Relationship of long-term air pollution exposure with asthma and rhinitis in Italy: an innovative multipollutant approach.

BACKGROUND: air pollution is a complex mixture; novel multipollutant approaches could help understanding the health effects of multiple concomitant exposures to air pollutants. AIM: to assess the relationship of long-term air pollution exposure with the prevalence of respiratory/allergic symptoms and diseases in an Italian multicenter study using single and multipollutant approaches. METHODS: 14420 adults living in 6 Italian cities (Ancona, Pavia, Pisa, Sassari, Turin, Verona) were investigated in 2005-2011 within 11 different study cohorts. Questionnaire information about risk factors and health outcomes was collected. Machine learning derived mean annual concentrations of PM10, PM2.5, NO2 and mean summer concentrations of O3 (µg/m3) at residential level (1-km resolution) were used for the period 2013-2015. The associations between the four pollutants and respiratory/allergic symptoms/diseases were assessed using two approaches: a) logistic regression models (single-pollutant models), b) principal component logistic regression models (multipollutant models). All the models were adjusted for age, sex, education level, smoking habits, season of interview, climatic index and included a random intercept for cohorts. RESULTS: the three-year average (± standard deviation) pollutants concentrations at residential level were: 20.3 ± 6.8 µg/m3 for PM2.5, 29.2 ± 7.0 µg/m3 for PM10, 28.0 ± 11.2 µg/m3 for NO2, and 70.9 ± 4.3 µg/m3 for summer O3. Through the multipollutant models the following associations emerged: PM10 and PM2.5 were related to 14-25% increased odds of rhinitis, 23-34% of asthma and 30-33% of night awakening; NO2 was related to 6-9% increased odds of rhinitis, 7-8% of asthma and 12% of night awakening; O3 was associated with 37% increased odds of asthma attacks. Overall, the Odds Ratios estimated through the multipollutant models were attenuated when compared to those of the single-pollutant models. CONCLUSIONS: this study enabled to obtain new information about the health effects of air pollution on respiratory/allergic outcomes in adults, applying innovative methods for exposure assessment and multipollutant analyses.

[The role of exposure to airborne pollutants in the workplace on the prevalence and severity of chronic respiratory disease in Italy]. / Il ruolo dell'esposizione a inquinanti aerodispersi nel luogo di lavoro sulla prevalenza e gravità della malattia respiratoria cronica in Italia.

OBJECTIVES: occupational exposure to vapours, gases, dusts and fumes (VGDF) plays an important role in the development and exacerbation of respiratory diseases. The aim of this study is to evaluate the possible association of occupational exposure to airborne pollutants and chronic respiratory diseases. DESIGN: multicase-control study. SETTING AND PARTICIPANTS: cases of chronic respiratory diseases and controls from the Italian multicentric study Gene Environment Interaction in Respiratory Diseases (GEIRD). MAIN OUTCOME MEASURES: the occurrence of rhinitis, asthma, chronic bronchitis/chronic obstructive pulmonary disease (COPD), asthma severity, spirometry data, exhaled nitric oxide (FeNO) were examined in relation to chronic and acute occupational exposures to airborne pollutants using multiple regression models. RESULTS: 2,943 subjects were enrolled in the study. Regularm exposure to VGDF was associated with a higher prevalence of chronic bronchitis/COPD (OR 1.40, 95%CI 0.98-1.99), especially in those also having asthma (OR 1.80, 95%CI 1.14-2.85), a lower prevalence of remittent asthma (OR 0.53, 95%CI 0.29-0.96) and, in those with asthma, an increased activity of the disease (severity score) (OR 1.77, 95%CI 1.20-2.60). No associations were observed between occupational exposure and prevalence of rhinitis, spirometry and FeNO data. Finally, an association was found between acute exposure to airborne pollutants (occupational and non-occupational) and the respiratory diseases investigated, in particular active asthma and asthma associated chronic bronchitis/BPCO. CONCLUSIONS: these data confirm a significant role of occupational exposure to airborne pollutants on respiratory health, underlying the importance of workplace exposure prevention, in particular for more susceptible subjects, as those with respiratory diseases.

Influence of residential land cover on childhood allergic and respiratory symptoms and diseases: Evidence from 9 European cohorts.

INTRODUCTION: Recent research focused on the interaction between land cover and the development of allergic and respiratory disease has provided conflicting results and the underlying mechanisms are not fully understood. In particular, green space, which confers an overall positive impact on general health, may be significantly contributing to adverse respiratory health outcomes. This study evaluates associations between surrounding residential land cover (green, grey, agricultural and blue space), including type of forest cover (deciduous, coniferous and mixed), and childhood allergic and respiratory diseases. METHODS: Data from 8063 children, aged 3-14 years, were obtained from nine European population-based studies participating in the HEALS project. Land-cover exposures within a 500 m buffer centred on each child's residential address were computed using data from the Coordination of Information on the Environment (CORINE) program. The associations of allergic and respiratory symptoms (wheeze, asthma, allergic rhinitis and eczema) with land coverage were estimated for each study using logistic regression models, adjusted for sex, age, body mass index, maternal education, parental smoking, and parental history of allergy. Finally, the pooled effects across studies were estimated using meta-analyses. RESULTS: In the pooled analyses, a 10% increase in green space coverage was significantly associated with a 5.9%-13.0% increase in the odds of wheezing, asthma, and allergic rhinitis, but not eczema. A trend of an inverse relationship between agricultural space and respiratory symptoms was observed, but did not reach statistical significance. In secondary analyses, children living in areas with surrounding coniferous forests had significantly greater odds of reporting wheezing, asthma and allergic rhinitis. CONCLUSION: Our results provide further evidence that exposure to green space is associated with increased respiratory disease in children. Additionally, our findings suggest that coniferous forests might be associated with wheezing, asthma and allergic rhinitis. Additional studies evaluating both the type of green space and its use in relation to respiratory conditions should be conducted in order to clarify the underlying mechanisms behind associated adverse impacts.

Inhalation therapy in the next decade: Determinants of adherence to treatment in asthma and COPD.

Proceedings of the European Seminars in Respiratory Medicine course, Inhalation therapy in the next decade: Determinants of adherence to treatment in asthma and COPD, held in Taormina, Italy, on 3-4 March, 2017.

Integrating the care of the complex COPD patient.

Proceedings of the European Seminars in Respiratory Medicine course, Long-Term Integrated Care of COPD Patients held in Stresa, Italy, on 16-17 June, 2016.

Indoor air pollution and respiratory health in the elderly.

Data on respiratory effects of indoor air pollution in elderly are scanty. The purpose of this review is to summarize current knowledge on adverse respiratory effects of indoor air pollution in individuals aged over 65 years, by presenting existing epidemiological evidence. Using MEDLINE database through PubMed, we identified relevant publications published between 1991 and 2011 in English on respiratory health effects of indoor air pollution in elderly (>65 years). A total of 61 studies were found and after application of the inclusion criteria: (i) epidemiologic studies published in English in peer-reviewed journals between January 1991 and December 2011, (ii) study population with age over or equal 65 years, and (iii) outcome of respiratory symptoms and disease with the exclusion of lung cancer, 33 relevant publications were selected. Most of them showed significant relationships between exposure to major indoor air pollutants and various short-term and long-term respiratory health outcomes such as wheezing, breathlessness, cough, phlegm, asthma, COPD, lung cancer and more rarely lung function decline. The most consistent relationship is found between chronic obstructive pulmonary disease (COPD) and environmental tobacco smoke (ETS). Further studies in the elderly population are needed in order to define causal relationships between exposures to indoor air pollution and underlying mechanisms in this sub-population.

Long-term residential exposure to air pollution and risk of chronic respiratory diseases in Italy: The BIGEPI study.

Long-term exposure to air pollution has adverse respiratory health effects. We investigated the cross-sectional relationship between residential exposure to air pollutants and the risk of suffering from chronic respiratory diseases in some Italian cities. In the BIGEPI project, we harmonised questionnaire data from two population-based studies conducted in 2007-2014. By combining self-reported diagnoses, symptoms and medication use, we identified cases of rhinitis (n = 965), asthma (n = 328), chronic bronchitis/chronic obstructive pulmonary disease (CB/COPD, n = 469), and controls (n = 2380) belonging to 13 cohorts from 8 Italian cities (Pavia, Turin, Verona, Terni, Pisa, Ancona, Palermo, Sassari). We derived mean residential concentrations of fine particulate matter (PM10, PM2.5), nitrogen dioxide (NO2), and summer ozone (O3) for the period 2013-2015 using spatiotemporal models at a 1 km resolution. We fitted logistic regression models with controls as reference category, a random-intercept for cohort, and adjusting for sex, age, education, BMI, smoking, and climate. Mean ± SD exposures were 28.7 ± 6.0 µg/m3 (PM10), 20.1 ± 5.6 µg/m3 (PM2.5), 27.2 ± 9.7 µg/m3 (NO2), and 70.8 ± 4.2 µg/m3 (summer O3). The concentrations of PM10, PM2.5, and NO2 were higher in Northern Italian cities. We found associations between PM exposure and rhinitis (PM10: OR 1.62, 95%CI: 1.19-2.20 and PM2.5: OR 1.80, 95%CI: 1.16-2.81, per 10 µg/m3) and between NO2 exposure and CB/COPD (OR 1.22, 95%CI: 1.07-1.38 per 10 µg/m3), whereas asthma was not related to environmental exposures. Results remained consistent using different adjustment sets, including bi-pollutant models, and after excluding subjects who had changed residential address in the last 5 years. We found novel evidence of association between long-term PM exposure and increased risk of rhinitis, the chronic respiratory disease with the highest prevalence in the general population. Exposure to NO2, a pollutant characterised by strong oxidative properties, seems to affect mainly CB/COPD.

Symptom control and health-related quality of life in allergic rhinitis with and without comorbid asthma: A multicentre European study.

BACKGROUND: Allergic rhinitis (AR) is a major non-communicable disease that affects the health-related quality of life (HRQoL) of patients. However, data on HRQoL and symptom control in AR patients with comorbid asthma (AR + asthma) are lacking. METHODS: In this multicentre, cross-sectional study, patients with AR were screened and administered questionnaires of demographic characteristics and health conditions (symptoms/diagnosis of AR and asthma, disease severity level, and allergic conditions). HRQoL was assessed using a modified version of the RHINASTHMA questionnaire (30, 'not at all bothered' - 150 'very much bothered') and symptom control was evaluated by a modified version of the Control of Allergic Rhinitis/Asthma Test (CARAT) (0, 'no control' - 30, 'very high control'). RESULTS: Out of 643 patients with AR, 500 (78%) had asthma as a comorbidity, and 54% had moderate-severe intermittent AR, followed by moderate-severe persistent AR (34%). Compared to the patients with AR alone, patients with AR + asthma had significantly higher RHINASTHMA (e.g., median RHINASTHMA-total score 48.5 vs. 84, respectively) and a significantly lower CARAT score (median CARAT-total score 23 vs. 16.5, respectively). Upon stratifying asthma based on severity, AR patients with severe persistent asthma had worse HRQoL and control than those with mild persistent asthma. The association was significantly higher among non-obese participants compared to obese ones, with RHINASTHMA-upper symptoms score but not with CARAT. CONCLUSIONS: Our observation of poorer HRQoL and symptoms control in AR patients with comorbid asthma supports the importance of a comprehensive approach for the management of AR in case of a comorbid allergic condition.

Impact of asthma and comorbid allergic rhinitis on quality of life and control in patients of Italian general practitioners.

OBJECTIVE: Asthma is a disease with elevated prevalence within the general population. Although general practitioners (GPs) are among the first health-care professionals to whom patients refer for their symptoms, there are few evaluations of this disease based on data provided by the GPs. The aim of this observational study is to assess the impact of asthma and comorbid allergic rhinitis on individual/social burden, quality of life, and disease control in asthmatic patients of Italian GPs. METHODS: Throughout Italy, 107 GPs enrolled 995 patients diagnosed with asthma and using anti-asthmatic drug prescriptions, or with asthma-like symptoms during the previous 12 months. Data were collected through questionnaires filled out by GPs and patients. RESULTS: Of the 995 asthmatic patients, 60.6% had concomitant allergic rhinitis (R+A), 39.4% had asthma alone. The latter, compared to those with R+A, showed significantly lower prevalence of intermittent asthma (37.5% vs. 55.6%) and higher prevalence of mild, moderate, and severe persistent asthma (28.4% vs. 23.2%, 28.7% vs. 18.8%, and 5.4% vs 2.4%, respectively). Individual/social burden due to asthma was frequent and increased with disease severity: 87.5% of severe persistent asthma patients reported at least one medical consultation in the last 12 months, 37.5% emergency department visits, 26.7% hospitalization, and 62.5% limitations in daily activities. Control and quality of life were inversely associated with disease severity and were worse in patients with R+A than in those with asthma alone. CONCLUSIONS: This study showed the negative impact of high severity levels and comorbid allergic rhinitis on quality of life of asthmatic patients and on individual/social burden due to asthma in an Italian GPs setting.

The Italian severe/uncontrolled asthma registry (RItA): A 12-month clinical follow-up.

BACKGROUND: follow-up studies on registries of severe/uncontrolled asthma (SUA) patients are scanty. OBJECTIVE: to analyze baseline and follow-up characteristics of SUA patients and their longitudinal patterns. METHODS: 180 adult patients (age ≥15 yrs) were investigated at baseline and 12-month follow-up through the Italian SUA registry (RItA). Latent transition analysis (LTA) was performed to detect cross-sectional SUA phenotypes and longitudinal patterns. Risk factors for longitudinal patterns were assessed through logistic regression. RESULTS: a significant/borderline improvement of asthma control outcomes in the last 2-4 weeks emerged at follow-up with respect to baseline for: daily activities limitations (Δ -16%), frequent diurnal symptoms (Δ -25%), uncontrolled asthma symptoms according to ACT (Δ -26%). Last 12-month use of oral corticosteroids was less frequent at follow-up than at baseline (Δ -25%). Health status improvement was confirmed by lung function test results. Through LTA, two longitudinal patterns were detected considering last 12-month control outcomes: "persistence/worsening" (53.9%), "under control/improvement" (46.1%). A lower likelihood of having "persistence/worsening" SUA was exhibited by patients under anti-IgE (OR 0.38, 95% CI 0.17-0.84) and inhaled corticosteroids-bronchodilator association treatment (OR 0.13, 95% CI 0.01-1.26, borderline value), while a higher likelihood was shown by older age at first asthma diagnosis (OR 1.04, 95% CI 1.01-1.07). CONCLUSION: the implementation of a SUA registry, the availability of patient-level data and the application of an innovative longitudinal analysis allowed to observe a general improvement in asthma control, one year after baseline, and a lower risk of SUA "persistence/worsening" in patients under anti-IgE and regular ICS-bronchodilator association use.

A nationwide study of air pollution from particulate matter and daily hospitalizations for respiratory diseases in Italy.

BACKGROUND/AIM: The relationship between air pollution and respiratory morbidity has been widely addressed in urban and metropolitan areas but little is known about the effects in non-urban settings. Our aim was to assess the short-term effects of PM10 and PM2.5 on respiratory admissions in the whole country of Italy during 2006-2015. METHODS: We estimated daily PM concentrations at the municipality level using satellite data and spatiotemporal predictors. We collected daily counts of respiratory hospital admissions for each Italian municipality. We considered five different outcomes: all respiratory diseases, asthma, chronic obstructive pulmonary disease (COPD), lower and upper respiratory tract infections (LRTI and URTI). Meta-analysis of province-specific estimates obtained by time-series models, adjusting for temperature, humidity and other confounders, was applied to extrapolate national estimates for each outcome. At last, we tested for effect modification by sex, age, period, and urbanization score. Analyses for PM2.5 were restricted to 2013-2015 cause the goodness of fit of exposure estimation. RESULTS: A total of 4,154,887 respiratory admission were registered during 2006-2015, of which 29% for LRTI, 12% for COPD, 6% for URTI, and 3% for asthma. Daily mean PM10 and PM2.5 concentrations over the study period were 23.3 and 17 µg/m3, respectively. For each 10 µg/m3 increases in PM10 and PM2.5 at lag 0-5 days, we found excess risks of total respiratory diseases equal to 1.20% (95% confidence intervals, 0.92, 1.49) and 1.22% (0.76, 1.68), respectively. The effects for the specific diseases were similar, with the strongest ones for asthma and COPD. Higher effects were found in the elderly and in less urbanized areas. CONCLUSIONS: Short-term exposure to PM is harmful for the respiratory system throughout an entire country, especially in elderly patients. Strong effects can be found also in less urbanized areas.

Geographical information system and environmental epidemiology: a cross-sectional spatial analysis of the effects of traffic-related air pollution on population respiratory health.

BACKGROUND: Traffic-related air pollution is a potential risk factor for human respiratory health. A Geographical Information System (GIS) approach was used to examine whether distance from a main road (the Tosco-Romagnola road) affected respiratory health status. METHODS: We used data collected during an epidemiological survey performed in the Pisa-Cascina area (central Italy) in the period 1991-93. A total of 2841 subjects participated in the survey and filled out a standardized questionnaire on health status, socio-demographic information, and personal habits. A variable proportion of subjects performed lung function and allergy tests. Highly exposed subjects were defined as those living within 100 m of the main road, moderately exposed as those living between 100 and 250 m from the road, and unexposed as those living between 250 and 800 m from the road. Statistical analyses were conducted to compare the risks for respiratory symptoms and diseases between exposed and unexposed. All analyses were stratified by gender. RESULTS: The study comprised 2062 subjects: mean age was 45.9 years for men and 48.9 years for women. Compared to subjects living between 250 m and 800 m from the main road, subjects living within 100 m of the main road had increased adjusted risks for persistent wheeze (OR = 1.76, 95% CI = 1.08-2.87), COPD diagnosis (OR = 1.80, 95% CI = 1.03-3.08), and reduced FEV1/FVC ratio (OR = 2.07, 95% CI = 1.11-3.87) among males, and for dyspnea (OR = 1.61, 95% CI = 1.13-2.27), positivity to skin prick test (OR = 1.83, 95% CI = 1.11-3.00), asthma diagnosis (OR = 1.68, 95% CI = 0.97-2.88) and attacks of shortness of breath with wheeze (OR = 1.67, 95% CI = 0.98-2.84) among females. CONCLUSION: This study points out the potential effects of traffic-related air pollution on respiratory health status, including lung function impairment. It also highlights the added value of GIS in environmental health research.

Percentiles of inspiratory capacity in healthy nonsmokers: a pilot study.

BACKGROUND: Over the past decade inspiratory capacity (IC) has received increasing attention, especially in studies on chronic obstructive pulmonary disease. Though a few recent studies provide reference values for IC, still little is known on the distribution of its values in healthy subjects. OBJECTIVE: To estimate percentiles of IC in a sample of healthy nonsmokers by applying quantile regression. METHODS: We applied quantile regression to estimate seven percentiles of IC from 5 to 95% for a given age, height and body mass index, separately in males and females, in a sample of 411 healthy nonsmokers, aged 8-73 years, drawn from the general population in Northern Italy. RESULTS: The magnitude and statistical significance of the effect of age, height and body mass on IC varied across percentiles and between genders. When the 50th percentile of IC was compared with the predicted values of several studies, including those published by the European Community for Coal and Steel, the differences were as large as 0.86 liters in males and 0.90 liters in females. The possible advantage of the 5th percentile predicted from quantile regression over the 'traditional 5th percentile' as lower limit of normal was also illustrated. CONCLUSIONS: Inference on percentiles, rather than just the mean, of IC and other lung function measures may help in the future to better understand the effect of various risk factors, model growth curves and derive more accurate reference values.

Short-Term Effects of Air Pollution on Cardiovascular Hospitalizations in the Pisan Longitudinal Study.

Air pollution effects on cardiovascular hospitalizations in small urban/suburban areas have been scantly investigated. Such effects were assessed among the participants in the analytical epidemiological survey carried out in Pisa and Cascina, Tuscany, Italy (2009-2011). Cardiovascular hospitalizations from 1585 subjects were followed up (2011-2015). Daily mean pollutant concentrations were estimated through random forests at 1 km (particulate matter: PM10, 2011-2015; PM2.5, 2013-2015) and 200 m (PM10, PM2.5, NO2, O3, 2013-2015) resolutions. Exposure effects were estimated using the case-crossover design and conditional logistic regression (odds ratio-OR-and 95% confidence interval-CI-for 10 µg/m3 increase; lag 0-6). During the period 2011-2015 (137 hospitalizations), a significant effect at lag 0 was observed for PM10 (OR = 1.137, CI: 1.023-1.264) at 1 km resolution. During the period 2013-2015 (69 hospitalizations), significant effects at lag 0 were observed for PM10 (OR = 1.268, CI: 1.085-1.483) and PM2.5 (OR = 1.273, CI: 1.053-1.540) at 1 km resolution, as well as for PM10 (OR = 1.365, CI: 1.103-1.690), PM2.5 (OR = 1.264, CI: 1.006-1.589) and NO2 (OR = 1.477, CI: 1.058-2.061) at 200 m resolution; significant effects were observed up to lag 2. Larger ORs were observed in males and in subjects reporting pre-existent cardiovascular/respiratory diseases. Combining analytical and routine epidemiological data with high-resolution pollutant estimates provides new insights on acute cardiovascular effects in the general population and in potentially susceptible subgroups living in small urban/suburban areas.

Global Burden of Chronic Respiratory Diseases.

Background: Noncommunicable diseases (NCDs) and chronic respiratory diseases (CRDs) are the main causes of mortality and morbidity worldwide. Methods: The main evidences about the NCDs and CRDs burden and related risk factors, from updated international reports and results of original researches, were collected and described in this review. Results: Most recent evidence is available from the Global Burden of Diseases Study (GBD) 2017 reports. There were 3.2 million deaths due to chronic obstructive pulmonary disease (COPD) and 495,000 deaths due to asthma. COPD was the seventh leading cause of years of life lost (YLLs). Overall, prevalent cases of CRDs were 545 million: about 50% for COPD and 50% for asthma. Incident cases of CRDs were 62 million, mostly due to asthma (69%) and COPD (29%). COPD accounted for 81.6 million disability-adjusted life years, asthma for 22.8 million. COPD prevalence of 9.1% has been found in a recent general population sample of North-Eastern Italy, while in Central Italy a 25-year follow-up of a general population sample has shown an increased prevalence of COPD and asthma up to 6.8% and 7.8%, respectively. In Central Italy, a COPD incidence of 8% and an asthma incidence of 3.2% have been found in adult subjects at an 18-year follow-up. Among the risk factors, a relevant role is played by smoking and high body mass index for asthma, while smoking, particulate matter pollution, ambient ozone pollution, occupational exposure to particulate matter, gases and fumes, as well as second-hand smoke, play an important role for COPD. Forecasting the YLLs by 2040 indicates a rising toll from several NCDs due to population growth and aging, with COPD expected to reach the fourth leading cause. Conclusions: Several recent studies and international reports highlighted the huge global health burden of CRDs and other major NCDs, pointing out the need for implementing international collaborations to fight this epidemic trend.

Longitudinal Asthma Patterns in Italian Adult General Population Samples: Host and Environmental Risk Factors.

BACKGROUND: Asthma patterns are not well established in epidemiological studies. AIM: To assess asthma patterns and risk factors in an adult general population sample. METHODS: In total, 452 individuals reporting asthma symptoms/diagnosis in previous surveys participated in the AGAVE survey (2011-2014). Latent transition analysis (LTA) was performed to detect baseline and 12-month follow-up asthma phenotypes and longitudinal patterns. Risk factors associated with longitudinal patterns were assessed through multinomial logistic regression. RESULTS: LTA detected four longitudinal patterns: persistent asthma diagnosis with symptoms, 27.2%; persistent asthma diagnosis without symptoms, 4.6%; persistent asthma symptoms without diagnosis, 44.0%; and ex -asthma, 24.1%. The longitudinal patterns were differently associated with asthma comorbidities. Persistent asthma diagnosis with symptoms showed associations with passive smoke (OR 2.64, 95% CI 1.10-6.33) and traffic exposure (OR 1.86, 95% CI 1.02-3.38), while persistent asthma symptoms (without diagnosis) with passive smoke (OR 3.28, 95% CI 1.41-7.66) and active smoke (OR 6.24, 95% CI 2.68-14.51). CONCLUSIONS: LTA identified three cross-sectional phenotypes and their four longitudinal patterns in a real-life setting. The results highlight the necessity of a careful monitoring of exposure to active/passive smoke and vehicular traffic, possible determinants of occurrence of asthma symptoms (with or without diagnosis). Such information could help affected patients and physicians in prevention and management strategies.

Effects of Particulate Matter on the Incidence of Respiratory Diseases in the Pisan Longitudinal Study.

The current study aimed at assessing the effects of exposure to Particulate Matter (PM) on the incidence of respiratory diseases in a sub-sample of participants in the longitudinal analytical epidemiological study in Pisa, Italy. Three hundred and five subjects living at the same address from 1991 to 2011 were included. Individual risk factors recorded during the 1991 survey were considered, and new cases of respiratory diseases were ascertained until 2011. Average PM10 and PM2.5 exposures (µg/m3, year 2011) were estimated at the residential address (1-km2 resolution) through a random forest machine learning approach, using a combination of satellite data and land use variables. Multivariable logistic regression with Firth's correction was applied. The median (25th-75th percentile) exposure levels were 30.1 µg/m3 (29.9-30.7 µg/m3) for PM10 and 19.3 µg/m3 (18.9-19.4 µg/m3) for PM2.5. Incidences of rhinitis and chronic phlegm were associated with increasing PM2.5: OR = 2.25 (95% CI: 1.07, 4.98) per unit increase (p.u.i.) and OR = 4.17 (1.12, 18.71) p.u.i., respectively. Incidence of chronic obstructive pulmonary disease was associated with PM10: OR = 2.96 (1.50, 7.15) p.u.i. These results provide new insights into the long-term respiratory health effects of PM air pollution.

Health effects of air pollution: a Southern European perspective.

OBJECTIVE: To summarize the main updated evidence about the health effects of air pollution, with a special focus on Southern Europe. DATA SOURCES: Literature was obtained through PubMed Central and the official websites of European Agencies and Scientific Societies. STUDY SELECTION: Recent shreds of evidence about the health effects of air pollution coming from international reports and original research were collected and described in this review. RESULTS: Air pollution is an avoidable risk factor that causes a huge burden for society, in terms of death, health disorders, and huge socio-economic costs. The southern European countries face a more threatening problem because they experience the effects of both anthropogenic pollutants and natural dusts (particulate matter [PM]). The European Environment Agency reported the number of premature deaths in the 28 countries of the European Union attributable to air pollutant exposure in the year 2016: 374,000 for PM2.5, 68,000 for nitrogen dioxide, and 14,000 for ozone. In Italy, time series and analytical epidemiological studies showed increased cardio-respiratory hospital admissions and mortality, as well as increased risk of respiratory diseases in people living in urban areas. CONCLUSIONS: Based on abundant evidence, the World Health Organization, which hosts the Global Alliance against Chronic Respiratory Diseases (GARD), the scientific respiratory societies, and the patients' associations, as well as others in the health sector, must increase their engagement in advocacy for clean air policies.

18-yr cumulative incidence of respiratory/allergic symptoms/diseases and risk factors in the Pisa epidemiological study.

BACKGROUND: Few population-based studies on the effects of environmental exposure variation exist. AIM: Assessing respiratory symptom/disease incidence related to risk factor exposure changes. METHODS: A longitudinal general population sample from two surveys (PISA2:1991-1993; PISA3:2009-2011; no. = 970), aged ≥20 years at baseline, completed a questionnaire on respiratory symptoms/diseases, risk factor exposure and performed spirometry. 18-year follow-up cumulative incidence of respiratory symptoms/diseases and longitudinal changes (persistence, incidence, remittance) in risk factor exposure were computed. RESULTS: Cumulative incidence values were: 3.2% (corresponding to a 1.8‰/year incidence rate), asthma; 6.6% (3.8‰/year), asthma attacks; 4.5% (2.6‰/year), wheeze; 31.7% (21.0‰/year), allergic rhinitis-AR; 7.6% (4.4‰/year), chronic obstructive pulmonary disease-COPD; 16.1% (9.7‰/year), usual cough; 18.5% (11.3‰/year), usual phlegm; 30.7% (20.1‰/year), dyspnoea 1+; 13.9% (8.3‰/year), airway obstruction. The following associations emerged among respiratory symptom/disease cumulative incidence and risk factor exposure changes: a two-to-five fold higher risk for COPD, phlegm, cough, dyspnoea, asthma attacks, airway obstruction in persistent smokers; a two-to-three fold higher risk for COPD in remittent smokers; a two-fold higher risk for AR, phlegm and a four-fold higher risk for asthma in subjects with persistent occupational exposure; a two-fold higher risk for cough, phlegm, dyspnoea, AR in subjects with incident occupational exposure; a two-fold higher risk for AR, asthma attacks, COPD in subjects with incident traffic exposure. CONCLUSIONS: Our study showed noteworthy respiratory symptom/disease incidence values and indicated that life-style and environmental exposure changes can differently influence onset. This information could be useful for primary prevention strategies in order to reduce the chronic disease burden in the general population.

Prescriptive adherence to GINA guidelines and asthma control: An Italian cross sectional study in general practice.

BACKGROUND: Although general practitioners (GPs) are frequently the first healthcare professionals whom asthma patients refer to for their symptoms, few studies have explored the extent of adherence to guidelines for asthma management based on data provided directly by GPs. Aims of the present study were to assess drug prescriptions for asthma by GPs and to evaluate prescriptive adherence to GINA guidelines (GL) and its relationship with disease control in real life. METHODS: 995 asthmatic patients (45% males, mean age 43.3 ±â€¯17.7 yrs) were enrolled by 107 Italian GPs distributed throughout the country. Data on diagnosis, disease severity, prescribed anti-asthmatic drugs and control were collected through questionnaires filled out by GPs taking into consideration the 2009 GINA Guidelines. Data on drug use and chronic sinusitis, nasal polyposis, chronic bronchitis, emphysema were reported by patients through a self-administered questionnaire. RESULTS: The large majority of patients were classified by GPs as having intermittent (48.4%) or mild persistent asthma (25.3%); 61% had co-morbid allergic rhinitis (AR). The prevalent therapeutic regimen used by patients was a combination of inhaled corticosteroids (ICS) plus long-acting ß2-agonists (LABA) (54.1%), even in the intermittent/mild persistent group. ICS as mono-therapy or in combination with other drugs but LABA, was the second most frequently adopted treatment (14.4%). In general, the GPs adherence to GL treatment indications was 28.8%, with a significant association with a good asthma control (OR 1.85, 95% CI 1.18-2.92). On the other hand, comorbidity (OR 0.52, 95% CI 0.32-0.84), moderate (0.44, 0.28-0.69) and severe (0.06, 0.02-0.20) persistent asthma showed significant negative effects on asthma control. CONCLUSIONS: Our results show that over-treatment of intermittent/mild persistent asthma is frequent in the GPs setting while therapeutic regimens are more appropriately applied for moderate/severe asthma. In general, we found low adherence to GINA GL treatment recommendations even if its relevance in asthma control was confirmed.