The secrets of men since born: Il Machiavelli di Lord Acton

Lord Acton was one of the most eminent intellectuals of the Victorian age. His political thought aimed at reconciling his Catholic faith with liberal prin-ciples. Although he has never written a book, his essays expressed an histo-riography that has exerted great influence in the study of history, the most known example of which is the Cambridge Modern History, conceived by Lord Acton himself. This article aims at showing that his interpretation of Ma-chiavelli, expressed in the introduction to the famous edition of the Prince edited by Arthur Burd, is a precious testimony of the widespread circulation of Machiavellian thought in Europe

Asthma Control: The Right Inhaler for the Right Patient.

Inhaled therapy is the cornerstone of asthma management in that it optimizes the delivery of the medication to the site of action. The effectiveness of inhaled therapy is affected by the correct choice of the device and proper inhalation technique. In fact, this influences the drug delivery and distribution along the bronchial tree, including the most peripheral airways. In this context, accumulating evidence supports the contribution of small airways in asthma, and these have become an important target of treatment. In reality, the “ideal inhaler” does not exist, and not all inhalers are the same. Advances in technology has highlighted these differences, and have led to the design of new devices and the development of formulations characterized by extrafine particles that facilitate the distribution and deposition of the drug particles along the respiratory tract. In addition, efforts have been made to implement adherence to chronic treatment, which translates into clinical benefit. Taken together, the optimal control of asthma depends on the drug that is selected, the device that is employed and the removal of factors that reduce patient’s adherence to therapy. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12325-015-0201-9) contains supplementary material, which is available to authorized users

«Tagliare a pezzi». Cesare Borgia tra rimandi biblici e fonte senofontea in Machiavelli

Only in three parts of Machiavelli’s writings occurs a stark expression: «tagliare a pezzi». Two of them are in The Prince, the third one in Discorsi. Two of them concern ancient examples (Hiero and Clearchus), the other one a modern experience, the famous and violent episode in which Cesare Borgia executes his lieutenant Rimirro, a capital punishment that Machiavelli watched in Cesena. The essay tries to show how all of Machiavelli’s examples deal in a subtle way with a topical Machiavelli’s view – civil principality. From this discussion, a survey (or journey) between Machiavelli’s text and historical context begins, where some other striking questions are approached, such as the absence of Cesare Borgia in Discorsi (so sensational as neglected), the relationship between Machiavelli and Michelangelo linked by a ‘republican’ David, or the figure of pope Leo X, that would be, according to this essay, that «certain prince of present times, whom it is best not to name», and not, according to the common opinion, Ferdinand the Catholic

The geriatric asthma: pitfalls and challenges

Historically, asthma has been envisioned as a disease of younger ages. This has led to the assumption that respiratory symptoms suggestive of asthma occurring in older ages are to be attributed to conditions other than asthma, mainly COPD. Old observational reports and new epidemiological studies confirm that asthma is as frequent in older as it is in younger populations. Nevertheless, under-recognition, misdiagnosis and under-treatment are still relevant issues. The characterization of asthma in the aged suffers from the fact that there has been very little original research in this field. Indeed, geriatric asthma is often excluded from clinical trials because of age and comorbidities. The current review paper revises the areas that need to be elucidated, and highlights the gaps in the management of this condition. It follows that a multidimensional management is advocated for elderly asthmatics to evaluate the severity and establish the complexity of the disease. We suggest that the term “geriatric” asthma should be preferred to “senile” asthma, which is confined to the age-related changes in the lung, or the more generic “asthma in the elderly”, which is only descriptive of the prevalence in specific age groups

Association between reduced bronchodilatory effect of deep inspiration and loss of alveolar attachments

BACKGROUND: We have previously shown that the bronchodilatory effect of deep inspiration is attenuated in individuals with COPD. This study was designed to investigate whether the impairment in this effect is associated with loss of alveolar attachments. METHODS: We measured deep inspiration (DI)-induced bronchodilation in 15 individuals with and without COPD (67 ± 2.2 yrs of age, mean ± SEM) undergoing lobar resection for peripheral pulmonary nodule. Prior to surgery, we measured TLCO and determined the bronchodilatory effect of deep inspiration after constricting the airways with methacholine. The number of destroyed alveolar attachments, as well as airway wall area and airway smooth muscle area, were determined in tumor-free, peripheral lung tissue. RESULTS: The bronchodilatory effect of deep inspiration correlated inversely with the % destroyed attachments (r = -0.51, p = 0.05) and directly with the airway smooth muscle area (r = 0.59, p = 0.03), but not with the total wall area (r = 0.39, p = 0.15). CONCLUSION: We postulate that attenuation of airway stretch due to loss of alveolar attachments contributes to the loss of the bronchodilatory effect of lung inflation in COPD

Asthma and metabolic syndrome: Current knowledge and future perspectives.

Asthma and obesity are epidemiologically linked; however, similar relationships are also observed with other markers of the metabolic syndrome, such as insulin resistance and dyslipidemia, which cannot be accounted for by increased body mass alone. Obesity appears to be a predisposing factor for the asthma onset, both in adults and in children. In addition, obesity could make asthma more difficult to control and to treat. Although obesity may predispose to increased Th2 inflammation or tendency to atopy, other mechanisms need to be considered, such as those mediated by hyperglycaemia, hyperinsulinemia and dyslipidemia in the context of metabolic syndrome. The mechanisms underlying the association between asthma and metabolic syndrome are yet to be determined. In the past, these two conditions were believed to occur in the same individual without any pathogenetic link. However, the improvement in asthma symptoms following weight reduction indicates a causal relationship. The interplay between these two diseases is probably due to a bidirectional interaction. The purpose of this review is to describe the current knowledge about the possible link between metabolic syndrome and asthma, and explore potential application for future studies and strategic approaches

Physician's mistakes in the interpretation of spirometry

Background. The most recent ATS/ERS recommendations on lung function testing include a definition of airflow obstruction based on lower limit of normal (LLN) of FEV1/FVC and suggest to measure total lung capacity (TLC) in suspected cases of \u201cpseudo-restriction\u201d (normal FEV1/FVC ratio because of concomitant reductions in FEV1 and FVC), that can conceal airflow obstruction if the subject does not exhale long enough. Aims. To evaluate the skill of physicians in the interpretation of spirometry. Methods. A questionnaire focusing on the interpretation of five spirograms was administered to 127 physicians (aged 25-67yrs; 39% pulmonologists, 20% geriatrics). Correlates of spirometric misinterpretation were assessed by logistic regression. Results. Overall, 31% of physicians made at least one mistake in the interpretation of the spirograms administered. The percentage decreases to 15% among pulmonologists (OR=3.7; p=0.005). One quarter of physicians wrongly diagnosed airflow obstruction in a 75yrs old subject with FEV1/FVCLLN. About 1 out of 5 physicians did not recognize a mixed ventilatory defect (obstruction + restriction), while less than 15% (45% of pulmonologists) highlighted the need to measure TLC in suspected pseudo-restriction. Factors significantly associated with a lower amount of mistakes included higher n\ub0 of test performed, scientific articles read, respiratory congress attended, COPD and asthma patients visited in the last year. Conclusions. Inappropriate spirometric interpretation is not rare among physicians and airway obstruction is still frequently overdiagnosed among elderly. Diagnosis by pulmonologists and scientific update of physicians allow to reduce spirometric interpretative errors

Asthma in the elderly: A different disease?

Asthma is a chronic airway disease that affects all ages, but does this definition also include the elderly? Traditionally, asthma has been considered a disease of younger age, but epidemiological studies and clinical experience support the concept that asthma is as prevalent in older age as it is in the young. With the ever-increasing elderly population worldwide, the detection and proper management of the disease in old age may have a great impact from the public health perspective. Whether asthma in the elderly maintains the same characteristics as in young populations is an interesting matter. The diagnostic process in older individuals with suspected asthma follows the same steps, namely a detailed history supported by clinical examination and laboratory investigations; however, it should be recognised that elderly patients may partially lose reversibility of airway obstruction. The correct interpretation of spirometric curves in the elderly should take into account the physiological changes in the respiratory system. Several factors contribute to delaying the diagnosis of asthma in the elderly, including the age-related impairment in perception of breathlessness. The management of asthma in advanced age is complicated by the comorbidities and polypharmacotherapy, which advocate for a comprehensive approach with a multidimensional assessment. It should be emphasised that older age frequently represents an exclusion criterion for eligibility in clinical trials, and current asthma medications have rarely been tested in elderly asthmatics. Ageing is associated with pharmacokinetic changes of the medications. As a consequence, absorption, distribution, metabolism and excretion of antiasthmatic medications can be variably affected. Similarly, drug-to-drug interactions may reduce the effectiveness of inhaled medications and increase the risk of side-effects. For this reason, we propose the term “geriatric asthma” be preferred to the more generic “asthma in the elderly”