Gianfranco Schiraldi

How air pollution influences clinical management of respiratory diseases. A case-crossover study in Milan

BackgroundEnvironmental pollution is a known risk factor for multiple diseases and furthermore increases rate of hospitalisations. We investigated the correlation between emergency room admissions (ERAs) of the general population for respiratory diseases and the environmental pollutant levels in Milan, a metropolis in northern Italy.MethodsWe collected data from 45770 ERAs for respiratory diseases. A time-stratified case-crossover design was used to investigate the association between air pollution levels and ERAs for acute respiratory conditions. The effects of air pollutants were investigated at lag 0 to lag 5, lag 0–2 and lag 3–5 in both single and multi-pollutant models, adjusted for daily weather variables.ResultsAn increase in ozone (O3) levels at lag 3–5 was associated with a 78% increase in the number of ERAs for asthma, especially during the warm season. Exposure to carbon monoxide (CO) proved to be a risk factor for pneumonia at lag 0–2 and in the warm season increased the risk of ERA by 66%. A significant association was found between ERAs for COPD exacerbation and levels of sulphur dioxide (SO2), CO, nitrate dioxide (NO2), and particulate matter (PM10 and PM2.5). The multipollutant model that includes all pollutants showed a significant association between CO (26%) and ERA for upper respiratory tract diseases at lag 0–2. For chronic obstructive pulmonary disease (COPD) exacerbations, only CO (OR 1.19) showed a significant association.ConclusionsExposure to environmental pollution, even at typical low levels, can increase the risk of ERA for acute respiratory diseases and exacerbation of obstructive lung diseases in the general population.

Refractory pulmonary aspergillosis: compassionate trial with terbinafine

The frequency of bronchopulmonary aspergillosis is increasing due to the growing number of patients requiring steroids or other immunosuppressive therapies. Conventional treatments are ineffective in some patients and side–effects are an important issue. The aim of this work was to evaluate the effectiveness and safety of terbinafine, a new allylamine antimycotic drug, in three immunocompetent patients affected by lower respiratory tract aspergillosis [one chronic empyema due to Aspergillus fumigatus (AF) and two chronic necrotising aspergillosis] not responsive to the usual antimycotic therapies. In in vitro and animal model systems, terbinafine is as active as amphotericin B and itraconazole. Patients received terbinafine at doses ranging from 5 to 15 mg/kg per day, according to clinical status, for 3–5 months, depending on the clinical course of the disease and compliance. In patient 1 a negative anti–AF precipitin was obtained together with eradication of AF from the pleural cavity, which allowed a successful intrathoracic myo–omento–mammoplasty. In patients 2 and 3, AF was eradicated, anti–AF immunoprecipitins decreased, and clinical and radiological findings significantly improved. On the basis of the effectiveness of terbinafine demonstrated in this preliminary work, large studies to evaluate the use of terbinafine in bronchopulmonary aspergillosis are warranted. Moreover, the drug is not associated with resistance or significant side–effects.

Quality standards for the management of bronchiectasis in Italy: A national audit

Although historically considered a neglected disease, bronchiectasis has become a disease of renewed interest over recent decades in light of an increase in prevalence and a substantial burden on healthcare systems [1–3]. In 2010, the British Thoracic Society (BTS) published guidelines on the management of bronchiectasis in adults, along with specific quality standards [4, 5]. To date, these represent the only quality standards available in Europe. These have been tested over a number of years in the UK with progressive improvements in the standard of care [6]. No national guidelines are available in Italy and no indications on which guideline should be followed have been given by the Italian Society of Respiratory Medicine (SIP). There are limited published data on the quality of bronchiectasis care in Europe outside of the UK. The BTS standards have not been tested in continental Europe or in Italy, where information on characteristics and management of bronchiectasis patients are lacking. The majority of the quality standards for the management of bronchiectasis in adults are not met in Italy http://ow.ly/YKMpU

Terbinafine in the treatment of non‐immunocompromised compassionate cases of bronchopulmonary aspergillosis

Summary. Conventional treatments of bronchopulmonary aspergillosis are often ineffective and result in associated side‐effects. Terbinafine (a new allylamine derivative), although as active against Aspergillus in vitro as amphotericin B and itraconazole, is less effective in rodent models because of a rapid hepatic first‐pass effect. As terbinafine is metabolized differently in humans, the aim of this work was to evaluate this drug, for the first time, in the treatment of seven immunocompetent patients with lower respiratory tract mycotic infections unresponsive to the usual antimycotic drugs. Diagnosis was based on identification of fungal isolates, worsening of respiratory function tests, chest radiographs and computerized tomographic (CT) scan changes, positive skin test, aspergillin precipitins and clinical history. Terbinafine was administered at doses ranging from 5 to 15 mg kg‐1 day‐1 depending on the clinical severity of the disease, and was given for 90–270 days depending on clinical progress and compliance. In three patients A. fumigatus was suppressed with resolution of signs and symptoms; four patients showed transitory A. fumigatus suppression with marked clinical and radiological improvement. During relapses no resistance to terbinafine was observed. No significant side‐effects were detected. Terbinafine appeared to be as effective as amphotericin B and itraconazole in the treatment of bronchopulmonary aspergillosis in non‐immunocompromised patients. These preliminary results suggest that controlled studies are warranted.

Particulate matter, science and European Union policy

To the Editors: The editorial of Annesi-Maesano et al. 1 summarises current evidence concerning the adverse health effects of particulate matter (PM) and correctly outlines that: 1) the health effects of air pollution are a big problem worldwide; and 2) several scientific questions are still open. In addition, the authors press for more stringent measures of prevention, in order to achieve adequate protection of the exposed population. In particular, they outline that “experimental research has rapidly progressed” and only “details of the pathophysiological mechanisms remain to be elucidated”. We agree with most of their statements and are in favour of more stringent rules for the European Union (EU). However, we would like to make some comments concerning the open questions, in order to increase the scientific strength that should convince EU authorities. The World Health Organization estimates that inhalation of PM in ambient air causes 500,000 premature …

Efficacy and safety of levosulpiride versus metoclopramide in patients with emesis induced by high doses of salmon calcitonin

Abstract The antiemetic activity of levosulpiride 25 mg IV was compared with that of metoclopramide 10 mg IV in 30 patients with bone metastasis secondary to pulmonary carcinoma who were treated with intravenous salmon calcitonin. In this randomized, double-blind, crossover study, levosulpiride was significantly more effective than metoclopramide in reducing the intensity of nausea and the number of vomiting episodes. No differences were seen when the drugs were administered in the first or second cycle of therapy, indicating that there was no carryover effect of one drug on the other. Levosulpiride was significantly better tolerated than metoclopramide. Not only did levosulpiride induce fewer side effects (11 versus 42 for metoclopramide), but it also reduced the number of undesired events caused by the elevated doses of salmon calcitonin (20 versus 48 for metoclopramide).