procedures in thoracic surgery. PFTs are usually used to assess the pre-operative risk, post-operative outcomes and complications after pulmonary resections. The only functional parameter used in common practice is the forced expiratory volume in one second (FEV). However, the FEV alone poorly reflects lung pathophysiology, especially in patients with pre-operative emphysema and airflow obstruction; moreover, the predictive power of spirometric parameters in guiding the surgical approach in terms of the extension of the excision is currently unknown. In the present critical overview, we report and discuss the results of four studies that compared pre and post-surgery FEV and forced vital capacity (FVC) in patients undergoing lobectomy or segmentectomy, highlighting the critical aspects of spirometry in lung surgery and suggesting new approaches for the interpretation of pulmonary mechanics in patients undergoing major or minor parenchymal resections. Overall, the literature on the topic is limited to spirometric parameters, and post-surgical function loss and the consequent recovery are often analysed in inhomogeneous study samples, with varying respiratory comorbidities and functional phenotypes. We underline the role of static lung volumes in the patients' initial assessment. In fact, they tend to decrease in patients with emphysema that undergo a lobectomy, followed by a decrease in lung compliance; some of these patients experience also an increase in closing volume, a condition that worsens the stresses implicated in lung ventilation and promotes the damage to the remaining airways. Spirometric data should be therefore always associated to body-plethysmography and indexes of ventilation distribution, to improve the evaluation of the functional characteristics in patients undergoing lung surgery. Prospective studies are needed to establish the relationship and long-term consequences of different surgical approaches in terms of lung mechanics and functional loss.
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http://dx.doi.org/10.21037/jtd.2019.12.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330776PMC
June 2020

Day and Night Control of COPD and Role of Pharmacotherapy: A Review.

Int J Chron Obstruct Pulmon Dis 2020 4;15:1269-1285. Epub 2020 Jun 4.

Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy.

The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients' adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient's profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic "24-hour control of COPD and role of pharmacotherapy", held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.
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http://dx.doi.org/10.2147/COPD.S240033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283230PMC
June 2020

Tidal expiratory flow limitation induces expiratory looping of the alveolar pressure-flow relation in COPD patients.

J Appl Physiol (1985) 2020 07 5;129(1):75-83. Epub 2020 Jun 5.

Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy.

During spontaneous breathing at rest, the alveolar pressure (P)-flow (V̇) relation exhibits a prominent expiratory loop in many chronic obstructive pulmonary disease (COPD) patients. Among the possible determinants of the loop, tidal expiratory flow limitation (tEFL) may be the main responsible. To compare the characteristics of the expiratory loop in COPD patients with flow limitation (FL) and without flow limitation (NFL), tEFL was assessed with the negative expiratory pressure technique in stable mild to very severe COPD patients undergoing body plethysmography before and after bronchodilation (BD), an intervention that is able to reduce mechanical heterogeneity, recruitment/derecruitment, and gas trapping but rarely abolishes tEFL. The magnitude of the expiratory loop was indexed by the integral of P on V̇ during expiration (). Before BD, was 360% greater in FL ( = 35) than in NFL ( = 25) patients ( < 0.001). After BD, was unchanged in NFL patients (Δ 0%, = 0.882) and slightly decreased in FL patients who remained FL ( = 32, Δ -17%, = 0.064). Three FL patients became NFL after BD, and their decreased markedly (Δ -61%), reaching values similar to those observed in NFL patients at baseline. In conclusion, the greater measured in FL relative to NFL COPD patients, its relative invariance after BD when flow limitation persists, and its fall when flow limitation is abolished indicate that tEFL is a major determinant of the magnitude of the expiratory loop. Furthermore, can be used as a predictor of the presence of tEFL. In stable chronic obstructive pulmonary disease (COPD) patients spontaneously breathing at rest, tidal expiratory flow limitation is the major determinant of the occurrence of expiratory looping in the plethysmographic flow-alveolar pressure diagram. In these patients the magnitude and the characteristics of the loop can be used as predictors of the presence of tidal expiratory flow limitation.
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http://dx.doi.org/10.1152/japplphysiol.00664.2019DOI Listing
July 2020

Enhanced platelet inhibition treatment improves hypoxemia in patients with severe Covid-19 and hypercoagulability. A case control, proof of concept study.

Pharmacol Res 2020 08 23;158:104950. Epub 2020 May 23.

Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milano, Italy; Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy. Electronic address:

Patients affected by severe coronavirus induced disease-2019 (Covid-19) often experience hypoxemia due to alveolar involvement and endothelial dysfunction, which leads to the formation of micro thrombi in the pulmonary capillary vessels. Both hypoxemia and a prothrombotic diathesis have been associated with more severe disease and increased risk of death. To date, specific indications to treat this condition are lacking. This was a single center, investigator initiated, compassionate use, proof of concept, case control, phase IIb study (NCT04368377) conducted in the Intermediate Respiratory Care Unit of L. Sacco University Hospital in Milano, Italy. Our objective was to explore the effects of the administration of anti-platelet therapy on arterial oxygenation and clinical outcomes in patients with severe Covid-19 with hypercoagulability. We enrolled five consecutive patients with laboratory confirmed SARS-CoV-2 infection, severe respiratory failure requiring helmet continuous positive airway pressure (CPAP), bilateral pulmonary infiltrates and a pro-thrombotic state identified as a D-dimer > 3 times the upper limit of normal. Five patients matched for age, D-dimer value and SOFA score formed the control group. Beyond standard of care, treated patients received 25 μg/Kg/body weight tirofiban as bolus infusion, followed by a continuous infusion of 0.15 μg/Kg/body weight per minute for 48 hours. Before tirofiban, patients received acetylsalicylic acid 250 mg infusion and oral clopidogrel 300 mg; both were continued at a dose of 75 mg daily for 30 days. Fondaparinux2.5 mg/day sub-cutaneous was given for the duration of the hospital stay. All controls were receiving prophylactic or therapeutic dose heparin, according to local standard operating procedures. Treated patients consistently experienced a mean (SD) reduction in A-a O2 gradient of -32.6 mmHg (61.9, P = 0.154), -52.4 mmHg (59.4, P = 0.016) and -151.1 mmHg (56.6, P = 0.011; P = 0.047 vs. controls) at 24, 48 hours and 7 days after treatment. PaO2/FiO2 ratio increased by 52 mmHg (50, P = 0.172), 64 mmHg (47, P = 0.040) and 112 mmHg (51, P = 0.036) after 24, 48 hours and 7 days, respectively. All patients but one were successfully weaned from CPAP after 3 days. This was not true for the control group. No major adverse events were observed. Antiplatelet therapy might be effective in improving the ventilation/perfusion ratio in Covid-19 patients with severe respiratory failure. The effects might be sustained by the prevention and interference on forming clots in lung capillary vessels and by modulating megakaryocytes' function and platelet adhesion. Randomized clinical trials are urgently needed to confirm these results.
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http://dx.doi.org/10.1016/j.phrs.2020.104950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7244436PMC
August 2020

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper.

Respiration 2020 19;99(6):493-499. Epub 2020 May 19.

Respiratory Rehabilitation of the Institute of Montescano, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy.

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.
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http://dx.doi.org/10.1159/000508399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316664PMC
August 2020

The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study.

Tob Induc Dis 2020 2;18:29. Epub 2020 Apr 2.

Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy.

Introduction: Cigarette smoking is the most important risk factor for Crohn's disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood.

Methods: This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months.

Results: Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22-32; vs 25 and 22-28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9-13; vs 14 and 12-15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD.

Conclusions: The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.
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http://dx.doi.org/10.18332/tid/119161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177387PMC
April 2020

Helmet CPAP to Treat Acute Hypoxemic Respiratory Failure in Patients with COVID-19: A Management Strategy Proposal.

J Clin Med 2020 Apr 22;9(4). Epub 2020 Apr 22.

Department of Biomedical and Clinical Sciences (DIBIC), Division of Respiratory Diseases, Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi, 74-20157 Milano, Italy.

Since the beginning of March 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused more than 13,000 deaths in Europe, almost 54% of which has occurred in Italy. The Italian healthcare system is experiencing a stressful burden, especially in terms of intensive care assistance. In fact, the main clinical manifestation of COVID-19 patients is represented by an acute hypoxic respiratory failure secondary to bilateral pulmonary infiltrates, that in many cases, results in an acute respiratory distress syndrome and requires an invasive ventilator support. A precocious respiratory support with non-invasive ventilation or high flow oxygen should be avoided to limit the droplets' air-dispersion and the healthcare workers' contamination. The application of a continuous positive airway pressure (CPAP) by means of a helmet can represent an effective alternative to recruit diseased alveolar units and improve hypoxemia. It can also limit the room contamination, improve comfort for the patients, and allow for better clinical assistance with long-term tolerability. However, the initiation of a CPAP is not free from pitfalls. It requires a careful titration and monitoring to avoid a delayed intubation. Here, we discuss the rationale and some important considerations about timing, criteria, and monitoring requirements for patients with COVID-19 respiratory failure requiring a CPAP treatment.
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http://dx.doi.org/10.3390/jcm9041191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230457PMC
April 2020

Early consensus management for non-ICU acute respiratory failure SARS-CoV-2 emergency in Italy: from ward to trenches.

Eur Respir J 2020 05 21;55(5). Epub 2020 May 21.

Dept of Medical Sciences, San Giuseppe Hospital MultiMedica IRCCS, and Department of Clinical Sciences and Community Health, UniversitàdegliStudi di Milano, Milan, Italy

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http://dx.doi.org/10.1183/13993003.00632-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144262PMC
May 2020

Patients with psoriatic arthritis have higher levels of FeNO than those with only psoriasis, which may reflect a higher prevalence of a subclinical respiratory involvement.

Clin Rheumatol 2020 Oct 2;39(10):2981-2988. Epub 2020 Apr 2.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Psoriatic arthritis (PsA) patients are often affected by numerous comorbidities. However, contrasting results have been reported with regard to the respiratory involvement in PsA patients. The aim of this study was to evaluate the presence of subclinical airway inflammation in non-smoking PsA patients compared to patients with only psoriasis using the fraction of exhaled nitric oxide (FeNO) as an indirect marker of airway inflammation.

Methods: The study included 164 non-smoking psoriatic patients (Psoriasis Area of Severity Index or PASI score > 10): 82 with and 82 without PsA, who underwent FeNO tests at different flow rates (30, 50, 100, 200 mL/s). PsA patients were evaluated with Disease Activity in PSoriatic Arthritis Score (DAPSA). Both study groups were compared in terms of FeNO values and its association with the PASI score. The correlations between the variables were evaluated by means of Pearson's coefficient.

Results: Patient with PsA had higher levels of FeNO than those with psoriasis but without arthritis (at 30 mL/s, 71.09 ± 18.40 ppb vs 66.88 ± 19.12 ppb (NS); at 50 mL/s, 36.61 ± 9.30 ppb vs 30.88 ± 9.73 ppb (p < 0.001); at 100 mL/s, 19.09 ± 4.66 ppb vs 16.63 ± 4.90 ppb (p < 0.001); and at 200 mL/s, 10.88 ± 2.53 ppb vs 9.43 ± 2.55 ppb (p < 0.001), respectively). PASI score correlated to FeNO only in psoriatic patients without arthritis. However, CASPAR index correlated with FeNO (FeNO30: r = 0.81, p < 0.001; FeNO50: r = 0.84, p < 0.001; FeNO100: r = 0.71, p < 0.001; FeNO200: r = 0.58, p < 0.001). DAPSA was also correlated with FeNO to all flows (FeNO30: r = 0.43, p < 0.001; FeNO50: r = 0.33, p < 0.001; FeNO100: r = 0.34, p < 0.001; FeNO200: r = 0.25, p < 0.001).

Conclusions: PsA patients seem to have more commonly subclinical airway inflammation than those with only psoriasis. Further studies are needed to replicate these findings. Key Points • Fraction of exhaled nitric oxide (FeNO) is a useful device to detect and monitor airway inflammation not only in asthma but also in systemic inflammatory diseases such as psoriatic arthritis and psoriasis. • Clinicians should be aware to check respiratory diseases in patients with psoriatic arthritis.
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http://dx.doi.org/10.1007/s10067-020-05050-2DOI Listing
October 2020

The Relevance of Targeting Treatment to Small Airways in Asthma and COPD.

Respir Care 2020 Sep 24;65(9):1392-1412. Epub 2020 Mar 24.

Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCs San Martino, Genova, Italy.

COPD and asthma have different risk factors and pathogenesis, but they share a pathophysiologic hallmark characterized by small airways disease. Although difficult to explore and measure, modifications of distal airways' pathophysiology and biology represent an early sign of obstructive disease and should be researched and assessed in everyday clinical practice. In the last 15 years, computed microtomography scans have shed light on the anatomy and physiology of the so-called silent zone, and research devoted to investigate the effect of inhaled treatments on small airway pathophysiology has been increasing. This narrative review offers a historical summary of researchers and landmark studies that reported, defined, and advanced the research on small airways. We then discuss the latest findings on the role and characteristics of the small airways' inflammatory and cellular structure, and we describe the assessment tools available to detect small airways dysfunction in COPD and asthma and the effect of bronchodilators and inhaled steroids on functional and biological biomarkers. Finally, we analyze the newest technological therapeutic advances aimed at small airways treatment in terms of inhalation devices and small particle size molecules.
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http://dx.doi.org/10.4187/respcare.07237DOI Listing
September 2020

Omalizumab for Severe Allergic Asthma Treatment in Italy: A Cost-Effectiveness Analysis from PROXIMA Study.

Risk Manag Healthc Policy 2020 22;13:43-53. Epub 2020 Jan 22.

Drug Science Department, Pavia University, Pavia, Italy.

Introduction: Inadequately controlled severe asthma patients require additional therapy accounting for significant clinical and economic burden. Our analysis aims to determine the cost-effectiveness of omalizumab in the management of severe allergic asthma in Italy based on observational data from the PROXIMA study.

Methods: Observational data on efficacy, healthcare resource utilization and changes in quality of life at 12 months after the initiation of omalizumab were examined to estimate the cost-effectiveness compared to pre-omalizumab period and results were expressed with Incremental Cost-Effectiveness Ratio (ICER). The cost-utility analysis estimated the cost per quality-adjusted life-year (QALY) gained. Direct health costs were assessed from the perspective of the Italian National Health Service (NHS).

Results: Omalizumab reduced the incidence of exacerbations, number of hospitalizations, physician visits, and improved quality of life after 12 months of treatment. Omalizumab had a greater effectiveness than pre-omalizumab treatment involving 0.132 QALYs gained and led to a €3729 per patient reduction in direct healthcare costs, excluding the add-on treatment cost. Nevertheless, the addition of omalizumab cost led to €7478 increase in total direct costs with respect to pre-omalizumab period. Based on difference in total direct cost and difference in QALY between post and pre-omalizumab period, the ICER was €56,847. According to sensitivity analysis, omalizumab provided a cost-effective use of NHS resources, already at 20% discounted price.

Conclusion: This study offers a real-world evidence of omalizumab effectiveness in Italy. Despite the high acquisition cost of the innovative drug, omalizumab is a sustainable treatment option for patients with uncontrolled severe allergic asthma.
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http://dx.doi.org/10.2147/RMHP.S211321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986414PMC
January 2020

The role of phenotype on ventilation and exercise capacity in patients affected by COPD: a retrospective study.

Multidiscip Respir Med 2020 01 3;15(1):476. Epub 2020 Feb 3.

Department of Health Sciences, University of Milan, Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.

Background: The idea of phenotype in chronic obstructive pulmonary disease (COPD) has evolved in the last decades, and the importance of peculiar treatment strategies has now been acknowledged. Although dyspnea and exercise limitation are hallmarks of COPD, this aspect has never been fully explored in literature in terms of disease phenotype. The aim of the present study was to explore the relevance of clinical COPD phenotypes on exercise ventilation and maximal capacity.

Methods: In this observational cohort retrospective study we analyzed the data of 50 COPD patients who underwent cardiopulmonary exercise test, categorized as emphysematous (n=29), and non-emphysematous (n=21) according to a previously validated model.

Results: We found a significant difference in terms of VE/VCO slope (median values 32.4 28.0, =0.015) and VE/VCO ratio at nadir (median values 37 . 33, =0.004), which resulted higher in emphysematous patients, who also presented lower PCO values (median values 32.6 35.6, =0.008). In a subgroup of 31 tests which met the maximality criteria, emphysematous patients presented a significantly lower work rate at peak (median value 51 72% predicted, =0.016), and showed a lower peak oxygen consumption, although at the limit of significance (median values of 63 85 % predicted, =0.051).

Conclusions: This study extends our knowledge about the characterization of the COPD phenotypical expression of disease, showing that patients affected by emphysema are more prone to ventilatory inefficiency during exercise, and that this is likely to be an important cause of their overall reduced exercise capacity.
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http://dx.doi.org/10.4081/mrm.2020.476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037504PMC
January 2020