Sonia Cerrai

Adverse effects of outdoor pollution in the elderly.

With fewer newborns and people living longer, older people are making up an increasing fraction of the total population. Epidemiological evidence shows that older-age-related health problems affect a wide and expanding proportion of the world population. One of the major epidemiological trends of this century is the rise of chronic diseases that affect more elderly than younger people. A total of 3.7 million premature deaths worldwide in 2012 are attributable to outdoor air pollution; the susceptibility to adverse effects of air pollution is expected to differ widely between people and within the same person, and also over time. Frailty history, a measure of multi-system decline, modifies cumulative associations between air pollution and lung function. Moreover, pre-existing diseases may determine susceptibility. In the elderly, due to comorbidity, exposure to air pollutants may even be fatal. Rapid and not-well-planned urbanization is associated with high level of ambient air pollution, mainly caused by vehicular exhausts. In general, there is sufficient evidence of the adverse effects related to short-term exposure, while fewer studies have addressed the longer-term health effects. Increased pollution exposures have been associated with increased mortality, hospital admissions/emergency-room visits, mainly due to exacerbations of chronic diseases or to respiratory tract infections (e.g., pneumonia). These effects may also be modulated by ambient temperature and many studies show that the elderly are mostly vulnerable to heat waves. The association between heat and mortality in the elderly is well-documented, while less is known regarding the associations with hospital admissions. Chronic exposure to elevated levels of air pollution has been related to the incidence of chronic obstructive pulmonary disease (COPD), chronic bronchitis (CB), asthma, and emphysema. There is also growing evidence suggesting adverse effects on lung function related to long-term exposure to ambient air pollution. Few studies have assessed long-term mortality in the elderly. It is still unclear what are the pollutants most damaging to the health of the elderly. It seems that elderly subjects are more vulnerable to particulate matter (PM) than to other pollutants, with particular effect on daily cardio-respiratory mortality and acute hospital admissions. Not many studies have targeted elderly people specifically, as well as specific respiratory morbidity. Most data have shown higher risks in the elderly compared to the rest of the population. Future epidemiological cohort studies need to keep investigating the health effects of air pollutants (mainly cardiopulmonary diseases) on the elderly.

Indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in Europe

Few data exist on respiratory effects of indoor air quality and comfort parameters in the elderly. In the context of the GERIE study, we investigated for the first time the relationships of these factors to respiratory morbidity among elderly people permanently living in nursing homes in seven European countries. 600 elderly people from 50 nursing homes underwent a medical examination and completed a standardised questionnaire. Air quality and comfort parameters were objectively assessed in situ in the nursing home. Mean concentrations of air pollutants did not exceed the existing standards. Forced expiratory volume in 1 s/forced vital capacity ratio was highly significantly related to elevated levels of particles with a 50% cut-off aerodynamic diameter of <0.1 µm (PM0.1) (adjusted OR 8.16, 95% CI 2.24–29.3) and nitrogen dioxide (aOR 3.74, 95% CI 1.06–13.1). Excess risks for usual breathlessness and cough were found with elevated PM10 (aOR 1.53 (95% CI 1.15–2.07) and aOR 1.73 (95% CI 1.17–10.3), respectively) and nitrogen dioxide (aOR 1.58 (95% CI 1.15–2.20) and aOR 1.56 (95% CI 1.03–2.41), respectively). Excess risks for wheeze in the past year were found with PM0.1 (aOR 2.82, 95% CI 1.15–7.02) and for chronic obstructive pulmonary disease and exhaled carbon monoxide with formaldehyde (aOR 3.49 (95% CI 1.17–10.3) and aOR 1.25 (95% CI 1.02–1.55), respectively). Breathlessness and cough were associated with higher carbon dioxide. Relative humidity was inversely related to wheeze in the past year and usual cough. Elderly subjects aged ≥80 years were at higher risk. Pollutant effects were more pronounced in the case of poor ventilation. Even at low levels, indoor air quality affected respiratory health in elderly people permanently living in nursing homes, with frailty increasing with age. The effects were modulated by ventilation. Poor air quality in European nursing homes impairs respiratory health in the elderly permanently living in them http://ow.ly/Es8VQ

COPD management according to old and new GOLD guidelines: an observational study with Italian general practitioners

Abstract Background: Guideline recommendations for COPD management are only partially applied within primary care clinical practice. Objective: To compare the COPD management by Italian general practitioners (GPs) according to either the old GOLD (oGOLD) or the new GOLD (nGOLD) guidelines. Research design and methods: Observational study in different Italian areas. A total of 176 GPs enrolled their patients with a COPD diagnosis. Questionnaires were used to collect data on: COPD symptoms, disease severity, exacerbations, prescribed pharmacological and non-pharmacological treatments. COPD severity was estimated according to oGOLD and nGOLD guidelines. Results: A total of 526 subjects had complete information to assess COPD severity level according to guidelines (symptoms level, spirometry, history of exacerbations). The investigated subjects were more frequently males (71.2%) with a mean age of 72.5 years, and ex-smokers (44.4%). GPs reported sufficient control of the disease in 47.2% of the subjects with over two exacerbations in the last 12 months. Most patients have moderate COPD (51.5%), according to oGOLD, and belong to D groups (high risk, more symptoms) (45.6%), according to nGOLD. Overall, a low use of post-bronchodilator spirometry (65.1%) and of pulmonary rehabilitation (13.4%) was shown. The results highlighted a low prescriptive appropriateness but with higher value according to nGOLD than oGOLD: 61.4% vs 35.6%. Study limitations: Prescription data only provide limited information to judge prescribing quality, thus the results have to be evaluated with caution; moreover, this study was not designed to assess the difference between oGOLD and nGOLD. Conclusions: Guideline recommendations are applied only partially within clinical practice. A higher prescriptive appropriateness is shown by GPs using nGOLD classification. This might be due to the fact that nGOLD, with respect to oGOLD, takes into account anamnestic usual features considered by GPs in their clinical practice.

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.

Respiratory symptoms/diseases prevalence is still increasing: a 25-yr population study

BACKGROUND Few epidemiological surveys on general population samples estimated changes in prevalence of respiratory symptoms/diseases over a long time interval; our study aims to quantify the temporal changes in the prevalence rates of asthma, allergic rhinitis and Chronic Obstructive Pulmonary Disease (COPD) after 25 years from baseline. METHODS A general population sample participated in 3 cross-sectional surveys carried out in Central Italy (Pisa) in 1985-88 (n = 3865), 1991-93 (n = 2841), 2009-11 (n = 1620). 2276 (47%) subjects participated in at least 1 survey, 1723 (35.5%) in at least 2 surveys and 849 (17.5%) in all the 3 surveys. All subjects filled in a standardized questionnaire about health status and risk factors; a sub-sample performed spirometry. Chi-square test was used to compare adjusted prevalence rates of respiratory symptoms/diseases and descriptive characteristics among the surveys. Generalised estimating equations (GEE) were used to analyze the association between respiratory symptoms/diseases and risk factors. RESULTS There was an increasing trend in prevalence rates of all respiratory symptoms/diseases throughout the surveys: current asthma attacks (1st-3rd survey prevalence: 3.4-7.2%), allergic rhinitis (16.2-37.4%), usual phlegm (8.7-19.5%) and COPD (2.1-6.8%) more than doubled. The GEE model confirmed these increasing trends, indicating higher risk of having respiratory symptoms/diseases in the second and third surveys. CONCLUSIONS While asthma and allergic rhinitis increasing trends were confirmed, with respect to other international studies, also a COPD increasing prevalence rates was shown.

The ARGA study with Italian general practitioners: prescriptions for allergic rhinitis and adherence to ARIA guidelines

Abstract Background: General practitioners (GPs) are the healthcare professionals to whom patients with rhinitis firstly refer for their symptoms. Objective: In the present study, we assessed drug prescriptions for allergic rhinitis (AR) and evaluated prescriptive adherence to ARIA treatment guidelines. Methods: Data on 1379 AR patients were collected by 107 Italian GPs. Adherence to ARIA guidelines was evaluated according to AR severity classification. Results: AR was diagnosed by GPs as mild intermittent for 46.2% of patients, mild persistent for 26.6%, moderate–severe intermittent for 20.2%, and moderate–severe persistent for 7%; 43.7% of AR patients had concomitant asthma. The most frequently prescribed therapeutic groups were antihistamines (anti-H, 76%) and nasal corticosteroids (NCS, 46%). Anti-H were significantly used more often to treat AR alone than AR + asthma (85 vs. 68%, p < 0.001), whereas NCS were used more often to treat AR + asthma than AR alone (50 vs. 42%, p = 0.01). Among patients with only mild intermittent AR, 39% were prescribed combined therapy. Among patients with moderate–severe persistent AR, 30% of those with AR alone and 18% of those with AR + asthma were prescribed monotherapy based on anti-H. GPs were more compliant with ARIA guidelines while treating AR alone (57%) than AR + asthma (46%) patients. The adherence increased according to the severity grade and was satisfactory for moderate–severe persistent AR (89% for AR alone and 95% for AR + asthma). Conclusions: Adherence to ARIA guidelines is satisfactory only for treatment of more severe patients, thus GPs often tend to treat patients independently from ARIA guidelines. Since prescription data only provide limited information to judge prescribing quality, some deviation from the gold standard are to be expected.

Atopy as a predictor of allergic respiratory diseases in an Italian general population sample

Rationale: in recent decades, there has been an increase in the prevalence of allergic respiratory diseases. Aim: to evaluate the role of atopy as a risk factor for developing allergic respiratory diseases in an Italian general population sample surveyed twice 18 years apart. Methods: a general population sample participated in a prospective cohort study carried out in Pisa in 1991-93 (n=2841) and 2009-11 (n=1620). 987 subjects participated in both surveys completing twice a standardized questionnaire on health status and risk factors and undergoing prick tests at baseline. By logistic regression models we assessed the association of atopy (skin test positivity (STP): wheal >5mm) with incidence of allergic respiratory diseases, adjusting for: age, sex, exposure to environmental pollution sources, urban/suburban residence, asthma familiarity, allergic rhinitis familiarity. Results: STP prevalence was 17.5%, mainly to pollens (9.5%) and dust mites (8.1%). Allergic rhinitis (AR) and AR symptoms incidence were significantly linked to cumulative SPT [OR 5.40 (95% CI 3.06-9.55) and 2.00 (1.28-3.13), respectively], to pollen STP [3.55 (1.53-8.23) and 2.37 (1.18-4.75), respectively] and to moulds STP [5.95 (1.58-22.45) for only AR). Asthma diagnosis/symptoms incidence was significantly linked to dust mites STP [2.81 (1.09-7.23)]. Conclusions: our longitudinal study shows that atopic sensitization is a predictive factor of the risk of developing allergic respiratory diseases, with seasonal allergens linked to AR and perennial allergens (dust mites) to asthma. These results may be useful for preventive strategies.

COPD symptoms/diagnoses and work exposure: A 20 years population-based survey

Background: work exposure to fumes/gases/chemicals is associated with COPD symptoms/diagnosis but few epidemiological surveys on general population samples estimated such relationship over a long time interval. Objectives: to assess the association between long term work exposure to fume/gas/chemicals and COPD symptoms/diagnosis over a 20 yrs period. Methods: a general population sample participated in 2 surveys carried out in Pisa in 1991-93 and 2009-11. A standardised questionnaire on health status and risk factors was used. Chi-square test was used to compare long term work exposure [ever exposed (EE), at least once exposed (ATOE), never exposed (NE)] and the change in COPD symptoms/diagnosis from the 1st to the 2nd survey (COPD symptoms: persistent/incident vs never/remittent; COPD diagnosis: persistent/incident vs never/remittent). Logistic regression models (LRM) were run to analyse the association between persistent/incident COPD symptoms/diagnosis and work exposure adjusted for gender, age, smoking habits, asthma symptoms/diagnosis at the 1st survey, smoking habits and lifetime passive smoke exposure. Results: there were 1107 longitudinal subjects: 27.5% EE, 30.4% ATOE and 42.1% NE. LRM showed a significantly higher risk of having persistence/onset of: COPD diagnosis (OR=2.4, 95%CI=1.4-3.9), dyspnoea (OR=2.0, 95%CI=1.4-2.9), usual phlegm (OR=2.2, 95%CI=1.5-3.3), usual cough (OR= 1.6, 95%CI=1.0-2.3), in EE; dyspnoea (OR=1.7, 95%CI=1.2-2.3), usual phlegm (OR=1.5, 95%CI=1.1-2.2) in ATOE. Conclusions: our findings indicate a longitudinal association between work exposure and COPD. There is a need for the EU to implement effective strategies for COPD prevention in work settings.

Odor annoyance perception and health effects in an Italian general population sample

Background: Recently, there has been a growing interest about the emission of unpleasant odors due to their potential health impacts. Aim: to evaluate the associations between odor annoyance perception and health in neighbors of Pisa waste incinerator. Methods: the circular study area, centered on the incinerator, was divided in 5 rings, with radius 0.4, 0.8, 1.4, 2.7, 4.0, for sampling subjects according to household residence. Controls were randomly chosen outside the study area. 1407 subjects filled out a self-administered standardized questionnaire on respiratory symptoms/diseases, cancer, cardiovascular diseases, risk factors and odor annoyance levels (no, slightly annoying, very annoying). Results: prevalence rates of odor annoyance perception in 1407 subjects participating in the survey (50% males, mean age 44 ± 22 yrs) were: 39.8% no odor perceived;19.1% slightly annoying odors; 41.2% very annoying odors. By multivariate analysis, adjusted for independent effects ofgender, age, residence-incinerator distance, education, working position, active and passive smoking, residence duration, occupational exposure, odor annoyance perception was significantly associated with the following respiratory symptoms/diseases: phlegm (OR 2.13, 95%CI 1.40-3.23), cough (OR 2.54, 95%CI 1.74-3.71), Chronic Obstructive Pulmonary Disease (OR 1.88, 95%CI 1.01-3.48), dyspnea (OR 1.89, 95%CI 1.33-2.67), asthma (OR 1.95, 95%CI 1.14-3.35), asthma symptoms (OR 1.85, 95%CI 1.23-2.78) and allergic rhinitis (OR 1.53, 95%CI 1.05-2.24). Conclusion: Our study shows an association among respiratory effects and odor annoyance perception, which thus might be used as a proxy of environmental air pollution exposure.