Interactions between SERPINA1 PiMZ genotype, occupational exposure and lung function decline.

OBJECTIVES: We evaluated interactions between SERPINA1 PiMZ genotype, associated with intermediate α1-antitrysin deficiency, with outdoor particulate matter ≤10 µm (PM10), and occupational exposure to vapours, dusts, gases and fumes (VGDF), and their effects on annual change in lung function. METHODS: Pre-bronchodilator spirometry was performed in 3739 adults of the Swiss Cohort Study on Air Pollution and Lung Disease in Adults (SAPALDIA) for whom SERPINA1 genotypes were available. At baseline in 1991, participants were aged 18-62 years; follow-up measurements were conducted from 2001 to 2003. In linear mixed regression models of annual change in lung function, multiplicative interactions were evaluated between PiMZ genotype (PiMM as reference) and change in PM10 (µg/m(3)), and VGDF exposure (high-level, low-level or no exposure as reference) during follow-up. RESULTS: Annual declines in forced expiratory flow at 25-75% of forced vital capacity (FEF25-75%) (-82 mL/s, 95% CI -125 to -39) and forced expiratory volume in 1 s over forced vital capacity (FEV1/FVC) (-0.3%, 95% CI -0.6% to 0.0%) in association with VGDF exposure were observed only in PiMZ carriers (Pinteraction<0.0001 and Pinteraction=0.03, respectively). A three-way interaction between PiMZ genotype, smoking and VGDF exposure was identified such that VGDF-associated FEF25-75% decline was observed only in ever smoking PiMZ carriers (Pinteraction=0.01). No interactions were identified between PiMZ genotype and outdoor PM10. CONCLUSIONS: SERPINA1 PiMZ genotype, in combination with smoking, modified the association between occupational VGDF exposure and longitudinal change in lung function, suggesting that interactions between these factors are relevant for lung function decline. These novel findings warrant replication in larger studies.

Upper airway symptoms among workers with work-related respiratory complaints.

BACKGROUND: Work-related rhinitis and asthma symptoms frequently co-exist. AIMS: To determine the prevalence and nature of nasal, pharyngeal, laryngeal and sinus symptoms among individuals with work-related respiratory symptoms. METHODS: Individuals referred to a tertiary occupational asthma clinic for investigations with specific inhalation challenges were evaluated using the RHINASTHMA quality of life questionnaire and a questionnaire that assessed the nature and frequency of upper airway symptoms, their relationship to the workplace and their temporal relationship with the onset of asthma symptoms. RESULTS: There were 83 study participants. At least one upper airway symptom was reported by all of these individuals: nasal in 92%; pharyngeal in 82%; laryngeal in 65% and sinus in 53% of participants. Overall, there were no significant differences in the frequencies of nasal, pharyngeal, laryngeal and sinus symptoms when comparing these with occupational asthma (OA), work-exacerbated asthma (WEA) and work-related respiratory symptoms (WRS), except that nasal bleeding was most frequent among those with WRS. The presence of laryngeal symptoms was significantly associated with rhinitis-specific quality of life impairment. Individuals with workplace exposures to high molecular weight agents had greater impaired quality of life than those who were exposed to low molecular weight agents (RHINASTMA Upper Airway sub-scores: 24.0±10.4 versus 19.8±6.8; P < 0.05). CONCLUSIONS: Individuals who were referred for work-related respiratory symptoms experienced high rates of work-related nasal, pharyngeal, laryngeal and sinus symptoms, regardless of having OA, WEA or WRS.

[Occupational rhinitis and asthma]. / Berufliche Rhinitis und Asthma.

Allergic rhinoconjunctivits and asthma are frequent diseases. About one in ten asthma cases is caused by an occupational hazard, either by an allergic or a non-immunologic mechanism. Primary or secondary preventive measures should be able to prevent these cases. Often, occupational rhinitis precedes the development of occupational asthma. Important causative agents are flours, plant and enzyme powders, laboratory animals, latex, isocyanates and hardeners, epoxy resins, acrylates, formaldehyde and welding fumes. Early diagnosis and the installation of protective measures are decisive for the prognosis of occupational respiratory disease.

Factors influencing duration of exposure with symptoms and costs of occupational asthma.

The most important factor for the prognosis of occupational asthma is the length of exposure with symptoms prior to removal from exposure. We wanted to identify factors, including socioeconomic status, that can influence the delay in submitting a claim to a medicolegal agency after the onset of asthmatic symptoms, and to confirm that this delay is associated with worse respiratory prognosis and higher direct costs. This is a cross-sectional study of subjects who claimed compensation for occupational asthma at the Workers' Compensation Board of Quebec, Canada. Data were collected at re-evaluation ∼2.5 yrs after diagnosis. Information on the number of years with symptoms and removal from exposure was obtained from the medicolegal file. 60 subjects were included in the study. Being older, having a revenue of >30,000 Canadian dollars and having occupational asthma due to high molecular weight agents were all positively associated with the number of years of exposure with symptoms before removal from exposure. Subjects with persistent airway hyperresponsiveness at follow-up had a higher number of years with symptoms. Experiencing symptoms in the workplace for <1 yr generated lower direct costs. These findings might help in surveillance programmes that could be preferentially targeted for these subgroups of workers.

Asthma tests in the assessment of military conscripts.

BACKGROUND: Respiratory diseases such as asthma may affect individuals' fitness for military service. In order to assess fitness for military service in subjects with asthma symptoms at conscription, objective and reliable tests are needed. OBJECTIVE: To prospectively determine the diagnostic value of the mannitol and methacholine bronchial provocation test (BPT) as well as exhaled nitric oxide in assessing physician-diagnosed asthma in a group of Swiss Armed Forces conscripts. METHODS: Questionnaire, spirometry, BPT with methacholine and mannitol, exhaled nitric oxide (FeNO) and skin prick testing were conducted in 18-20-year-old male conscripts. Asthma was diagnosed by a military physician not involved in this study according to the medical record, results of BPT, current respiratory symptoms and use of asthma medication. RESULTS: Two hundred and eighty four subjects participated in the study. Complete data for the BPT with methacholine, mannitol and measurement of FeNO were available on 235 subjects. Forty-two conscripts (17.9%) had physician-diagnosed asthma. The sensitivity/specificity of mannitol to identify physician-diagnosed asthma was 41%/93% and for methacholine it was 43%/92%. Using a cut-off point of 36.5 p.p.b., FeNO had a similar negative predictive value to rule out physician-diagnosed asthma as BPT with mannitol or methacholine. CONCLUSION: BPT with mannitol has a sensitivity and specificity similar to methacholine for the diagnosis of physician-diagnosed asthma in military conscripts but is less costly to perform without the need to use and maintain a nebulizer.

Quality of spirometry in primary care for case finding of airway obstruction in smokers.

BACKGROUND: Diagnosis of chronic obstructive pulmonary disease (COPD) and its severity determination is based on spirometry. The quality of spirometry is crucial. OBJECTIVES: Our aim was to assess the quality of spirometry performed using a spirometer with automated feedback and quality control in a general practice setting in Switzerland and to determine the prevalence of airflow limitation in smokers aged > or =40 years. METHOD: Current smokers > or =40 years of age were consecutively recruited for spirometry testing by general practitioners. General practitioners received spirometry training and were provided with an EasyOne spirometer. Spirometry tests were assigned a quality grade from A to D and F, based on the criteria of the National Lung Health Education Program. Only spirometry tests graded A-C (reproducible measurements) were included in the analysis of airflow limitation. RESULTS: A total of 29,817 spirometries were analyzed. Quality grades A-D and F were assigned to 33.9, 7.1, 19.4, 27.8 and 11.8% of spirometries, respectively. 95% required < or =5 trials to achieve spirometries assigned grade A. The prevalence of mild, moderate, severe and very severe airway obstruction in individuals with spirometries graded A-C was 6, 15, 5 and 1%, respectively. CONCLUSION: Spirometries in general practice are of acceptable quality with reproducible spirometry in 60% of measurements. Airway obstruction was found in 27% of current smokers aged > or =40 years. Office spirometry provides a simple and quick means of detecting airflow limitation, allowing earlier diagnosis and intervention in many patients with early COPD.

Malt can cause both occupational asthma and allergic alveolitis.

Specific inhalation challenge can help differentiate occupational asthma from allergic alveolitis caused by malt.

Use of B-type natriuretic peptide in the risk stratification of community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries. Risk stratification has previously been difficult. METHODS: Markers of cardiac stress (B-type natriuretic peptide, BNP) and inflammation (C-reactive protein, white blood cell count, procalcitonin) as well as the pneumonia severity index (PSI) were determined in 302 consecutive patients presenting to the emergency department (ED) with CAP. The accuracy of these parameters to predict death was evaluated as the primary endpoint. Prediction of treatment failure was considered as the secondary endpoint. RESULTS: B-type natriuretic peptide levels increased with rising disease severity as classified by the PSI (P = 0.015). BNP levels were significantly higher in nonsurvivors compared to survivors [median 439.2 (IQR 137.1-1384.6) vs. 114.3 (51.3-359.6) pg mL(-1), P < 0.001]. In a receiver operating characteristic analysis for the prediction of survival the area under the curve (AUC) for BNP was comparable to the AUC of the PSI (0.75 vs. 0.71, P = 0.52). Importantly, the combination of BNP and the PSI significantly improved the prognostic accuracy of the PSI alone (AUC 0.78 vs. 0.71; P = 0.02). The optimal cut-off for BNP was 279 pg mL(-1). The accuracy of BNP to predict treatment failure was identical to the accuracy to predict death (AUC 0.75). CONCLUSIONS: In patients with CAP, BNP levels are powerful and independent predictors of death and treatment failure. When used in conjunction with the PSI, BNP levels significantly improve the risk prediction when compared with the PSI alone.

[A smoking cessation intervention in the Swiss Armed Forces]. / «Feuer einstellen!¼ - eine kontrollierte Rauchstoppintervention bei Rekrutenschulen der Schweizer Armee.

Smoking is a major health risk in young adults. We undertook a study in young Swiss military recruits to determine the impact of intensive training and of help offered on smoking cessation during Basic Military Training (BMT). A questionnaire including questions according to their smoking status, sporting activities and, alcohol use was administered to 999 conscripts at beginning and at the end of the BMT. The results were compared to a control group of BMT schools where no such intervention took place. The study shows that the prevalence of smokers in the intervention group decreased (start BMT 31.9%, end BMT 25.5%; p = 0.021), while the prevalence of smokers increased in the control group (start BMT 26.4%, end BMT 32.6%; p = 0.038). A motivation to serve in the armed forces, as well as the willingness to stop smoking in the next month were the factors associated with a subsequent cessation of smoking during BMT. A smoke stop intervention during BMT is viable and can lead to a decrease in the prevalence of smoking at the end of BMT.

[Smoking behaviour and willingness to stop smoking in patients admitted in an internal medicine ward]. / Untersuchung der Rauchgewohnheiten und der Bereitschaft zum Rauchstopp bei Patienten einer internistischen Abteilung.

Smoking is one of the leading preventable risk factors for the development of lung-, cardio-vascular diseases and cancer. We report results of a prospective survey regarding smoking behaviour and willingness to stop smoking in patients of an internal medicine clinic. Twenty percent of participants admitted smoking cigarettes in the previous 7 days. Smokers were more often males and were younger than non- or ex-smokers. Every second smoker reported being told to stop smoking by a physician before but only about a third was offered active support in doing so. About half of the smoking participants were interested to quit smoking and to participate in a hospital-based smoking cessation program. In patients admitted to the hospital, smoking behaviour and willingness to quit smoking should be recorded and help in quitting smoking should be offered actively. Beside recording smoking behaviour and willingness to quit, patients who are admitted in the hospital should be offered help to quit smoking or to join a proactive structured smoking cessation program.

General practitioner's adherence to the COPD GOLD guidelines: baseline data of the Swiss COPD Cohort Study.

PRINCIPLES: Chronic obstructive pulmonary disease (COPD) is a major burden on patients and healthcare systems. Diagnosis and the management of COPD are often administered by general practitioners (GPs). This analysis investigated the adherence of GPs in Switzerland to the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) guidelines. METHODS: As part of an ongoing investigation into the effect of GPs prescriptions on the clinical course of COPD, 139 GPs submitted a standardised questionnaire for each COPD patient recruited. Information requested included spirometric parameters, management and demographic data. Participating GPs were provided with and received instruction on a spirometer with automatic feedback on quality. Patients were grouped by the investigators into the GOLD COPD severity classifications, based on spirometric data provided. Data from the questionnaires were compared between the groups and management was compared with the recommendations of GOLD. RESULTS: Of the 615 patients recruited, 44% did not fulfil GOLD criteria for COPD. Pulmonary rehabilitation was prescribed to 5% of all patients and less than one-third of patients exercised regularly. Less than half the patients in all groups used short-acting bronchodilators. Prescribing long-acting bronchodilators or inhaled corticosteroids conformed to GOLD guidelines in two-thirds of patients with GOLD stage III or IV disease, and approximately half of the less severe patients. Systemic steroids were inappropriately prescribed during stable disease in 6% of patients. CONCLUSIONS: Adherence to GOLD (COPD) guidelines is low among GPs in Switzerland and COPD is often misdiagnosed or treated inappropriately. This is probably due to poor knowledge of disease definitions.

Respiratory symptoms, atopy and bronchial hyperreactivity in professional firefighters.

The aim of the present study was to assess respiratory health in professional firefighters. A total of 101 male professional firefighters from Basel, Switzerland, were included in the study. A control group consisting of 735 male subjects of the general population was composed of the Basel sample of the Swiss Study on Air Pollution and Lung Diseases in Adults. All subjects were administered a standardised questionnaire, spirometry, skin-prick tests and bronchial challenge testing to methacholine. Respiratory symptoms at work were more frequent in firefighters compared with the control group, including burning eyes (21 versus 3%), running nose (19 versus 2%), itchy throat (26 versus 3%), cough (28 versus 3%), dyspnoea (7 versus 2%) and headache (25 versus 3%), respectively. Atopy was present in 51% of firefighters compared with 32% in the control group. The odds ratio for hyperreactivity to methacholine was 2.24 (95% confidence interval 1.12-4.48) for firefighters compared with the control group. Firefighters reported more respiratory symptoms at work and suffered more often from atopy compared with the control group. Bronchial hyperreactivity was more pronounced in firefighters, but it was not related to acute exposure or duration of employment. It remains unclear whether these findings were present at recruitment or developed after joining the workforce.