Giorgio Castellana

Pulmonary nocardiosis in Chronic Obstructive Pulmonary Disease: A new clinical challenge

Pulmonary nocardiosis (PN) is a rare but severe disease caused by Nocardia spp. Despite the traditional description as opportunistic infection, case reports and case series of pulmonary nocardiosis have recently been reported in immunocompetent patients too, in particular among people with chronic pulmonary diseases such as advanced Chronic Obstructive Pulmonary Disease (COPD). PN is characterized by non-specific symptoms and radiological findings; bacteriological culture can be difficult. For the reasons above, diagnosis of PN is challenging, sometimes resulting in a misdiagnosis of tuberculosis. We report an interesting case of PN in a 75-year-old male with COPD. He complained a 3-months history of fatigue, evening rise in body temperature, night sweats, unexplained weight loss of 5 kg, worsening dyspnea, cough and mucopurulent sputum. The chest X-ray showed multiple nodules with cavitations bilaterally in the apical and subclavian regions. Nocardia cyriacigeorgica with 100% identity was identified in three sputum samples. Since the patient has never undergone a systemic and/or inhaled steroid therapy, and has no respiratory failure and comorbidities entailing immunodepression, it is conceivable that, in this immunocompetent patient, the COPD could represent an isolated risk factor for PN. Risk factors, clinical presentations, radiographic findings, differential diagnosis and review of the literature of PN cases in COPD, pointing out the similarities and differences, are also described.

The role of education in the self-compilation of Epworth sleepiness scale questionnaire in patients with suspected obstructive sleep apnea

Dear Editor, Epworth Sleepiness Scale (ESS) is a simple, validated questionnaire which is able to provide an accurate measurement of the subjects’ degree of diurnal hypersomnolence [1]. ESS is commonly used for the evaluation of patients potentially affected by OSA in sleep laboratories, and it has a good specificity in detecting undiagnosed OSA [2] (Table 1). On one hand, it should be highlighted that one of the ESS upsides is that it can be self-administered, hence, not requiring physician labor. On the other hand, self-administration of the questionnaire is characterized by a significant rate of errors [3, 4]. Based on the above, the aim of our study was to evaluate the role of instruction in the self-compilation of ESS, in two groups of subjects with suspected OSA. We enrolled 76 patients referred to our Sleep Disorders Breathing Service between January and October 2016. Inclusion criteria were the following: (1) age > 18 years; (2) no previous evaluation for suspected OSA; (3) no shiftworkers; (4) absence of psychiatric (e.g., schizophrenia, nonspecific psychosis, and depression) and neurologic (e.g., insomnia and narcolepsy) comorbidities; (5) no intake of sleepinducing medications. The study population was divided into two groups, according to their ability for self-administering ESS. Group 1 was composed of 48 subjects who selfadministered ESS. Group 2 consisted of 28 individuals whose ESSwas administered by a sleepmedicine physician. Twentyfour hours after completing the questionnaire, subjects of group 1 underwent physician-assessed ESS. Thus, we calculated the parameter BΔESS^, defined as the difference between physician-administered and self-administered ESS score. Subsequently, we divided patients of group 1 into two subgroups according to theirΔESS. Group 1a was made of 17 subjects withΔESS ≥ 1 (having higher score with physicianadministered ESS) and group 1b was composed of 31 individuals with ΔESS < 1 (having higher score with selfadministered ESS). The study was carried out in accordance with the principles of the Helsinki Declaration and it was approved by the local ethics committee. An informed consent was signed by all the participants. The Italian ESS version, validated by Vignatelli L et al., was adopted for the current study [5]. All patients underwent an ambulatory overnight cardiorespiratory polygraphy recording (Somtè, Compumedics Inc). The following parameters were detected: oxyhemoglobin saturation, heart rate, snoring sound, body posture, nasal pressure, and thoracic/abdominal movements. Patients baseline characteristics were reported as mean ± standard deviation for continuous variables and as percentage for categorial variables. Continuous variables were compared by Student’s t-test for independent samples and Fisher’s χ-test. Univariate logistic regression was performed assuming the ability of self-administering ESS as the dependent variable and all the parameter objects of the study as the independent variable. Significant predictors by univariate analysis were tested on a model of multivariate logistic regression with data input by blocks. To verify the accuracy of the multivariate model, a ROC-curve was built based on the probability of belonging to group 1. A p value <0.05 was considered statistically significant. * Silvano Dragonieri silvano.dragonieri@uniba.it

Nocturnal Hypoventilation May Have a Protective Effect on Ischemic Heart Disease in Patients with Obesity Hypoventilation Syndrome

The importance of nocturnal hypoventilation (nHyp) in the development of cardiovascular comorbidity (CVM) in patients with obesity hypoventilation syndrome (OHS) is controversial. We recently hypothesized that nHyp may have a protective effect on CVM in OHS. The aim of this study was to evaluate the link between nHyp and CVM in patients with OHS. We performed a retrospective analysis of the clinical records of 60 patients with OHS. The initial population was divided into two groups: (1) 31 subjects with OHS and nHyp (nhOHS); (2) 29 individuals with OHS without nHyp (wnhOHS). All patients had also obstructive sleep apnea. Anthropometric data, medical history, electrocardiogram, pulmonary function testing, arterial blood gas test, and sleep recordings were collected. Patients with nhOHS, compared with those wnhOHS, showed higher values of PaCO2 (48.75 ± 3.78 vs. 46.91 ± 2.09 mmHg; p = 0.023), lower percentage of ischemic heart disease (3.2% vs. 20.7%; p = 0.042), higher oxygen desaturation index (ODI; 55.10/h ± 28.76 vs. 38.51/h ± 23.21; p = 0.017), and higher total sleep time (TST90) with SpO2 <90% (53.58% ± 26.90 vs. 25.64% ± 21.67; p = 0.000). Moreover, individuals in the nhOHS group showed a significantly different (p = 0.031) distribution of the three ODI tertiles 0-32/h, 33-72/h, >72/h compared with those in wnhOHS group (19.4% vs. 37%, 41.9% vs. 51.7%, 38.7% vs. 10.3%, respectively). Subsequent discriminant analysis correctly classified nhOHS and wnhOHS in 66.7% of the cases. Ours is the first study analyzing the correlation between nHyp and CVM in patients with OHS. We showed that nHyp in OHS may have a protective effect on cardiovascular morbidity, in particular on ischemic cardiac disease.

Clinical and Functional Lung Parameters Associated With Frequent Exacerbator Phenotype in Subjects With Severe COPD

BACKGROUND: COPD is currently recognized as a syndrome associated with a high prevalence of comorbidities and various phenotypes. Exacerbations are very important events in the clinical history of COPD because they drive the decline in lung function. In the present study, we aim to identify whether there are any clinical and functional specific features of frequent exacerbators in a population of patients with severe COPD. METHODS: We conducted a cross-sectional, case control study. All subjects had Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3 or 4 COPD (FEV1 < 50% predicted). Frequent exacerbators (n = 183) reported ≥2 exacerbations or ≥1 determining hospitalization during the previous 12 months, and infrequent exacerbators (n = 162) reported <2 exacerbations over the last 12 months without hospitalization. Multivariate logistic regression was performed to determine the clinical and functional factors significantly associated with frequent exacerbator status. RESULTS: Frequent exacerbators had a significantly lower inspiratory capacity percentage predicted. The Motley index (residual volume/total lung capacity percentage) was significantly increased in frequent exacerbators. Infrequent exacerbators had lower Modified Medical Research Council dyspnea scale and BODE index than frequent exacerbators. In the multivariate model, a reduced inspiratory capacity percentage predicted and an increase of residual volume/total lung capacity percentage, BODE index and Modified Medical Research Council dyspnea scale were associated with the frequent exacerbation phenotype. CONCLUSIONS: Static hyperinflation and respiratory disability, measured by Motley index and Modified Medical Research Council dyspnea scale, respectively, in the same way as the multidimensional BODE index staging system, were independently associated with frequent exacerbation status in subjects with severe COPD.

Voluntary lung function screening to reveal new COPD cases in southern Italy

Background Underdiagnosis of COPD is a relevant issue, and most frequently involves patients at early stages of the disease. Physicians do not routinely recommend smokers to undergo spirometry, unless they are symptomatic. Aims To investigate the effectiveness of voluntary lung function screening in bringing to light patients with previously unknown COPD and to evaluate the relationships among symptoms, smoking status, and airway obstruction. Methods A voluntary screening study for COPD was conducted during two editions of the annual Fiera del Levante (2014 and 2015), an international trade fair in Bari. Subjects were eligible for the study if they fulfilled the following inclusion criteria: age ≥35 years, smoker/ex-smoker ≥5 pack-years (PYs), or at least one chronic respiratory symptom (cough, sputum production, shortness of breath, and wheezing). A free post-β2-agonist spirometry test was performed by trained physicians for each participant using portable spirometers. Post-β2-agonist forced expiratory volume in 1 second (FEV1):forced vital capacity ratio <0.7 was chosen to establish the diagnosis of COPD. Sensitivity, specificity, and negative and positive predictive values (NPVs and PPVs) of symptoms for the presence of obstruction were calculated. Results A total of 1,920 individuals were eligible for the study; 188 subjects (9.8%) met COPD criteria. There was a 10.4% prevalence of COPD in subjects with one or more symptoms who had never smoked or smoked ≤5 PYs. Among COPD patients, prevalence of symptoms increased in the presence of FEV1 <80%. COPD smokers were more symptomatic than smokers without COPD. Sensitivity and specificity in all subjects with one or more symptoms were 87% and 32%, respectively, whereas in smoker subgroups, sensitivity and specificity were 71% and 41% (≥5 PYs) and 74% and 35% (≥10 PYs), respectively. In all subjects, the presence of at least one symptom was associated with a low PPV for COPD of 11%, but a very high NPV (96%). These data did not change if the analysis was limited to smokers. Conclusion Voluntary public lung function screening programs in Italy are effective, and may detect a large number of undiagnosed subjects with COPD in early stages. In our population, COPD symptoms had low specificity and PPV, even considering smokers only.

Bilateral pulmonary nodules and acute respiratory failure in a 22-year-old man with dyspnoea and fever

A 22-year-old white male presented complaining of a 3-week history of fatigue, cough and haemoptysis, accompanied by fever (38°C max), dyspnoea and mucopurulent sputum in the last few days. He denied nausea, vomiting, diarrhoea, dysuria and weight loss. Can you diagnose the cause of this man’s bilateral pulmonary nodules and acute respiratory failure? http://ow.ly/NfED30dDBzm

Static hyperinflation and respiratory disability were associated with frequent-exacerbation phenotype in patients with severe COPD

Background: acute exacerbations are very important events in the clinical history of COPD because are responsible for the decline in lung function. Aims and objectives: we aim to identify whether there are any clinical and functional features of frequent exacerbators in severe COPD patients. Methods: we assessed an observational, cross sectional, case control cohort study. All subjects had GOLD stage 3 or 4. “Frequent exacerbators” (n = 183) reported a number of >2 exacerbations in the last 12 months or > 1 with hospitalization and “infrequent exacerbators” (n = 162) had Results: no significant differences were found in age, sex, body mass index, presence of chronic cough, six minute walking test and Charlson Comorbidity Index between the two groups. Frequent exacerbators had significantly lower inspiratory capacity (IC) % of predicted and higher residual volume/total lung capacity (RV/TLC) ratio. Infrequent exacerbators had lower mMRC score and BODE index than frequent exacerbators. In the multivariate model an increase of RV/TLC ratio and mMRC score were independently associated with frequent exacerbations. Conclusions: static hyperinflation and respiratory disability, misured by mMRC score, were independently associated w ith frequent exacerbations in severe COPD patients.

Does Nocturnal Hypoventilation Have a Protective Effect on Cardiovascular Comorbidity in Obesity Hypoventilation Syndrome

with sustained hypoxemia than with intermittent hypoxemia. Patients with OHS are exposed to both types of hypoxemia; therefore, it is likely that there is an additive effect. In fact in our study, the prevalence of cardiovascular morbidity was lowest in patients with OHS who also had the most severe form of OSA. This finding supports the notion that sustained and intermittent hypoxemia may result in a more powerful angiogenic stimulation than either one alone. Clearly these findings are hypothesis generating, and further research is necessary. In summary, we do not think sustained hypoxemia is the only reason for the protective cardiovascular effect we observed in our patients with OHS and the most severe form of OSA, but rather it is a combination of cumulative exposure to significant hypoxemia during wakefulness due to hypoventilation plus intermittent hypoxemia during sleep due to very severe OSA. It remains unclear whether hypercapnia modulates the effect of hypoxemia, since experiments involving hypoxic preconditioning did not include exposure to hypercapnia.