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Pierluigi Paggiaro,1 Simona Barbaglia,2 Stefano Centanni,3,4 Davide Croce,5 Enrico Desideri,6 Saffi Giustini,7,8 Claudio Micheletto,9 Antonino Musarra,10 Nicola Scichilone,11 Ugo Trama,12 Maria Teresa Zedda,7,13 Giorgio Walter Canonica14 1Department of Surgery, Medicine, Molecular Biology, and Critical Care, University of Pisa, Pisa, Italy; 2Associazione Nazionale Pazienti "Respiriamo Insieme", Padova, Italy; 3Department of Health Sciences, Università degli Studi di Milano, Milan, Italy; 4Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy; 5Center for Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Castellanza, Italy; 6Fondazione Innovazione e Sicurezza in Sanità, Rome, Italy; 7Italian General Practitioners' Association "SIMG", Florence, Italy; 8Local Health Unit of Montale, Pistoia, Italy; 9Cardio-Thoracic Department, Respiratory Unit, Integrated University Hospital, Verona, Italy; 10Allergy Unit, National Healthcare System, Reggio Calabria, Italy; 11Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy; 12Dirigente UOD 06 Politica del Farmaco e Dispositivi, Naples, Italy; 13General Practice, Cagliari, Italy; 14Personalized Medicine Asthma & Allergy Clinic, Humanitas University and Research Hospital-IRCCS, Milan, ItalyCorrespondence: Pierluigi PaggiaroDepartment of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Via Paradisa No. 2, Pisa, 56124, ItalyTel +39 050 995365Fax +39 050 580124Email pierluigi.paggiaro@unipi.itIntroduction: People with severe asthma (SA) often have poor disease control and quality of life, and are at high risk of exacerbations, lung function decline and asthma-related death. The present expert opinion article aimed to identify unmet needs in the management of SA in Italy, and propose possible solutions to address these needs.Methods: At five multidisciplinary events in Italy, attendees identified factors that interfered with the effective management of SA and suggested how these barriers could be overcome. A core group of 12 Italian experts (pulmonologists, general practitioners, allergists, payers and patients) identified the main issues and proposed possible solutions based on the results from the meetings and relevant articles from the literature.Results and Conclusions: We reviewed the gap between real-world practice and guidelines, oral corticosteroid overuse, SA-related mortality, and barriers to effective SA treatment. Common themes were lack of awareness about SA among both patients and clinicians, and lack of networking/information exchange between those involved in the treatment of SA. Participants agreed on the need to implement patient education and create multidisciplinary groups of specialists to improve SA management through multidisciplinary educational initiatives, meetings with local experts, development of a flow chart for referral/connection with local experts and specialized centers. Clinical instruments that might help specialists improve SA management included referral networks, integrated care pathways, phenotyping and treatment algorithms, exacerbation tracking, and examination of electronic medical records for patients with uncontrolled asthma. The following actions need to be implemented in Italy: i) maximize the use of advanced therapies, eg, biologics; ii) increase/improve education for physicians and patients; iii) improve multidisciplinary communication and care coordination; iv) introduce regional and local protocols for SA diagnosis and treatment; and v) change the structure of healthcare services to reduce specialist waiting times and facilitate access to biologic therapies.Keywords: biologic therapy, expert opinion, oral corticosteroids, severe asthma, unmet needs

We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted for 60% of variance of the data. Importantly, couch potatoes (i.e. the most inactive cluster) were characterised by higher BMI, lower FEV1, worse dyspnoea and higher ADO index compared to other clusters (p < 0.05 for all). Daily physical activity measures and hourly patterns are heterogeneous in COPD. Clusters of patients were identified solely based on physical activity data. These findings may be useful to develop interventions aiming to promote physical activity in COPD. ; The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: RM is supported by the National Council of Scientific and Technological Development (CNPq), Brazil (246704/2012-8). DB holds a Canada Research Chair, Canada. SSCK was funded by the Medical Research Council, UK. WD-CM was funded by the Medical Research Council, UK, and the National Institute for Health Research, UK. MSP was supported by an unrestricted research grant from Astra Zeneca. KCF is supported by the Coordination for the Improvement of Higher Education Personnel (CAPES), Brazil. SZ, DM, SD and JDL were supported by the following foundations: 'Gottfried und Julia Bangerter-Rhyner-Stiftung', 'Freiwillige Akademische Gesellschaft Basel' and 'Forschungsfonds der Universitat Basel', Switzerland. DS was supported by GSK and by the Medical Research Council, UK (G0701628). FP is supported by CNPq, Brazil. PRE was supported by an NHMRC Research Fellowship, Australia (1042341). MIP's contribution to this manuscript was funded by the NIHR Respiratory Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College, UK. EFMW was supported by Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. AWV was supported by 'Stichting de Weijerhorst' and Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, Netherlands. MAS was supported by Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. Part of the data was sponsored by GlaxoSmithKline (data from the ECLIPSE cohort sub-study). Data from Ireland was supported by Beaumont Foundation, Ireland and SwordMedical Ltd, Ireland. The Australian sites were supported by a National Health and Medical Research Grant, Australia (grant no.: 570814). Part of the data collection in the UK (data from Leicester) was supported by the National Institute for Health Research (NIHR) Leicestershire, Northamptonshire and Rutland Collaboration for Leadership in Applied Health Research and Care and took place at University Hospitals of Leicester NHS Trust, UK, and by the NIHR Leicester Respiratory Biomedical Research Unit, UK. Data from the PAC-COPD study was funded by grants from the following Spanish institutions: Fondo de Investigacion Sanitaria, Ministry of Health (FIS PI020541); Agencia d'Avaluacio de Tecnologia i Recerca Mediques, Catalonia Government (AATRM 035/20/02); Spanish Society of Pneumology and Thoracic Surgery (SEPAR 2002/137); Catalan Foundation of Pneumology (FUCAP 2003 Beca Maria Rava); Red RESPIRA (RTIC C03/11); Red RCESP (RTIC C03/09), Fondo de Investigacion Sanitaria (PI052486); Fondo de Investigacion Sanitaria (PI052302); Fundacio La Marato de TV3 (No. 041110); and DURSI (2005SGR00392); and by unrestricted educational grants from Novartis Farmaceutica and AstraZeneca Farmaceutica.