Michele Arigliani

Evaluation of the global lung initiative 2012 reference values for spirometry in African children

Rationale: Despite the high burden of respiratory disease, no spirometry reference values for African children are available. Objectives: Investigate whether the Global Lung Initiative (GLI‐2012) reference values for spirometry are appropriate for children in sub‐Saharan Africa and assess the impact of malnutrition on lung function. Methods: Anthropometry and spirometry were obtained in children aged 6 to 12 years from urban and semiurban schools in three African countries. Spirometry z‐scores were derived using the GLI‐2012 prediction equations for African Americans. Thinness (body mass index z‐score < −2) was a surrogate for malnutrition. Spirometry outcomes were compared with those of African American children from the third National Health and Nutrition Survey. Measurements and Main Results: Spirometry data were analyzed from 1,082 schoolchildren (51% boys) aged 6.0 to 12.8 years in Angola (n = 306), Democratic Republic of the Congo (n = 377), and Madagascar (n = 399). GLI‐2012 provided a good fit with mean (SD) z‐scores of −0.11 (0.83) for FEV1, −0.08 (0.86) for FVC, and −0.07 (0.83) for FEV1/FVC. Because of low scatter, the fifth centile corresponded to −1.3 z‐scores in boys and −1.5 z‐scores in girls. Malnourished African children had a normal FEV1/FVC ratio but significant reductions of ˜0.5 z‐scores (˜5%) in FEV1 and FVC compared with African American peers from the third National Health and Nutrition Survey. Children in Angola had the lowest, and those in Madagascar had the highest, zFEV1 and zFVC. Conclusions: The results of this study support the use of GLI‐2012 reference values for schoolchildren in sub‐Saharan Africa. Malnutrition affects body growth, leading to a proportionately smaller FEV1 and FVC without respiratory impairment, as shown by the normal FEV1/FVC ratio.

Unexpectedly high rates of obesity and dysglycemia among villagers in Cameroon.

Our survey in Cameroon recorded obesity and dysglycemia in inhabitants, which are similar to those reported elsewhere in the region. Typically these metabolic disturbances are attributed to the adoption of a new urban lifestyle including diminished physical activity and an altered (‘Western’) diet. Unexpectedly we found that, like urban populations, our rural population had high rates of metabolic disturbances, despite living in villages and being physically active and consuming traditional diet that is high in plant sources of food and low in meat. From our preliminary study, we raise the possibility that the environmental elements that are driving the pandemic of obesity and diabetes in sub‐Saharan Africa are far more complex than heretofore appreciated. Copyright

Increased carotid thickness in subjects with recently-diagnosed diabetes from rural Cameroon.

Background We have recently shown a high prevalence of diabetes and obesity in rural Cameroon, despite an improved lifestyle. Diabetes in rural Africa remains underdiagnosed and its role in increasing risk of atherosclerosis in these populations is unknown. We investigated the prevalence of carotid atherosclerosis and cardiovascular risk factors in a population of subjects with recently-diagnosed diabetes from rural Cameroon. Methodology/Principal Findings In a case-control study, carotid intima-media thickness (IMT) was measured in 74 subjects with diabetes (diagnosed <2 years), aged 47–85 and 109 controls comparable for age and sex. Subjects were recruited during a health campaign conducted in April 2009. Blood glucose control (HbA1c, fasting blood glucose) and major cardiovascular risk factors (complete lipid panel, blood pressure) were also measured. Mean carotid IMT was higher in subjects with diabetes than healthy controls at each scanned segment (common, internal carotid and bulb) (P<0.05), except the near wall of the left bulb. Vascular stiffness tended to be higher and pressure-strain elastic modulus of the left carotid was increased in subjects with diabetes than controls (P<0.05), but distensibility was similar between the two groups. At least one plaque >0.9 mm was found in 4%, 45.9% and 20% of diabetic subjects at the common, bulb or internal carotid, respectively. Only 25% of patients had an HbA1c<7%, while over 41.6% presented with marked hyperglycemia (HbA1c>9%). The prevalence of diabetic subjects with abnormal levels of LDL-cholesterol, triglycerides, HDL-cholesterol or blood pressure was 45%, 16.6%, 15% and 65.7%, respectively. Conclusions Carotid thickness is increased in subjects with diabetes from a rural area of Cameroon, despite the relatively recent diagnosis. These findings and the high rate of uncontrolled diabetes in this population support the increasing concern of diabetes and cardiovascular diseases in African countries and indicate the need for multifaceted health interventions in urban and rural settings.

Diagnostic Accuracy of Obstructive Airway Adult Test for Diagnosis of Obstructive Sleep Apnea.

Rationale. The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. Objectives. To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. Methods. Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. Measurements and Main Results. The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 (p < 0.01). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81–1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82–0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76–0.92) for severe OSA (AHI ≥ 30). Conclusions. The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.

Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea

The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients.

Coeliac disease in infants: antibodies to deamidated gliadin peptide come first!

BackgroundThe onset of coeliac disease (CD) in the first year of life is uncommon and the diagnosis can be challenging due to the suboptimal sensitivity of tissue transglutaminase antibodies (tTG) at this age and the many other possible causes of malabsorption in infants. Antibodies to deamidated gliadin peptides (anti-DGPs), especially IgG, may appear earlier than IgA anti-tTG in very young children with CD.Case presentationWe report here on an 8-month-old child who was evaluated for failure to thrive, constipation and developmental delay. The symptoms started following gluten introduction in the diet. Laboratory tests showed high fecal elastase concentration, normal serum IgA levels with positive IgG and IgA anti-DGPs, whereas anti-tTG were not detected. The duodenal biopsy revealed a complete villous atrophy (Marsh-Oberhuber 3C). The culture of biopsy fragments in the presence of gliadin peptides did not stimulate the production of IgA anti-endomysial antibodies. Genetic testing proved the child was positive for HLA-DQ2 (DQA1*05; DQB1*02) and HLA-DQ8 (DQA1*03, DQB1*0302). Having initiated the gluten-free diet, the symptoms disappeared and the infant experienced rapid catch-up growth with normalization of psychomotor development.ConclusionsThis case report highlights the utility of anti-DGPs for screening infants with suspected CD. The pattern with positivity for IgG and IgA anti-DGPs only is rare in IgA-competent children with biopsy-proven CD. It could be explained in infancy as immaturity of the adaptive immune system.

Nutrition and Lung Growth

Experimental evidence from animal models and epidemiology studies has demonstrated that nutrition affects lung development and may have a lifelong impact on respiratory health. Chronic restriction of nutrients and/or oxygen during pregnancy causes structural changes in the airways and parenchyma that may result in abnormal lung function, which is tracked throughout life. Inadequate nutritional management in very premature infants hampers lung growth and may be a contributing factor in the pathogenesis of bronchopulmonary dysplasia. Recent evidence seems to indicate that infant and childhood malnutrition does not determine lung function impairment even in the presence of reduced lung size due to delayed body growth. This review will focus on the effects of malnutrition occurring at critical time periods such as pregnancy, early life, and childhood, on lung growth and long-term lung function.

Measuring empathy in pediatrics: validation of the Visual CARE measure

BackgroundEmpathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED).MethodsThe empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7.The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated.ResultsSeven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor.Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93).ConclusionsThe Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics.

Italian Physicians’ Opinions on Rotavirus Vaccine Implementation

Rotavirus (RV) infection is the main cause of severe acute gastroenteritis (GE) in the pediatric population and has a major impact in both developing and industrialized countries. The reduction of severe RVGE cases, followed by death or hospitalization, is considered the main benefit of RV vaccination, even though its implementation often faces obstacles. In Italy, the recently approved National Immunization Plan aims to overcome the differences among regions, offering a universal free RV vaccination. The aim of the study was to evaluate the opinions on benefit and acceptability of RV vaccination related to the perception of the burden of RV disease. Data were collected from 108 physicians in 2015 by a questionnaire consisting of 12 questions; some answers were compared with those obtained with a similar tool in 2011. The majority of respondents (76.2%) was convinced of the benefit of the vaccine and 57.4% recommended it routinely, but more than half indicated a <25% adherence to RV vaccination among their patients. As the main reasons of vaccine refusal, skepticism about the vaccine (60.4%) and its cost (34.1%) were indicated. Our data confirm that more information and counselling are needed to increase RV vaccine coverage.

G112(P) Lung function in paediatric subjects with sickle cell anaemia: A comparison between UK and Italy

Background respiratory morbidity is common in patients with sickle cell anaemia (SCA). The quality of care and environmental factors might have an influence on their respiratory health. Aims to compare spirometry lung function in children and adolescents attending sickle cell centres in UK and Italy. Methods anthropometry and spirometry were undertaken in SCA-patients (SS,Sb0) aged 6–17 years. Exclusion criteria: SCArelated morbidity within the last two weeks and inability to perform an adequate spirometry. Portable spirometers (Pony FX, Cosmed-IT, Easy-on PC, NDD-CH) were used. Z-scores of anthropometric and spirometric data were derived, respectively, from CDC2000 and GLI-black equation (Quanjer, ERJ2012). Spirometry patterns were classified as normal, obstructive (zFEV1/FVC < 1.64) or restrictive (zFVC < 1.64 +zFEV1/ FVC ³ 1.64). Differences between groups were assessed by ttests and considered statistically significant for p values<0.05. Results Eighty-five subjects of African ancestry were included (n.46 UK; n.39 Italy; 42% girls; age-range: 6.2–17.9 years). Prevalence of obstructive pattern was higher in SCA-patients from UK, while a restrictive pattern was more common in subjects living in Italy (table). Mean FEV1/FVC was ~0.6 z-scores lower in SCA patients from UK (p<0.01). Age was negatively correlated (p<0.05) with both zFEV1(R2 0.19) and zFVC(R2 0.136). Conclusion obstructive lung disease is more common among paediatric subjects with SCA living in UK than in Italy. Differences in the level of ambient air pollution and prevalence of allergies, could have contributed to these findings. It seems that SCA patients from Italy develop earlier a restrictive picture. These results need further confirmation. Abstract G112(P) Table 1 Mean (SD) values, unless otherwise specified Index Sickle cell UK Sickle cell ITA Diff between means (95% CI) n (%male) 46 (54%) 39 (61%) Age (years) 11.8 (2.9) 11.3 (3.5) 0.5 (-0.9 to 1.9) Height z-score -0.11 (1.23) -0.08 (1.09) -0.03 (-0.53 to 0.47) BMI z-score -0.26 (1.20) -0.55 (1.17) 0.29 (-0.24 to 0.82) FEV1 z-score -1.15 (1.09) -0.80 (0.97) -0.35 (-0.81 to 0.08) FVC z-score -0.79 (1.04) -0.71 (0.83) -0.08 (-0.53 to 0.32) FEV1/FVC z-score -0.87 (0.93) -0.27 (0.93) -0.60 (-1.0 to -0.019) Spirometry pattern Obstructive (% of total) 10 (21.7%) 3 (7.7%) Restrictive (% of total) 5 (10.8%) 8 (20.5%)