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Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

In Italy, peat extracted from the peat bogs of Lake Massaciuccoli is the only peat used for therapeutic purposes. Massaciuccoli peat (M-peat) soaked in the salty bromine–iodine water of Undulna Thermae has given positive results in various pathological situations, mainly in dermatological, rheumatological, and traumatological conditions. Morphological and biochemical analysis were performed using base M-peat samples matured in the salty bromine–iodine water of the Undulna Thermae for different times, to evaluate whether maturation time modifies peat chemico-physical properties. The maturation process induced particle aggregation, with an increase in the fractions with larger particle size. The presence of a high number of proteins derived from organic degradation was observed; after 6 months of maturation, a significant increase in proteins was found, suggesting that salty bromine–iodine water plays a role in the clinical action of the peat. The presence of lipids in M-peat was also confirmed, allowing us to draw important considerations on its therapeutic properties possibly deriving from the relevant interactions between lipids and humic acids. Finally, from our observations, it could be reasonably argued that longer periods of maturation do not result in additional advantages regarding clinical activity.

Background Gait instability is a major fall-risk factor in patients with chronic obstructive pulmonary disease (COPD). Clinical gait analysis is a reliable tool to predict fall onsets. However, controversy still exists on gait impairments associated with COPD. Research question Thus, the aims of this review were to evaluate the current understanding of spatiotemporal, kinematic and kinetic gait features in patients with COPD. Methods In line with PRISMA guidelines, a systematic literature search was performed throughout Web of Science, PubMed Medline, Scopus, PEDro and Scielo databases. We considered observational cross-sectional studies evaluating gait features in patients with COPD as their primary outcome. Risk of bias and applicability of these papers were assessed according to the QUADAS-2 tool. Results Seven articles, cross-sectional studies published from 2011 to 2017, met the inclusion criteria. Sample size of patients with COPD ranged 14–196 (mean age range: 64–75 years). The main reported gait abnormalities were reduced step length and cadence, and altered variability of spatiotemporal parameters. Only subtle biomechanical changes were reported at the ankle level. Significance A convincing mechanistic link between such gait impairments and falls in patients with COPD is still lacking. The paucity of studies, small sample sizes, gender and disease status pooling were the main risk of biases affecting the results uncertainty. Two research directions emerged: stricter cohorts characterization in terms of COPD phenotype and longitudinal studies. Quantitative assessment of gait would identify abnormalities and sensorimotor postural deficiencies that in turn may lead to better falling prevention strategies in COPD.

Background Non-communicable diseases (NCDs) kill 40 million people each year. The management of chronic respiratory NCDs such as chronic obstructive pulmonary disease (COPD) is particularly critical in Italy, where they are widespread and represent a heavy burden on healthcare resources. It is thus important to redefine the role and responsibility of respiratory specialists and their scientific societies, together with that of the whole healthcare system, in order to create a sustainable management of COPD, which could become a model for other chronic respiratory conditions. Methods These issues were divided into four main topics (Training, Organization, Responsibilities, and Sustainability) and discussed at a Consensus Conference promoted by the Research Center of the Italian Respiratory Society held in Rome, Italy, 3–4 November 2016. Results and conclusions Regarding training, important inadequacies emerged regarding specialist training - both the duration of practical training courses and teaching about chronic diseases like COPD. A better integration between university and teaching hospitals would improve the quality of specialization. A better organizational integration between hospital and specialists/general practitioners (GPs) in the local community is essential to improve the diagnostic and therapeutic pathways for chronic respiratory patients. Improving the care pathways is the joint responsibility of respiratory specialists, GPs, patients and their caregivers, and the healthcare system. The sustainability of the entire system depends on a better organization of the diagnostic-therapeutic pathways, in which also other stakeholders such as pharmacists and pharmaceutical companies can play an important role.

BACKGROUND Body composition has been shown to be correlated with physical performance, but data in older persons with diverse chronic diseases are lacking. OBJECTIVE We aimed at investigating the associations of body composition to gait speed and nutritional status of older people in different stages of chronic obstructive pulmonary disease (COPD). DESIGN, SETTING AND SUBJECTS Cross-sectional analysis of data from Pulmonary Rehabilitation Geriatric Unit at INRCA in Casatenovo, Italy including 132 consecutively admitted COPD patients (mean age: 75 years) with data on body composition, walking speed and respiratory parameters. METHODS Body mass parameters were assessed using bioelectrical impedance analysis. Pulmonary function tests included spirometry and arterial blood gases. Differences among body composition markers were compared according to gender. Separate multivariate linear regression models with gait speed as the dependent variable were used to test for independent associations with body composition markers after adjusting for multiple confounders. RESULTS Walking speed deteriorated with increasing severity of COPD. Men were heavier and had more lean mass than women. Participants in the fastest gait tertile were younger, had lower body mass index and fat mass (FM); higher lean-to-fat ratio and albumin levels and better respiratory function (FEV1, FVC) compared with those in the slower tertiles. Total body FM was an independent determinant of walking speed, while fat-free mass and lean-to-fat ratio were not. CONCLUSIONS Excess body fat may be harmful for physical functioning among elders with COPD.

BACKGROUND: Self-management education is associated with improvement in quality of life and reduction of hospital admissions. Nevertheless, the data are insufficient to formulate clear recommendations regarding the type and content of education programs for COPD patients, and few data are available on knowledge of the disease itself. OBJECTIVE: To test the level of patients’ knowledge of their disease and therapy at baseline and after an educational program (COPD-EP); the feasibility of structured educational sessions; the influence of clinical status (degree of severity of disease, presence of comorbidities, oxygen use), demographics status (age, sex), previous knowledge level, previous lessons attendance and adherence of COPD-EP to the variation of knowledge after program. METHODS: Selected COPD in-patients and out-patients referred to rehabilitative hospital departments were enrolled. The study was divided into 2 parts: a pre-study phase (educational materials and health team preparation) and a study phase. All COPD subjects received one educational brochure and were invited to attend seven 30-min group lessons to complete the educational program. Learning effect was evaluated by a 20-questions multiple choice learning questionnaire (LQ). RESULTS: We enrolled 158 subjects, of whom 44.9% had previous formal education lessons on COPD management and 69.6% had previous rehabilitative hospitalizations. At baseline, the LQ total score was 15.2 3.5 points, which increased to 16.9 3.0 points post COPD-EP (P < .001). Pre-to-post change of LQ scores significantly correlated with adherence (R 0.24, P .002) and Severity Index of Cumulative Illness Rating Scale score (R 0.22, P .001). Subjects with low baseline knowledge were more likely to have improved LQ scores than subjects with greater levels of knowledge. Subjects without prior educational COPD lessons improved more than subjects who had attended previous education. CONCLUSIONS: A formal COPD-EP is feasible and effective in improving subject knowledge and self-management. Specific learning instruments to follow up this population should be validated. Key words: self-management; questionnaire; learning; education. [Respir Care 2013;58(2):327–333. © 2013 Daedalus Enterprises]

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. For this reason, great efforts have been made in the search for interventions to improve efficacy, safety and appropriateness of prescriptions in this vulnerable population. Among these interventions, the avoidance of medications that are considered to be inappropriate, i.e. potentially inappropriate medications (PIMs), has been considered a valuable treatment option. The aim of the present review was to summarize evidence about the use of explicit criteria for PIMs to reduce the risk of adverse drug reactions (ADRs) in older people. A PIM is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is evidence in favour of a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs, and among these, the Beers criteria have been the most frequently applied until recently. However, evidence suggests that such criteria can not easily be applied in European countries: several drugs listed in the 2003 Beers criteria were rarely prescribed or were not available in Europe and 2003 Beers-listed PIMs were not associated with ADRs in some studies. In the past few years, START/STOPP criteria have been developed and applied in several different studies and populations showing a greater ability to predict ADRs with respect to Beers criteria and to prevent potentially inappropriate prescribing. In 2012, Beers criteria have been updated using an evidence-based approach and future studies will investigate the impact of these and other criteria coming from ongoing studies on clinical outcomes relevant to geriatric populations.

A fast and simple tool is needed to test for the risk of mortality and rehospitalization in older patients.The aim of this study was to construct and validate a prognostic index using specific items from the Comprehensive Geriatric Assessment (CGA) in a large population of older hospitalized adults.This was a prospective study of a 24-month follow-up period, between 2005 to 2008 in 3,043 elderly patients (mean age, 81 ± 6) discharged from three acute geriatric wards in the Marche region of Italy. Baseline predictors of demographics and 25 items from the CGA regarding functional and cognitive status, depression, co-morbidity, social isolation, and quality of life were used to build a summary score, the Hospitalized Older Patient Examination (HOPE) Index. The HOPE index was developed in 1,533 patients and validated in 1,510 consecutively hospitalized patients. Outcome measures were 24-month mortality and rehospitalization.Three risk categories of HOPE based on the best sensitivity and specificity for mortality and rehospitalization were: Low (≤4), moderate (4-8), and high (≥8). Categorizing data across the HOPE index, mortality ranged from 7.9% to 14.5% in the development cohort and 6.2% to 14.0% in the validation cohort, whereas rehospitalization ranged from 68.3% to 79.4% and 69.8% to 79.8%, respectively. Kaplan-Meier survival curves demonstrated that risk for mortality increased with a worsening across the HOPE index (p 0.001). In the development and validation cohorts, a close agreement was found for HOPE on mortality and rehospitalization with a receiver operating characteristic (ROC) of 0.69 (95% confidence interval [CI] 0.61-0.74) vs. 0.67 (95% CI 0.57-0.70) and rehospitalization of 0.62 (95% CI 0.58-0.66) vs. 0.60 (95% CI 0.56-0.63), respectively. In the development and validation cohorts, Cox proportional hazard models showed that a high HOPE index predicted risks of 2.38 (1.34-4.23) and 2.86 (1.24-6.61) on mortality and 1.27 (1.09-1.44) and 1.37 (1.10-1.64) on rehospitalization, respectively.HOPE may be useful for long-term clinical planning, discharge, and follow-up.

Associations between copper to zinc ratio (CZr) and mortality have suggested CZr as a biomarker of aging. Nevertheless, very limited data exist on the association between serum CZr and physical or functional status of very old people. We examined the relationship between serum CZr and physical performance, muscle strength, functional status, and survival from the ilSIRENTE Study: a longitudinal study of persons aged 80 years or older (n = 346). An adjusted linear regression model was subsequently performed to calculate the regression coefficients of the associations between baseline physical and functional measures (dependent variable) with CZr or “Cu and Zn” alone taking also into account the influence of other relevant factors, including hematological (albumin, cholesterol, and urea) and inflammatory biomarkers (IL-6 and CRP) that were significantly different across CZr tertiles. CZr showed significant and stronger relationships than Cu or Zn alone with all baseline physical and functional measures in models that did not include adjustments for inflammatory parameters. CZr was also associated with physical decline, measured as “SPPB% decline” at 2 years of follow-up and mortality at 4 years of follow-up. Subjects in the high CZr tertile had a higher risk of death with an adjusted hazard ratio of 1.92 (95% CI, 1.12–3.29; p = 0.02). In conclusion, we have confirmed the role of CZr as a predictor of mortality, whereas the role of CZr as a biomarker or predictor of physical or functional performance seems to be the consequence of its strict relationships with inflammatory parameters. In this context, further investigations need to be carried out.

We aimed at verifying whether unrecognized chronic kidney disease (CKD) (i.e., reduced estimated glomerular filtration rate in spite of normal serum creatinine) has prognostic significance in an unselected population of older patients discharged from 11 acute care hospitals located throughout Italy. Our series consisted of 396 participants aged 70 and older. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) study equation. We compared three groups: Normal renal function (normal serum creatinine levels and normal eGFR), concealed (normal serum creatinine levels and reduced eGFR), or overt (increased creatinine levels and reduced eGFR) renal failure. The relationship between renal function and 1-year mortality was evaluated using Kaplan-Meier curves and Cox regression analysis including potential confounders. Overall, 56 patients died over a cumulative follow-up time of 335 months, with an estimated incidence rate of 16.7/100 person-year (PY). The corresponding figures in patients with normal renal function, concealed CKD, and overt CKD were 9.8/100 PY (95% CI, 5.7-15.7), 28.3/100 PY (95% CI, 13.6-52.1), and 23.0 (95% CI, 15.4-33.0), respectively (log rank test p = 0.006). According to the fully adjusted model, both concealed (hazard ratio [HR], 2.35; 95% CI, 1.09-6.01) and overt CKD (HR, 2.09; 95% CI, 1.05-5.34) were significantly associated with the outcome. Concealed CKD contributes to profile the elderly patient at greater risk of death after being discharged from acute care medical wards. If confirmed in broader populations, this finding might have both clinical and epidemiological implications.

The role of inflammation in the pathophysiology of chronic age-related diseases is increasingly recognized, and inflammation could represent the common pathway linking diseases and disability. Thus, targeting inflammation could represent a useful strategy at preventing or delaying functional decline. In this paper we review recent evidence suggesting that selected drugs, such as statins, fibrates, angiotensin converting enzyme-inhibitors and angiotensin receptor blockers, and physical exercise may be able to contrast functional decline by blunting inflammation. Results from randomized trials investigating the effects of physical activity programs on inflammation and functional decline is still limited, and further investigations are warranted.

Patients with Chronic Obstructive Pulmonary Disease (COPD) and tracheostomy are at high risk for exacerbations and hospitalizations. Macrolide treatment has shown to reduce exacerbations in moderate-to-severe COPD. To evaluate the safety and the efficacy of long-term azithromycin use in outpatients with severe COPD and tracheostomy. A multicenter, randomized, uncontrolled, pilot trial evaluating the safety and the efficacy of azithromycin 500 mg three day-a-week for 6 months (AZI) vs. standard of care (SC) in severe COPD outpatients with tracheostomy. Patients were monitored for six months of treatment plus six months of follow up. The primary outcome was the reduction in the number of exacerbations and hospitalizations. A total of 22 patients was randomized (11 to SC and 11 to AZI). Patients in AZI had a significant lower cumulative number of exacerbations after the first 3 months of treatment when compared to patients in SC (p = 0.001), as well as hospitalizations (p = 0.02). Kaplan-Meier survival curves for time to first exacerbation showed a significant reduction in AZI of the rates of first exacerbation when compared to SC (log rank test = 12.14, p < 0.001), as well as to first hospitalization (log-rank = 4.09, p = 0.04). Azithromycin significantly improved the quality of life in comparison to SC. No serious adverse events in the AZI group were reported. Long-term azithromycin treatment seems to be safe and effective in severe COPD outpatients with tracheostomy in reducing exacerbations, hospitalizations, as well as in improving quality of life. © 2009 Elsevier Ltd. All rights reserved.

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age-related clinical conditions, because the long-term impact of diseases on functional status and on costs are greater in older people than in any other age group. With the aging of the population, it is becoming increasingly important to quantify the burden of illness in the elderly; this will be vital not only in planning for the necessary health services that will be required in coming years, but also in order to measure the benefit to be expected from interventions to prevent disability in older people. The management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance and healthcare interventions. Among these, pharmacological treatments and drug utilization in older people are pressing issues for healthcare managers and politicians; indeed, a relatively small proportion of the population accounts for a substantial part of public drug costs. Two key sources of pressure are well known: the growing number of elderly persons, who are the highest per-capita users of medicines, and the introduction of new, often more expensive, medicines. On the other hand, the development of strategies for controlling costs, while providing the elderly with equitable access to needed pharmaceuticals, should be based on an evaluation of the economic impact of pharmacological care in older people, taking into account the burden of illness, drug utilization data, drug technology assessment evidence and results. Furthermore, there are major factors affecting pharmacological care in older people: for example inappropriate prescribing, lack of adherence and compliance, and the burden of adverse drug events. The assessment of these factors should be considered a priority in pharmacoeconomic evaluations in the aging population, and the most relevant evidence will be reviewed in this paper with examples referring to particular settings or conditions and diseases, such as the presence of cardiovascular risk factors, diabetes and chronic pain.

We designed a prospective multicenter randomized controlled study in three long-term weaning units (LWU) to evaluate which protocol, inspiratory pressure support ventilation (PSV) or spontaneous breathing trials (SB), is more effective in weaning patients with chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation for more than 15 d. Fifty-two of 75 patients, failing an initial T-piece trial at admission, were randomly assigned to PSV or SB (26 in both groups). No significant difference was found in weaning success rate (73% versus 77% in the PSV and SB group, respectively), mortality rate (11.5% versus 7.6%), duration of ventilatory assistance (181 � 161 versus 130 � 106 h), LWU (33 � 12 versus 35 � 19 d), or total hospital stay. The results of these defined protocols were retrospectively compared with an “uncontrolled clinical practice” in weaning historical control patients. The overall 30-d weaning success rate was significantly greater (87% versus 70%) and the time spent under mechanical ventilation by survived and weaned patients was shorter in the patients in the study than in historical control patients (103 � 144 versus 170 � 127 h). The LWU and hospital stays were also significantly shorter (27 � 12 versus 38 � 18 and 38 � 17 versus 47 � 18 d). Spontaneous breathing trials and decreasing levels of PSV are equally effective in difficult-to-wean patients with COPD. The application of a well-defined protocol, independent of the mode used, may result in better outcomes than uncontrolled clinical practice. Endotracheal intubation and mechanical ventilation are often needed in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure who may undergo difficulties in the weaning process and related need of tracheostomy. A recent review of the literature (1) of patients in general intensive care units (ICUs) (a minority with COPD) was unable to identify a superior weaning technique among the three most popular modes (T-piece, synchronized intermittent mandatory ventilation [SIMV], or pressure support ventilation [PSV]) (2, 3). Furthermore recent trials have demonstrated that simply introducing a protocol or guideline for the weaning process leads to a decrease in weaning time independent of the mode used (4, 5). Similar studies have not been performed in a long-term weaning unit (LWU) setting yet, nor have studies been specifically dedicated to patients with COPD. These patients are characterized by a different response to ventilator disconnection and weaning compared with patients in acute settings. Therefore results of studies performed in the acute setting in patients without COPD cannot be applied to difficult-to-wean patients with COPD. A better knowledge of the best weaning modality could help improve the general management of such patients and, ultimately, lead to a greater rate of discontinuation of mechanical ventilation and closure of the tracheostomy with reduced need of home ventilation and reduced human and financial costs (6). Therefore, we designed a prospective, randomized multicenter study to identify which modality (if any), spontaneous breathing (SB) trials or decreasing levels of PSV, is superior in weaning tracheostomized patients with COPD requiring mechanical ventilation for more than 15 d. As a secondary end point, we also performed a retrospective comparison with historical control patients to determine whether a well-defined protocol, independent of the mode used, is more effective than uncontrolled clinical practice in weaning.