Severe asthma: One disease and multiple definitions

Introduction: There is, so far, no universal definition of severe asthma. This definition usually relies on: number of exacerbations, inhaled therapy, need for oral corticosteroids, and respiratory function. The use of such parameters varies in the different definitions used. Thus, according to the parameters chosen, each patient may result in having severe asthma or not. The aim of this study was to evaluate how the choice of a specific definition of severe asthma can change the allocation of patients. Methods: Data collected from the Severe Asthma Network Italy (SANI) registry were analyzed. All the patients included were then reclassified according to the definitions of U-BIOPRED, NICE, WHO, ATS/ERS, GINA, ENFUMOSA, and TENOR. Results: 540 patients, were extracted from the SANI database. We observed that 462 (86%) met the ATS/ERS criteria as well as the GINA criteria, 259 (48%) the U-Biopred, 222 (41%) the NICE, 125 (23%) the WHO, 313 (58%) the Enfumosa, and 251 (46%) the TENOR criteria. The mean eosinophil value were similar in the ATS/ERS, U-Biopred, and Enfumosa (528, 532 and 516 cells/mcl), higher in WHO and Tenor (567 and 570 cells/mcl) and much higher in the NICE classification (624 cells/mcl). Lung function tests resulted similarly in all groups, with WHO (67%) and ATS/ERS-GINA (73%), respectively, showing the lower and upper mean FEV1 values. Conclusions: The present observations clearly evidence the heterogeneity in the distribution of patients when different definitions of severe asthma are used. However, the recent definition of severe asthma, provided by the GINA document, is similar to that indicated in 2014 by ATS/ERS, allowing mirror reclassification of the patients examined. This lack of homogeneity could complicate the access to biological therapies. The definition provided by the GINA document, which reflects what suggested by ATS/ERS, could partially overcome the problem

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Asthma control in elderly asthmatics. An italian observational study.

Background: The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it. Methods: A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project. Findings: A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤ 19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n Z 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV1/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV1% of predicted and the coexistence of COPD were the only variables to enter the model. Interpretation: Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control

Chronic Urticaria Patient Perspective (CUPP) : The First Validated Tool for Assessing Quality of Life in Clinical Practice

Background There is a need for validated tools to assess health-related quality of life (HRQoL) in routine clinical practice. Objective The aim of this study was to validate the Chronic Urticaria Patient Perspective (CUPP) for assessment of patients with chronic urticaria (CU) in clinical practice. Methods A provisional CUPP was developed from candidate items identified by following an iterative process in a retrospective analysis of 249 Chronic Urticaria Quality of Life Questionnaire questionnaires. The psychometric properties of the CUPP were then tested on a sample of patients enrolled in 13 Italian centers. Results The study population in the validation phase comprised 152 patients. The 10-item version of the CUPP showed satisfactory internal consistency (Cronbach's alpha values of 0.76 at visit 1 and 0.90 at visit 2), good criteria, and discriminative and convergent validity. Reliability was assessed in 34 patients with no changes in health (Global Rating Scale = 0 at visit 2) and was satisfactory (CCC [concordance correlation coefficient] = 0.9). Changes in CUPP scores were significantly associated with changes in Urticaria Activity Score (UAS)-Hive count (r = 0.36, P <.001), UAS-Itch severity (r = 0.48, P <.001), and UAS-Total score (r = 0.342, P <.001), all of which indicated good responsiveness. The minimal important difference was 1.5. Conclusions CUPP is a simple 10-question tool with good psychometric properties that provides a valid, reliable, and standardized measurement of HRQoL in patients with CU

The Severe Asthma Network in Italy : Findings and Perspectives

Background: Severe Asthma Network in Italy (SANI) is a registry of patients recruited by accredited centers on severe asthma. Objective: To analyze epidemiological, clinical, inflammatory, functional, and treatment characteristics of severe asthmatics from the SANI registry. Methods: All consecutive patients with severe asthma were included into the registry, without exclusion criteria to have real-life data on demographics, asthma control, treatments (including biologics), inflammatory biomarkers, and comorbidities. Results: A total of 437 patients (mean age: 54.1 years, 57.2% females, 70.7% atopics, 94.5% in Global Initiative for Asthma severity step V) were enrolled into the study. The mean annual exacerbation rate was 3.75. The mean blood eosinophil level was 536.7 cells/mcL, and the average serum total IgE was 470.3 kU/L. Approximately 64% of patients were on regular oral corticosteroid treatment, 57% with omalizumab and 11.2% with mepolizumab. Most common comorbidities were rhinitis, nasal polyposis, and bronchiectasis. Patients with nasal polyposis had higher age of disease onset, higher blood eosinophil count, and lower frequency of atopy and atopic eczema. Bronchiectasis was associated with more frequent severe exacerbations, higher blood eosinophils, and total IgE. Stratifying patients, those with late-onset asthma were less frequently atopic (with less frequent allergic rhinitis and food allergy), and more frequently with nasal polyposis and higher serum total IgE levels. Conclusions: This study revealed a high frequency of relevant comorbidities and that a substantial proportion of patients have late-onset asthma; all these features define specific different disease phenotypes. Severe asthma complexity and comorbidities require multidisciplinary approaches, led by specifically trained pulmonologists and allergists

Severe asthma: One disease and multiple definitions

123noopenIntroduction: There is, so far, no universal definition of severe asthma. This definition usually relies on: number of exacerbations, inhaled therapy, need for oral corticosteroids, and respiratory function. The use of such parameters varies in the different definitions used. Thus, according to the parameters chosen, each patient may result in having severe asthma or not. The aim of this study was to evaluate how the choice of a specific definition of severe asthma can change the allocation of patients. Methods: Data collected from the Severe Asthma Network Italy (SANI) registry were analyzed. All the patients included were then reclassified according to the definitions of U-BIOPRED, NICE, WHO, ATS/ERS, GINA, ENFUMOSA, and TENOR. Results: 540 patients, were extracted from the SANI database. We observed that 462 (86%) met the ATS/ERS criteria as well as the GINA criteria, 259 (48%) the U-Biopred, 222 (41%) the NICE, 125 (23%) the WHO, 313 (58%) the Enfumosa, and 251 (46%) the TENOR criteria. The mean eosinophil value were similar in the ATS/ERS, U-Biopred, and Enfumosa (528, 532 and 516 cells/mcl), higher in WHO and Tenor (567 and 570 cells/mcl) and much higher in the NICE classification (624 cells/mcl). Lung function tests resulted similarly in all groups, with WHO (67%) and ATS/ERS-GINA (73%), respectively, showing the lower and upper mean FEV1 values. Conclusions: The present observations clearly evidence the heterogeneity in the distribution of patients when different definitions of severe asthma are used. However, the recent definition of severe asthma, provided by the GINA document, is similar to that indicated in 2014 by ATS/ERS, allowing mirror reclassification of the patients examined. This lack of homogeneity could complicate the access to biological therapies. The definition provided by the GINA document, which reflects what suggested by ATS/ERS, could partially overcome the problem.restrictedopenBagnasco D.; Paggiaro P.; Latorre M.; Folli C.; Testino E.; Bassi A.; Milanese M.; Heffler E.; Manfredi A.; Riccio A.M.; De Ferrari L.; Blasi F.; Canevari R.F.; Canonica G.W.; Passalacqua G.; Guarnieri G.; Patella V.; Maria Pia F.B.; Carpagnano G.E.; Colle A.D.; Scioscia G.; Gerolamo P.; Puggioni F.; Racca F.; Favero E.; Iannacone S.; Savi E.; Montagni M.; Camiciottoli G.; Allegrini C.; Lombardi C.; Spadaro G.; Detoraki C.; Menzella F.; Galeone C.; Ruggiero P.; Yacoub M.R.; Berti A.; Scichilone N.; Durante C.; Costantino M.T.; Roncallo C.; Braschi M.; D'Adda A.; Ridolo E.; Triggiani M.; Parente R.; Maria D.A.; Verrillo M.V.; Rolla G.; Brussino L.; Frazzetto A.V.; Cristina Z.M.; Lilli M.; Crimi N.; Bonavia M.; Corsico A.G.; Grosso A.; Del Giacco S.; Deidda M.; Ricciardi L.; Isola S.; Cicero F.; Amato G.; Vita F.; Spanevello A.; Pignatti P.; Cherubino F.; Visca D.; Massimo Ricciardolo F.L.; Anna Carriero V.M.; Bertolini F.; Santus P.; Barlassina R.; Airoldi A.; Guida G.; Eleonora N.; Aruanno A.; Rizzi A.; Caruso C.; Colantuono S.; Senna G.; Caminati M.; Arcolaci A.; Vianello A.; Bianchi F.C.; Marchi M.R.; Centanni S.; Luraschi S.; Ruggeri S.; Rinaldo R.; Parazzini E.; Calabrese C.; Flora M.; Cosmi L.; Di Pietro L.; Maggi E.; Pini L.; Macchia L.; Di Bona D.; Richeldi L.; Condoluci C.; Fuso L.; Bonini M.; Farsi A.; Carli G.; Montuschi P.; Santini G.; Conte M.E.; Turchet E.; Barbetta C.; Mazza F.; D'Alo S.; Pucci S.; Caiaffa M.F.; Minenna E.; D'Elia L.; Pasculli C.; Viviano V.; Tarsia P.; Rolo J.; Di Proietto M.; Lo Cicero S.Bagnasco, D.; Paggiaro, P.; Latorre, M.; Folli, C.; Testino, E.; Bassi, A.; Milanese, M.; Heffler, E.; Manfredi, A.; Riccio, A. M.; De Ferrari, L.; Blasi, F.; Canevari, R. F.; Canonica, G. W.; Passalacqua, G.; Guarnieri, G.; Patella, V.; Maria Pia, F. B.; Carpagnano, G. E.; Colle, A. D.; Scioscia, G.; Gerolamo, P.; Puggioni, F.; Racca, F.; Favero, E.; Iannacone, S.; Savi, E.; Montagni, M.; Camiciottoli, G.; Allegrini, C.; Lombardi, C.; Spadaro, G.; Detoraki, C.; Menzella, F.; Galeone, C.; Ruggiero, P.; Yacoub, M. R.; Berti, A.; Scichilone, N.; Durante, C.; Costantino, M. T.; Roncallo, C.; Braschi, M.; D'Adda, A.; Ridolo, E.; Triggiani, M.; Parente, R.; Maria, D. A.; Verrillo, M. V.; Rolla, G.; Brussino, L.; Frazzetto, A. V.; Cristina, Z. M.; Lilli, M.; Crimi, N.; Bonavia, M.; Corsico, A. G.; Grosso, A.; Del Giacco, S.; Deidda, M.; Ricciardi, L.; Isola, S.; Cicero, F.; Amato, G.; Vita, F.; Spanevello, A.; Pignatti, P.; Cherubino, F.; Visca, D.; Massimo Ricciardolo, F. L.; Anna Carriero, V. M.; Bertolini, F.; Santus, P.; Barlassina, R.; Airoldi, A.; Guida, G.; Eleonora, N.; Aruanno, A.; Rizzi, A.; Caruso, C.; Colantuono, S.; Senna, G.; Caminati, M.; Arcolaci, A.; Vianello, A.; Bianchi, F. C.; Marchi, M. R.; Centanni, S.; Luraschi, S.; Ruggeri, S.; Rinaldo, R.; Parazzini, E.; Calabrese, C.; Flora, M.; Cosmi, L.; Di Pietro, L.; Maggi, E.; Pini, L.; Macchia, L.; Di Bona, D.; Richeldi, L.; Condoluci, C.; Fuso, L.; Bonini, M.; Farsi, A.; Carli, G.; Montuschi, P.; Santini, G.; Conte, M. E.; Turchet, E.; Barbetta, C.; Mazza, F.; D'Alo, S.; Pucci, S.; Caiaffa, M. F.; Minenna, E.; D'Elia, L.; Pasculli, C.; Viviano, V.; Tarsia, P.; Rolo, J.; Di Proietto, M.; Lo Cicero, S