Psychiatric Disorders in Patients with Chronic Obstructive Pulmonary Disease: Clinical Significance and Treatment Strategies Pasquale Moretta, Nicola Davide Cavallo, Claudio Candia, Anna Lanzillo, Giuseppina Marcuccio, Gabriella Santangelo, Laura Marcuccio, Pasquale Ambrosino, Mauro Maniscalco Journal of Clinical Medicine, 2024 Chronic obstructive pulmonary disease (COPD) is a debilitating lung disease characterized by chronic airflow limitation and persistent respiratory symptoms. It is a major cause of morbidity and mortality worldwide, significantly impacting healthcare systems with considerable socioeconomic consequences. The main risk factors include exposure to tobacco smoke, environmental pollutants, occupational dust, and genetic factors such as alpha-1 antitrypsin deficiency. COPD is often associated with extrapulmonary comorbidities, particularly psychiatric disorders like depression and anxiety, which worsen patients’ quality of life and prognosis. The prevalence of these disorders in patients with COPD varies significantly but is always higher than in healthy controls. Psychiatric disorders can negatively influence COPD management and vice versa, creating a complex bidirectional interaction. Depression and anxiety are the most common psychiatric comorbidities in patients with COPD, influenced by factors such as social isolation, physical limitations, and fear of exacerbations. Diagnosis of these psychiatric disorders is complicated by the overlap of symptoms with those of COPD. However, some screening tools can facilitate early detection. The treatment of psychiatric disorders in patients with COPD in a rehabilitation setting requires a multidisciplinary approach involving pulmonologists, neurologists and psychologists. Pharmacological therapy with antidepressants shows mixed results in terms of efficacy and safety, with some studies reporting benefits on quality of life and others suggesting an increased risk of exacerbations and pneumonia. An integrated approach that includes the assessment and intervention of mental disorders is essential to improve the overall management of COPD and the quality of life of patients. This narrative review provides an overview of the main psychiatric comorbidities in COPD patients, aiming to fill gaps in the literature and suggest areas for future research.
family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation Pasquale MORETTA, Cinzia FEMIANO, Nicola D. CAVALLO, Anna LANZILLO, Fabrizio LUCIANO, Cesario FERRANTE, Antonio MAIORINO, Gabriella SANTANGELO, Laura MARCUCCIO European Journal of Physical and Rehabilitation Medicine, 2024 BACKGROUND Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN Cross-sectional study. SETTING Post-acute Unit of Neurorehabilitation. POPULATION DOC due to severe brain injury. METHODS Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in “caregiver in remote” and in “caregiver in presence” than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.
Cognitive Impairment in Convalescent COVID-19 Patients Undergoing Multidisciplinary Rehabilitation: The Association with the Clinical and Functional Status Pasquale Moretta, Pasquale Ambrosino, Anna Lanzillo, Laura Marcuccio, Salvatore Fuschillo, Antimo Papa, Gabriella Santangelo, Luigi Trojano, Mauro Maniscalco Healthcare Switzerland, 2022 Background. Cognitive impairment has been reported in the aftermath of severe acute respiratory syndrome due to coronavirus 2 (SARS-CoV-2) infection. We investigated the possible association between cognitive impairment and the main clinical and functional status variables in a cohort of convalescent COVID-19 patients without premorbid diseases potentially affecting cognition. Methods. We consecutively screened for inclusion of convalescent COVID-19 patients referring to a post-acute care facility for pulmonary rehabilitation. All the enrolled patients were assessed for cognitive functions. We also investigated features of psychological distress (anxiety, depression, symptoms of posttraumatic stress disorder and quality of life) and cardiac and pulmonary functional status. Results. The 63 enrolled patients (mean age 59.82 ± 10.78, male gender = 47) showed a high frequency of depressive symptoms (76.2%) and anxiety (55.5%), and a high prevalence of symptoms of posttraumatic stress disorder (PTSD, 44.4%). About half of the total sample showed reduced cognitive efficiency (RCE, 44.4%) in the domains of spatial and verbal long-term memory and executive functions. Patients with RCE more frequently showed alteration of blood pressure (BP) circadian rhythm (p = 0.01), higher levels of D-Dimer (p = 0.03), had experienced a severe illness (p = 0.02), had longer disease duration (p = 0.04), more clinically relevant symptoms of PTSD (p = 0.02), more frequent cognitive complaints (p = 0.002), higher anxiety scores (p = 0.01) and lower quality of life (p = 0.02) than patients with normal cognitive efficiency. Conclusions. Our findings indicated a possible association between the RCE after COVID-19 and some cardiological variables, including some indirect measures of a residual autonomic disorder, such as the presence of an altered BP circadian rhythm. Future research studies with large samples are needed to provide valid conclusions.
Cognitive impairment and endothelial dysfunction in convalescent COVID-19 patients undergoing rehabilitation Pasquale Moretta, Mauro Maniscalco, Antimo Papa, Anna Lanzillo, Luigi Trojano, Pasquale Ambrosino European Journal of Clinical Investigation, 2022 Dear Sir, The endothelium acts as the major regulator of vascular homeostasis, and its functions encompass maintenance of vascular integrity, regulation of haemostasis and control of inflammation.1 Endothelial dysfunction is the earliest mechanism of atherosclerosis, thus potentially underlying the association between traditional cardiovascular risk factors (eg hypertension, diabetes, dyslipidaemia) and some neurological disorders.2 However, studies on the relationship between endothelial function and neurocognition are relatively scarce.3 In these studies, the most used measure of endothelial function is flowmediated dilation (FMD) of the brachial artery, which is widely accepted as a reliable and costeffective tool and as an independent predictor of cardiovascular events.4,5 Adopting this method, some authors reported the association between an impaired FMD and poorer cognitive performances, particularly in the attention, executive and memory domains, mainly in patients with cardiac diseases.3 Similar findings were documented in patients with vascular cognitive impairment when considering other clinical or laboratory biomarkers related to endothelial function (eg adhesion molecules, inflammatory mediators, neuroimaging markers).6 Overall, the link between endothelial dysfunction and cognitive impairment is complex and not fully elucidated. In this regard, a number of mechanisms have been called into question, including an altered cerebral perfusion,7 a decreased cerebrovascular reactivity,8 a deficient production of brainderived neurotrophic factors9 and an inflammatory response in the central nervous system.10 More recently, endothelial dysfunction has been reported in convalescent coronavirus disease 2019 (COVID19) patients, with a direct correlation between the severity of pulmonary and vascular involvement.4,5 Moreover, cognitive impairment has been also documented in these patients up to six months after the acute phase.11 To the best of our knowledge, no study investigated the potential relationship between endothelial function, as assessed by FMD, and cognitive efficiency in this clinical setting. This investigation could provide strong support to the possible role of endothelial dysfunction in the pathogenesis of cognitive disorders related to COVID19. To address this issue, convalescent COVID19 patients admitted to the Pulmonary Rehabilitation Unit of Istituti Clinici Scientifici Maugeri IRCCS, Institute of Telese Terme, Benevento, Italy, within two months from swab test negativization were consecutively screened for inclusion. Patients were selected according to the following criteria: age between 18 and 65 years; presence of formal education (at least primary); no past or current psychiatric or neurological disease; and no premorbid clinically relevant cardiovascular or respiratory condition potentially impacting cognitive performance (ie hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease, asthma). Patients with missing data for the outcome of interest were excluded from the study. Wherever appropriate and applicable, this study was reported following the broad Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.12 All participants gave their informed consent in written form. The study was approved by the competent Ethics Committee and was performed according to the principles of the 1975 Helsinki Declaration. In all the enrolled patients, we assessed the following cognitive domains by means of standardized tests: spatial and verbal shortand longterm memory (Corsi blocktapping test, Rey's auditory learning test and supraspan learning on Corsi's test, respectively); executive functions (phonemic verbal fluency task and frontal assessment battery); attention (trail making test, TMT); abstract reasoning (Raven's Coloured Progressive Matrices, CPM47); and global cognitive functioning (Montreal Cognitive Assessment, MoCA). The tests were administered at study entry by an experienced neuropsychologist (P.M.). Patients’ scores on each test were evaluated in reference to available Italian ageand educationcorrected values. Patients who achieved two or more pathological scores on neuropsychological tests, and those who achieved one pathological score on one test plus one or more borderline
The Italian validation of the Communicative Effectiveness Index Questionnaire: a multicentric study Pasquale Moretta, Anna Lanzillo, Maria Daniela Lo Sapio, Simona Spaccavento, Fara Cellamare, Francesca Nisoli, Alessandra Ianni, Debora Pain, Sarah Feroldi, Chiara Angela Forlani, Sara Boccola, Francesca Madonia, Paolo Volanti, Antonia Pierobon, Ilaria Scola, Marina Manera, Giorgio Bertolotti, Luigi Trojano Neurological Sciences, 2021
Prognosis of severe acquired brain injury: Short and long-term outcome determinants and their potential clinical relevance after rehabilitation. A comprehensive approach to analyze cohort studies Bernardo Lanzillo, Giuseppe Piscosquito, Laura Marcuccio, Anna Lanzillo, Dino Franco Vitale Plos One, 2019 Background Accurate prognostic evaluation is a key factor in the clinical management of patients affected by severe acute brain injury (ABI) and helps planning focused therapies, better caregiver’s support and allocation of resources. Aim of the study was to assess factors independently associated with both the short and long-term outcomes after rehabilitation in patients affected by ABI in the setting of a single Rehabilitation Unit specifically allocated to these patients. Methods and findings In all patients (567) with age ≥ 18 years discharged from the Unit in the period 2006/2015 demographic, etiologic, comorbidity indicators, and descriptors of the disability burden (at hospital admission and discharge) were evaluated as potential prognostic factors of both short-term (4 classes of disability status at discharge) and long-term (mortality) outcomes. A comprehensive analytical method was adopted to combine several tasks. Select the factors with a significant independent association with the outcome, assess the relative weights and the “stability” (by bootstrap resampling) of them and estimate the role of the prognostic models in the clinical framework considering “cost” and “benefits”. The generalized ordered logistic model for ordinal dependent variables was used for the short-term outcome while the Cox proportional hazard model was used for the long-term outcome. The final short-term model identified 7 factors that independently account for 37% of the outcome variability as shown by pseudo R2 (pR2) = 0.37. The disability status descriptors show the strongest association since they account for more than 60% of the pR2, followed by age (14.8%), the presence of percutaneous endoscopic gastrostomy or nasogastric intubation (14.4%), a longer stay in the acute ward (5.9%) and concomitant coronary disease (1.3%). The final multivariable Cox model identified 4 factors that independently account for 52% of the outcome variability (R2 = 0.52). The disability extent and the disability recovered lead the long-term mortality since they account for the 53% of the global R2. The relevant effect of age (42%) is appreciable only after 2 years given the significant interaction with time. A longer stay in the acute ward explains the remaining fraction (5%). Considering ‘cost and benefits’, the decision curve analysis shows that the clinical benefit achieved by using both prognostic models is greater than the other possible action strategies, namely ‘treat all’ and ‘treat none. Several less obvious characteristics of the prognostic models are appreciated by integrating the results of multiple analytical methods. Conclusion The comprehensive analytical tool aimed to integrate statistical significance, weight, “stability” and clinical “net” benefit, gives back a prognostic framework explaining a relevant portion of both outcomes’ variability in which the strong association of the disability status with both outcomes is comparable to and followed by a time modulated role of age. Our data do not support a differentiated association of traumatic vs non-traumatic etiology. The results encourage the use of integrated approach to analyze cohort data.
