Riccardo Pistelli

Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease.

The aim of this study was to assess the prognostic role of co-morbidity in severe chronic obstructive pulmonary disease (COPD). A cohort of 270 COPD patients, mean (+/-SD) age 67+/-9 yrs, consecutively discharged from a University Hospital after an acute exacerbation was studied. Mean (+/-SD) forced expiratory volume in one second (FEV1) was 34+/-16% of predicted and FEV1/forced vital capacity (FVC) was 40.5+/-13.8%. The most common co-morbid diseases were: hypertension (28%), diabetes mellitus (14%), and ischaemic heart disease (10%). Clinical, electrocardiogram (ECG), and respiratory function data taken at the time of discharge were collected from the clinical records. The Charlsons index was used to quantify co-morbidity. Follow-up was conducted by means of telephone calls. Multivariate survival analysis was used to identify the independent predictors of death. The median survival of the cohort was 3.1 yrs. Death was predicted by the following variables: age (hazard rate (HR) 1.04; 95% confidence intervals (95% CI) 1.02-1.05), ECG signs of right ventricular hypertrophy (HR 1.76; 95% CI 1.30-2.38), chronic renal failure (HR 1.79; 95% CI 1.05-3.02), ECG signs of myocardial infarction or ischaemia (HR 1.42; 95% CI 1.02-1.96), FEV1 < 590 mL (HR 1.49; 95% CI 0.97-2.27). A score based upon these variables predicted mortality at 5 yrs with a sensitivity of 63% and a specificity of 77%. Selected co-morbid diseases and electrocardiogram signs of right ventricular hypertrophy play a major prognostic role in advanced chronic obstructive pulmonary disease. The clinical assessment of patients with chronic obstructive pulmonary disease should include these important and easily measurable variables.

Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease

PURPOSE To identify factors affecting the short-term prognosis of patients with acutely exacerbated chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS The 590 patients having COPD as primary disease who were hospitalized in the pneumology unit of a university hospital from 1981 to 1990 were studied. A standardized protocol for the treatment of acutely exacerbated COPD was adopted for all the patients. The patient records were retrospectively analyzed by two observers, and 23 clinical and laboratory variables defining the patient status on admission were collected. Age and arterial gas data were also taken into account, and the outcome mortality was recorded. Interobserver reproducibility was tested by computing the kappa coefficient and Spearmans rho for dichotomous and continuous variables, respectively. The relationship of clinical and laboratory factors to the outcome was assessed first by univariate analysis and then by a logistic regression analysis assessing the independent predictive role of variables previously shown to be univariately correlated with mortality. RESULTS The mortality rate was 14.4%. The logistic regression analysis identified four independent predictors of death: age (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.04 to 1.11), alveolar-arterial oxygen gradient greater than 41 mm Hg (OR 2.33; 95% CI 1.39 to 3.90), ventricular arrhythmias (OR 1.91; 95% CI 1.10 to 3.31), and atrial fibrillation (OR 2.27; 95% CI 1.14 to 4.51). CONCLUSIONS Patients with acutely exacerbated COPD having a high risk of death can be identified at the time of admission. Variables reflecting heart dysfunction are important determinants of this risk. Among pulmonary function data, only alveolar-arterial oxygen gradient contributes to the predictive model.

Consumption of fresh fruit rich in vitamin C and wheezing symptoms in children

BACKGROUND A beneficial effect of fresh fruit consumption on lung function has been observed in several studies. The epidemiological evidence of the effect on respiratory symptoms and asthma is limited. The consumption of fruit rich in vitamin C was examined in relation to wheezing and other respiratory symptoms in cross sectional and follow up studies of Italian children. METHODS Standardised respiratory questionnaires were filled in by parents of 18 737 children aged 6–7 years living in eight areas of Northern and Central Italy. The winter intake of citrus fruit and kiwi fruit by the children was categorised as less than once per week, 1–2 per week, 3–4 per week, and 5–7 per week. A subset of 4104 children from two areas was reinvestigated after one year using a second parental questionnaire to record the occurrence of wheezing symptoms over the intervening period. RESULTS In the cross sectional analysis, after controlling for several confounders (sex, study area, paternal education, household density, maternal smoking, paternal smoking, dampness or mould in the childs bedroom, parental asthma), intake of citrus fruit or kiwi fruit was a highly significant protective factor for wheeze in the last 12 months (odds ratio (OR) = 0.66, 95% confidence intervals (CI) 0.55 to 0.78, for those eating fruit 5–7 times per week compared with less than once per week), shortness of breath with wheeze (OR = 0.68, 95% CI 0.56 to 0.84), severe wheeze (OR = 0.59, 95% CI 0.40 to 0.85), nocturnal cough (OR = 0.73, 95% CI 0.65 to 0.83), chronic cough (OR = 0.75, 95% CI 0.65 to 0.88), and non-coryzal rhinitis (OR = 0.72, 95% CI 0.63 to 0.83). In the follow up study fruit intake recorded at baseline was a strong and independent predictor of all symptoms investigated except non-coryzal rhinitis. In most cases the protective effect was evident even among children whose intake of fruit was only 1–2 times per week and no clear dose-response relationship was found. The effect was stronger (although not significantly so (p = 0.13)) in subjects with a history of asthma; those eating fresh fruit at least once a week experienced a lower one year occurrence of wheeze (29.3%) than those eating fruit less than once per week (47.1%) (OR = 0.46, 95% CI 0.27 to 0.81). CONCLUSIONS Although the effect of other dietary components cannot be excluded, it is concluded that the consumption of fruit rich in vitamin C, even at a low level of intake, may reduce wheezing symptoms in childhood, especially among already susceptible individuals.

Do GOLD stages of COPD severity really correspond to differences in health status

The purpose of this study was to assess whether different stages of chronic obstructive pulmonary disease (COPD) severity defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria correlate with meaningful differences in health status. A total of 381 COPD patients, aged 73±6 yrs, were classified in the five GOLD stages. Disease-specific (St George Respiratory Questionnaire (SGRQ)) and generic indexes of health status were measured in all patients. Multivariate analysis of covariance or Kruskal Wallis tests were used to compare health status indexes across the spectrum of GOLD stages of COPD severity. GOLD stages of COPD severity significantly differed in SGRQ components and Barthels index, but not in the indexes assessing cognitive and affective status and quality of sleep. The largest variation in health status was observed at the transition from stage IIa to stage IIb, while there were no other significant differences between consecutive stages. Both female sex and comorbidity were associated with a greater impact of COPD on the health status. In conclusion, the upper limit of stage IIb (forced expiratory volume in one second of 49%) marks a threshold for dramatic worsening of health status. Progression of chronic obstructive pulmonary disease severity from stage 0 to stage IIa does not correspond to any meaningful difference in health status.

Dietary factors associated with wheezing and allergic rhinitis in children

The effect of dietary factors on asthma is controversial. This study examined food consumption and the use of fats in relation to wheezing and allergic rhinitis in children. Baseline questionnaire data on individual and family characteristics were recorded by parents of 5,257 children aged 6–7 yrs living in central Italy participating in the International Study on Asthma and Allergies in Childhood study. A total of 4,104 children (78.1%) were reinvestigated after 1 yr using a second parental questionnaire to record occurrence of respiratory symptoms over the intervening 12 months. Consumption of foods rich in antioxidants, such as vitamins C and E, animal fats, and food containing omega‐3 fatty acids were investigated using a food-frequency questionnaire. Frequency of use of fats was also evaluated. Wheezing, shortness of breath with wheeze, and symptoms of allergic rhinitis in the past 12 months were considered. Intake of cooked vegetables, tomatoes, and fruit were protective factors for any wheeze in the last 12 months and shortness of breath with wheeze. Consumption of citrus fruit had a protective role for shortness of breath with wheeze. Consumption of bread and margarine was associated with an increased risk of wheeze, while bread and butter was associated with shortness of breath with wheeze. Dietary antioxidants in vegetables may reduce wheezing symptoms in childhood, whereas both butter and margarine may increase the occurrence of such symptoms.

Socioeconomic status, number of siblings, and respiratory infections in early life as determinants of atopy in children.

Asthma and allergic disorders have been on the increase in recent decades, especially among children living in affluent countries; some aspects of the “Western” way of life may explain this trend. We evaluated the relation of aeroallergen skin test reactivity with socioeconomic status, number of siblings, and respiratory infections in early life. We examined a total of 2,226 schoolchildren, ages 7–11 years, in three areas of Lazio, Italy. Skin prick tests were performed to assess atopic status, and self‐administered questionnaires were completed by the parents. The prevalence of prick test positivity was greater among children whose fathers were in the highest educational level than among those in the lowest [prevalence ratio (PR) = 1.58; 95% confidence interval (CI) = 1.21–2.06]. There was also a lower prevalence of atopy among larger sibships (PR = 0.38 for subjects with four or more siblings vs those without siblings; 95% CI = 0.14–0.99). A history of bronchitis or bronchiolitis before age 2 years was weakly associated with an increased risk of atopy, whereas a history of pertussis or pneumonia was not. Both the effect of fathers education and the influence of larger sibship size remained when we adjusted for several potential confounding factors, including respiratory infections in early life. We infer that higher socioeconomic status and lower sibling number are determinants of atopy in this Italian population. Protection arising from early severe respiratory infections does not explain this association, although we cannot exclude a role for other viral infections.

Air pollution and lung function among susceptible adult subjects: a panel study

BackgroundAdverse health effects at relatively low levels of ambient air pollution have consistently been reported in the last years. We conducted a time-series panel study of subjects with chronic obstructive pulmonary disease (COPD), asthma, and ischemic heart disease (IHD) to evaluate whether daily levels of air pollutants have a measurable impact on the lung function of adult subjects with pre-existing lung or heart diseases.MethodsTwenty-nine patients with COPD, asthma, or IHD underwent repeated lung function tests by supervised spirometry in two one-month surveys. Daily samples of coarse (PM10–2.5) and fine (PM2.5) particulate matter were collected by means of dichotomous samplers, and the dust was gravimetrically analyzed. The particulate content of selected metals (cadmium, chrome, iron, nickel, lead, platinum, vanadium, and zinc) was determined by atomic absorption spectrometry. Ambient concentrations of nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), and sulphur dioxide (SO2) were obtained from the regional air-quality monitoring network. The relationships between concentrations of air pollutants and lung function parameters were analyzed by generalized estimating equations (GEE) for panel data.ResultsDecrements in lung function indices (FVC and/or FEV1) associated with increasing concentrations of PM2.5, NO2 and some metals (especially zinc and iron) were observed in COPD cases. Among the asthmatics, NO2 was associated with a decrease in FEV1. No association between average ambient concentrations of any air pollutant and lung function was observed among IHD cases.ConclusionThis study suggests that the short-term negative impact of exposure to air pollutants on respiratory volume and flow is limited to individuals with already impaired respiratory function. The fine fraction of ambient PM seems responsible for the observed effects among COPD cases, with zinc and iron having a potential role via oxidative stress. The respiratory function of the relatively young and mild asthmatics included in this study seems to worsen when ambient levels of NO2 increase.

Electrocardiographic Signs of Chronic Cor Pulmonale: A Negative Prognostic Finding in Chronic Obstructive Pulmonary Disease

BACKGROUND Chronic cor pulmonale (CCP) is a strong predictor of death in chronic obstructive pulmonary disease (COPD). The aims of this study were to assess the prognostic role of individual ECG signs of CCP and of the interaction between these signs and abnormal arterial blood gases. METHODS AND RESULTS Two hundred sixty-three patients (217 men) with COPD, mean age 67+/-9 years, were grouped according to whether they had no ECG signs (group 1, n=100) or >/=1 ECG signs (group 2, n=163) of CCP and were followed up for 13 years after an exacerbation of respiratory failure. The median survival was significantly shorter in group 2 than in group 1 (2.58 versus 3. 45 years, respectively; Mantel-Cox test, 9.58; P=0.002). The Cox regression analysis identified S1S2S3 pattern, right atrial overload (RAO), and alveolar-arterial oxygen gradient (PAO2-PaO2) >48 mm Hg during oxygen therapy as the strongest predictors of death, with hazard rate (HR)=1.81 (95% CI, 1.22 to 2.69), HR=1.58 (95% CI, 1.15 to 2.18), and HR=1.96 (95% CI, 1.19 to 3.25), respectively. The median survivals of patients having both S1S2S3 pattern and RAO (n=14) and of patients having either S1S2S3 pattern or RAO (n=77) were 1.33 and 2.70 years, respectively (P=0.022). Group 2 patients had a 3-year survival of 18% or 53%, depending on whether their PAO2-PaO2 during oxygen therapy was or was not >48 mm Hg. CONCLUSIONS Some ECG signs of CCP and PAO2-PaO2 >48 mm Hg during oxygen therapy qualified as a simple and inexpensive tool for targeting subsets of COPD patients with severe or very severe short-term prognosis.

Clinical characteristics and management of cancer-associated acute venous thromboembolism: findings from the MASTER Registry

MASTER is a multicenter registry of consecutively recruited patients with symptomatic, objectively confirmed, acute venous thromboembolism. One fifth of the patients enrolled had cancer. In these patients, venous thromboembolism has peculiar features, and its management is more problematic. Background Clinical characteristics and management of acute deep vein thrombosis and pulmonary embolism (PE) have been reported to be different in patients with and without cancer. The aim of this paper was to provide information on clinical characteristics and management of acute venous thromboembolism in patients with cancer by means of a large prospective registry. Design and Methods MASTER is a multicenter registry of consecutively recruited patients with symptomatic, objectively confirmed, acute venous thromboembolism. Information about clinical characteristics and management was collected by an electronic data network at the time of the index event. Results A total of 2119 patients were enrolled, of whom 424 (20%) had cancer. The incidence of bilateral lower limb deep vein thrombosis was significantly higher in patients with cancer than in patients without cancer (8.5% versus 4.6%; p<0.01), as were the rates of iliocaval thombosis (22.6% versus 14%; p<0.001), and upper limb deep vein thrombosis (9.9% versus 4.8%; p<0.001). Major bleeding (3.3% versus 1.1%; p=0.001), in-hospital treatment (73.3% versus 66.6%; p=0.02) and inferior vena cava filter implantation (7.3% versus 4.1%; p=0.005) were significantly more frequent in patients with cancer, in whom oral anticoagulants were less often used (64.2% versus 82%; p<0.0001). Conclusions The clinical presentation of acute venous thromboembolism is different and often more extensive in cancer patients than in patients free from malignancy. Moreover, the management of the acute phase of venous thromboembolism is more problematic in cancer patients, especially because of a higher rate of major bleeding and the need for implantation of inferior vena cava filters.

Effects of environment on atopic status and respiratory disorders in children

BACKGROUND We investigated whether living in areas with higher air pollution levels increases the prevalence of positive skin reactivity in children and the possible synergic effect of air pollution exposure and atopy on respiratory disorders. METHODS This cross-sectional study was conducted in an urban area, in an industrialized area, and in a rural control area in the Latium region of Italy. A total of 2226 subjects, aged 7 to 11 years, were studied. RESULTS The prevalence of children with positive skin test results did not vary significantly over the areas (urban area = 21.0%, industrialized area = 22.0%, rural area = 20.2%). Children living in polluted areas experienced significantly more cough and phlegm (odds ratio [OR] = 1.5), rhinitis (OR = 1.7), pneumonia (OR = 1.7), and early respiratory infections (OR = 1.4) than control subjects. The pattern of the odds ratios for atopy and air pollution suggested that the two factors were probably additive in affecting asthma and early respiratory infections (synergy index [SI] = 1.04 and 1.27, respectively), whereas they seemed to act synergically in regard to cough and phlegm (SI = 1.59), rhinitis (SI = 3.01), and pneumonia (SI = 2.75). CONCLUSION Environmental air pollution seems not to increase the prevalence of atopic status; it seems, however, to enhance the development of clinical symptoms among already sensitized subjects.