Domenica Chiurco

Efficacy of multiparametric telemonitoring on respiratory outcomes in elderly people with COPD: a randomized controlled trial

BackgroundChronic obstructive pulmonary disease (COPD) is a highly prevalent condition associated with a high health care resource consumption and health care expenditures, driven mainly by exacerbations-related hospitalizations. Telemedicine has been proposed as a mean for timely detection of exacerbation, but the available evidence is inadequate to provide conclusive information on its efficacy. The aim of this study is to evaluate the efficacy of a telemonitoring system in reducing COPD-related hospitalizations in an elderly population with COPD.MethodsThis is a parallel arms, randomized trial including patients aged 65 or older with COPD in GOLD stages II and III enrolled in a Pulmonary Medicine outpatient facility. Patients were randomly assigned to receive a non-invasive system able to telemonitor vital signs (oxygen saturation, heart rate, near-body temperature, overall physical activity) or standard care, and were followed up for 9 months. The outcome measures were the number of exacerbations and exacerbation-related hospitalization.ResultsFifty patients were included in the telemonitoring group and 49 in the control group. The incidence rate of respiratory events was 28/100 person/years in the telemonitoring group vs. 42/100 person/years in the control group (incidence rate ratio: 0.67, 95% CI: 0.32 – 1.36). The corresponding figures for hospital admissions where 13/100 person/years and 20/100 person/years, respectively (IRR: 0.66, 95% CI: 0.21 – 1.86).ConclusionsIn our study, COPD patients followed up with the aid of a multiparametric remote monitoring system experienced a lower rate of exacerbations and COPD-related hospitalizations compared to patients followed up using the standard model of care. These results need to be replicated in larger studies before they can be applied to the general COPD population. Trial registration number: NCT01481506 (clinicaltrials.gov). Funding: co-financed by Lazio Region and Intersistemi Inc.

Reproducibility and Respiratory Function Correlates of Exhaled Breath Fingerprint in Chronic Obstructive Pulmonary Disease

Background The electronic nose (e nose) provides distinctive breath fingerprints for selected respiratory diseases. Both reproducibility and respiratory function correlates of breath fingerprint are poorly known. Objectives To measure reproducibility of breath fingerprints and to assess their correlates among respiratory function indexes in elderly healthy and COPD subjects. Method 25 subjects (5 COPD patients for each GOLD stage and 5 healthy controls) over 65 years underwent e-nose study through a seven sensor system and respiratory function tests at times 0, 7, and 15 days. Reproducibility of the e nose pattern was computed. The correlation between volatile organic compound (VOC) pattern and respiratory function/clinical parameters was assessed by the Spearmans rho. Measurements and Main Results VOC patterns were highly reproducible within healthy and GOLD 4 COPD subjects, less among GOLD 1–3 patients.VOC patterns significantly correlated with expiratory flows (Spearmans rho ranging from 0.36 for MEF25% and sensor Co-Buti-TPP, to 0.81 for FEV1% and sensor Cu-Buti-TPP p<0.001)), but not with residual volume and total lung capacity. Conclusions VOC patterns strictly correlated with expiratory flows. Thus, e nose might conveniently be used to assess COPD severity and, likely, to study phenotypic variability. However, the suboptimal reproducibility within GOLD 1–3 patients should stimulate further research to identify more reproducible breath print patterns.

Reliability of equations to estimate glomerular filtration rate in the very old

Background and aims: Few studies have investigated the reliability of formulas estimating renal function in very old people. Methods: We studied 154 elderly people (mean age: 82 yrs). Serum creatinine (SC) was measured by the Jaffé method, and creatinine clearance (CrCl) with 24-h urine collection. Agreement was measured with the average ratio estimated/measured CrCl, and precision with the 95% agreement intervals (95% AI). We calculated the proportion of residents correctly classified as having renal insufficiency (accuracy). Results: The Cockcroft-Gault (CG) and Modification of Diet in Renal Disease 1 (MDRD1) formulas showed good average agreement with measured CrCl (0.95 and 1.016, respectively); the MDRD2 formula was more biased. Results were consistent in women, whereas the MDRD1 was more biased in men (average ratio: 1.196). The 95% AI showed that all formulas can yield results as low as 50% or as high as 200% of measured CrCl. The proportion of people with CrCl<60 ml/min misclassified by the CG, MDRD1, and MDRD2 formulas as having normal renal function was 21.4%, 27.0%, and 38.8%, respectively. These results were consistent across the various subgroups, especially in subjects with normal SC. Conclusions: The clinical usefulness of formulas commonly used to estimate CrCl was limited, regardless of subjects’ characteristics.

Association of Reduced Total Lung Capacity With Mortality and Use of Health Services

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

Pre-polysomnographic assessment using the Pittsburgh Sleep Quality Index questionnaire is not useful in identifying people at higher risk for obstructive sleep apnea

Background Polysomnography remains the diagnostic gold standard for obstructive sleep apnea syndrome (OSAS), but it is time consuming and requires dedicated personnel and setting. It may be more useful to plan a polysomnogram based on a preliminary screening. Objective To verify whether a questionnaire of general quality of sleep, the Pittsburgh Sleep Quality Index (PSQI), could outperform a dedicated questionnaire (Epworth Sleep Scale: ESS) in targeting OSAS patients in an at risk population. Methods 254 consecutive subjects attending the outpatient clinic for respiratory diseases were clinically evaluated for sleep apnea and referred to a 12 channel night-time polysomnography. All patients were administered the ESS and the PSQI before the procedure. The correlation between the Apnoea/Hypopnoea Index (AHI) and the global score of the PSQI was calculated; Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), Diagnostic accuracy and the area under the receiver operating characteristic curve (AUC) were calculated. ESS performance was used as a control reference. Results The mean age was 65.8 (standard deviation: 12.1) and the study group was 68.4% male. The mean BMI was 38.5; SD 7.7. Prevalence of OSAS in the study population was 55.5%; OSAS was severe in 60.5% of OSAS patients. ESS was significantly, but weakly, correlated with the AHI (AHI vs ESS: R = 0.308; p < 0.001), whereas PSQI was not (R = 0.037; p = 0.581). Both PSQI and ESS, however, performed unsatisfactorily: sensitivity 37.8% and 69.7%; Specificity 76.1% and 31.0%; Diagnostic Accuracy 57.5% and 49.8%; PPV 60% and 48.7%; NPV 56.3% and 52.2%; AUC 0.589 and 0.509, respectively. Conclusions The PSQI score is not helpful in the pre-polysomnographic assessment of people with suspected OSAS. Further studies are required to provide reliable pre-clinical instruments targeting patients amenable to polysomnography.

Genetic background of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive lung disease characterized by progressive fibrosing interstitial pneumonia. The histological pattern, which displays dense fibrosis with active areas of fibroblastic proliferation, suggests a pathogenetic role of aberrant response to healing of multiple microscopic, repeated alveolar epithelial injuries. Although the exact etiology of the disease is still under investigation, several studies suggest that a combination of genetic and environmental factors may play a causal role. The aim of this review is to describe the genetic background of IPF, reporting the latest advancements made possible by genomic techniques that allow a high-throughput analysis and the identification of target genes implicated in IPF. This information may help to clarify pivotal aspects on prognosis and diagnosis, and may help to identify potential targets for future therapies.

Spontaneous Resolution of a Giant Pulmonary Bulla in an Older Woman: Role of Functional Assessment

Pulmonary bullae usually occur as isolated abnormalities in otherwise normal lung tissue or, more frequently, in the presence of emphysema. Pulmonary bullae tend to progressively increase in their size, and spontaneous regressions have very rarely been reported. In this paper, we report the case of an older woman experiencing the spontaneous resolution of a giant pulmonary bulla. Interestingly, the reported case is characterized by a negligible improvement in respiratory function parameters, despite a substantial increase in the 6-min walking test and the oxygen arteriolar partial pressure.

Exhaled Breath Analysis for the Monitoring of Elderly COPD Patients Health‐state

This pilot study assesses how effectively a gas sensors array can follow the evolution of elderly patients with COPD, the most common chronic respiratory disease. In particular, reproducibility of breath analysis (calculated for each subject along three weekly measurements) resulted comparable to spirometry, except for a larger spread for breath analysis, whose patterns was significantly correlated with other heath status parameters (such as eosinophiles and Barthel index).