Sandra Baldacci

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

BackgroundTraffic-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.MethodsWe 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.ResultsThe 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.ConclusionThis 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.

Clinical vs. structured interview on anxiety and affective disorders by primary care physicians. Understanding diagnostic discordance

AIMSnTo assess in a national sample the ability of GPs to detect psychiatric disorders using a clinical vs. a standardized interview and to characterize the patients that were falsely diagnosed with an anxiety or affective disorder.nnnMETHODSnThis is a national, cross-sectional, epidemiological survey, carried out by GPs on a random sample of their patients. The GPs were randomly divided into two groups. Apart from the routine clinical interview, the experimental group (group A) had to administer the Mini-International Neuropsychiatric Interview (MINI).nnnRESULTSnData was collected by 143 GPs. 17.2% of all patients had a clinical diagnosis of an affective disorder, and 25.4% a clinical diagnosis of an anxiety disorder. In group A, the number of clinical diagnoses was about twice that of MINI diagnoses for affective disorders and one and a half times that for anxiety disorders. The majority of clinical diagnoses were represented by MINI subsyndromal cases (52.3%). Females showed a higher OR of being over-detected by GPs with anxiety disorders or of not being diagnosed with an affective disorder. Being divorced/separated/widowed increased the OR of over-detection of affective and anxiety disorders. The OR of over-detection of an affective or an anxiety disorder was higher for individuals with a moderate to poor quality of life.nnnCONCLUSIONSnIn the primary care a gap exists between clinical and standardized interviews in the detection of affective and anxiety disorders. Some experiential and social factors can increase this tendency. The use of a psycho.

Urban Residence Is Associated With Bronchial Hyperresponsiveness in Italian General Population Samples

BACKGROUNDnThe role of different risk factors for bronchial hyperresponsiveness (BHR), such as gender, atopy, IgE, and environmental factors (smoking, occupational exposure, infections), has been described. Indoor and outdoor pollution play an important role too, but few studies have analyzed the association with BHR. The aim of this study was to assess the effect of urban residence on BHR.nnnMETHODSnWe studied two general population samples enrolled in two cross-sectional epidemiological studies performed in Northern Italy (Po Delta, rural area) and Central Italy (Pisa, urban area). We analyzed 2,760 subjects (age range, 8 to 74 years). We performed analysis of variance and logistic regression analysis using ln slope of the dose-response curve of the methacholine challenge test as dependent variable, and sex, age, smoking habits, respiratory symptoms, skin-prick test results, IgE value, residence, and airway caliber as independent variables.nnnRESULTSnThe mean value of ln slope of the dose-response curve adjusted for initial airways caliber (by baseline FEV(1) percentage of predicted value) was significantly higher in female subjects, in smokers, in subjects with respiratory symptoms, in younger and older ages, in subjects with high values of IgE, and in subjects with positive skin-prick test results. After controlling for the independent effects of all these variables, living in urban area was an independent risk factor for having BHR (odds ratio, 1.41; 95% confidence interval, 1.13 to 1.76).nnnCONCLUSIONnLiving in urban area is a risk factor for increased bronchial responsiveness.

The global burden of chronic respiratory diseases

Key points Currently, the serious consequences of chronic diseases and their risk factors are not fully recognised by the international health community. In the period of 1990–2020, COPD deaths are expected to increase from 2.2 to 4.7 million worldwide. Reducing chronic disease death rates by an additional 2% annually would avert 36 million deaths by 2015. The abatement of the main risk factors for respiratory diseases, in particular tobacco smoking, environmental tobacco smoke, indoor biomass fuels, outdoor air pollution and unhealthy diet, can achieve huge health benefits. Educational aims To define the burden of chronic respiratory diseases all over the world. To underline the importance of chronic diseases recognition by the international health community. To provide details about the burden of chronic obstructive pulmonary disease (COPD): the predicted third cause of death by 2020. Summary Currently, the serious consequences of chronic diseases and their risk factors are not fully recognised by the international health community. Moreover, chronic diseases are not only a problem of the ageing population in developed countries. In fact, it has been estimated that 80% of mortality for chronic diseases occurred in low-income and middleincome countries in 2005. Thus, the World Health Organization (WHO) Dept of Chronic Diseases and Health Promotion has suggested a new Millennium Development Goal for the next few years: to reduce chronic disease death rates by an additional 2% annually, in order to avert 36 million deaths by 2015.

COPD, smoking behaviour, and the importance of teachers as role-models for adolescents

Chronic obstructive pulmonary disease (COPD) has been described by the ATS (American Thoracic Society)/ERS (European Respiratory Society) guidelines [1] as a disease characterized by airflow limitation that is not fully reversible. The diagnosis of COPD should be considered in any patient who experiences cough, sputum production, or dyspnea in association with specific risk factors, which for the vast majority is cigarette smoking [2,3]. COPD has long been acknowledged as a major cause of respiratory disability, but the magnitude of its impact has been only recently recognized. According to the World Health Organization, COPD will reach the 3rd rank as cause of mortality [4] and 7th rank as cause of disability by 2030 worldwide [5]. COPD represents a huge burden for the healthcare systems and causes increasing costs to society due to absence from work, visits to the doctors clinic, medication, and hospital admissions. The socio-economic burden from COPD is also expected to increase. n nRecently, the Burden of Obstructive Lung Disease (BOLD) Initiative measured the prevalence of COPD and its risk factors in 12 cities all over the world. Prevalence rates of GOLD-defined COPD stage II or higher (i.e. forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) 40 years [6]. n nWithin the Northern Ireland Cost and Epidemiology of Chronic Obstructive Pulmonary Disease (NICE-COPD) study on a general population sample in the Greater Belfast area, the prevalence of COPD varied from 4.9% (40-49 years) to 12.3% (60-69 years) in men and from 1.4% (40-49 years) to 4.5% (60-69 years) in women [7]. Data collected in a general population sample living in North Italy showed a progressive increase of the prevalence of chronic bronchitis and emphysema with age in both males and females, reaching values of 16% for chronic bronchitis and 7% for emphysema in males aged > 64 years [8]. Moreover, in the general adult population sample living in North Italy, airway obstruction (computed using the GOLD criterion) was present in 18.3%, varying from 9.9% (25-45 years) to 28.7% (> 45 years) [9]. n nThe growing burden of COPD is mainly due to the aging of the worlds population and to the continued use of tobacco [10]. Since the majority of smokers start smoking at adolescent age, the influence of society is important at this period, and in particular the school setting (above all teacher behaviour) could be crucial for adolescents future lifestyle. Unfortunately, the smoking rate of teachers is high and it is thought that also the COPD prevalence could be high in this category. For these reasons, Baris et al. performed a study, reported in the current issue of Multidisciplinary Respiratory Medicine (pag. 92-96), to evaluate smoking habit and COPD prevalence of teachers working in the schools of Kocaeli City (Turkey). The study was conducted in 660 teachers, with a mean age 38.9 ± 8.9 years, who filled out a questionnaire and performed a pulmonary function test. A high prevalence of smoking habits was found: 44.1% of the teachers were smokers, 17.7% ex-smokers. There was a higher prevalence of smokers and ex-smokers, a longer smoking history and a higher daily mean number of cigarettes smoked in males than in females. As regards the pulmonary function test, 1.7% of the teachers resulted obstructed according to GOLD criteria (FEV1/FVC < 70%); 18% were females and 82% males. These results highlight not only the high smoking rate, but also an apparently non negligible COPD prevalence in a population of young adults. n nMany recent studies, aimed at assessing the COPD prevalence, have focused on subjects older than 40 years, showing high prevalence rates ranging from about 5% to 20% [6,7,11]. The prevalence rate reported by Baris et al. is lower (1.7%), but it refers to younger subjects (with a mean age under 40 years) and with a quite low daily cigarette consumption among smokers (5.7 cigarettes/day). Indeed, this result is similar to the findings of the European Community Respiratory Health Survey, performed in a sample of young adults (20-44 years): 2.0% of the subjects had a FEV1/FVC ratio less than 70% [12]. In addition, Baris et al. reported a non negligible proportion of teachers with small airways disease (17.7%). n nThe higher COPD prevalence in males confirms the findings of other authors [7,12]; it could be due to the different smoking pattern of males (higher prevalence of smokers, longer history of smoking, higher number of daily cigarettes) with respect to females; however, it should be noted that recent studies have suggested an increasing risk of COPD in females due to their increasing smoking habits in the last decades [6]. n nA comment is necessary on the choice of Baris et al. to use the GOLD criterion for the definition of obstructed subjects. This fact could be one of the reasons for the low value of COPD prevalence found in their study; indeed the fixed cut-off of FEV1/FVC < 70% can lead to an underestimation of airflow obstruction in younger subjects with respect to the ERS-ATS recommended criterion [11]. n nThis aspect was considered also in the study by de Marco et al. [12], who evaluated the role of symptoms and smoking habits in predicting the main clinical outcomes in subjects with mild/moderate airflow obstruction, computed using the lower limit of normality (LLN) or the GOLD criterion: airflow obstruction at baseline, in smokers and subjects with respiratory symptoms, was associated with a steeper lung function decline and a higher rate of hospitalization for respiratory causes. The results were the same when using the LLN or the GOLD definition. In particular, the GOLD and the LLN were associated with long-term outcomes and had a similar rate of false positives. Neither of them predicted outcomes in non-smokers and asymptomatic subjects with airflow obstruction. Furthermore, the fact that the GOLD criterion identified a smaller number of obstructed young adults (2.0% vs. 6.2%) and was more strongly associated with the two studied outcomes than the LLN criterion highlighted the fact that the former has a higher specificity and a lower sensitivity than the latter and vice versa. In conclusion, the findings reported by Baris et al. highlight the need for educational programs encouraging smoking cessation targeted to this professional group, not only for their personal health protection but also in view of their importance as a role-model for adolescents. Moreover, this study confirms the importance for young smokers of seeking assessment of lung function. The identification of early cases of obstruction, including small airways disease, supports early smoking cessation, the most important action proven to reduce risk of severe outcome of the disease and to identify subjects with a possible worse long-term prognosis.