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Objective: to summarize the main updated evidence about the health effects of air pollution and to focus on Italian epidemiological experiences on the respiratory effects. Results: The recent literature indicates that there is strong evidence for causal relationships between PM2.5 air pollution exposure and all-cause mortality as well as mortality from acute lower respiratory infections, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lung cancer. A growing body of evidence also suggests causal relationships with type II diabetes and impacts on neonatal mortality from low birth weight and short gestation as well as neurologic effects in both children and adults. Italy, a Southern European country, faces a more threatening air pollution challenge because of the effects of both anthropogenic pollutants and natural dust (particulate matter, PM). The 2020 Report of the European Environment Agency highlighted the number of premature deaths in Italy attributable to main pollutants: 52.300 for PM2.5, 10.400 for NO2 and 3.000 for O3 in 2018. In Italy, original time series and analytical epidemiological studies showed increased cardio-respiratory hospital admissions and mortality and increased risk of respiratory diseases in people living in urban areas. Conclusions: adverse health effects of air pollutants, even at low levels, have been confirmed by recent epidemiological studies. Further studies should focus on the potential link between air pollution exposure and respiratory infections. This topic has become particularly important in the current SARS-COV-2 pandemic. Based on strong scientific evidence, the Italian government, which hosts the Global Alliance against Chronic Respiratory Diseases (GARD)-Italy at the Ministry of Health, the scientific respiratory societies and the patients' associations, as well as others in the health sector and civil society, must increase their engagement in advocacy for clean air policies, especially in light of the new Air Quality Guidelines of the World Health Organization.

Substantial knowledge is available on the association of the indoor school environment and its effect among schoolchildren. In the same context, the SINPHONIE (School indoor pollution and health: Observatory network in Europe) conducted a study to collect data and determine the distribution of several indoor air pollutants (IAPs), physical and thermal parameters and their association with eye, skin, upper-, lower respiratory and systemic disorder symptoms during the previous three months. Finally, data from 115 schools in 54 European cities from 23 countries was collected and included 5175 schoolchildren using a harmonized and standardized protocol. The association between exposures and the health outcomes were examined using logistic regression models on individual indoor air pollutants (IAPs); a VOC (volatile organic compound) score defined as the sum of the number of pollutants to which the children were highly exposed (concentration > median of the distribution) in classroom was also introduced to evaluate the multiexposure – outcome association, while adjusting for several confounding factors. Schoolchildren exposed to above or equal median concentration of PM2.5, benzene, limonene, ozone and radon were at significantly higher odds of suffering from upper, lower airways, eye and systemic disorders. Increased odds were also observed for any symptom (sick school syndrome) among schoolchildren exposed to concentrations of limonene and ozone above median values. Furthermore, the risks for upper and lower airways and systemic disorders significantly increased with the VOCs score. Results also showed that increased ventilation rate was significantly associated with decreased odds of suffering from eye, skin disorders whereas similar association was observed between temperature and upper airways symptoms. The present study provides evidence that exposure to IAPs in schools is associated with allergic and respiratory symptoms in children. Further investigations are needed to confirm our findings. © 2020 Elsevier B.V.

Air pollution is a well-established hazard to human health. Air quality is particularly important for subpopulations that are more susceptible (i.e. children, the elderly, subjects with cardiorespiratory diseases or those who are socioeconomically deprived) or at higher risk of specific exposures (workers exposed to inorganic dust, wood dust, fumes, gases and cleaning agents). Children are particularly vulnerable since they inhale a higher volume of air per body weight than adults, their lungs are growing, their immune system is incomplete and defence mechanisms are still evolving. Air pollution can affect the cells in the lung by damaging those that are most susceptible and, if the damaged cells are important in the development of new functional parts of the lung, the lung may not achieve its full growth and function as a child matures to adulthood. This can lead to enhanced susceptibility during adulthood to the effects of ageing and infections, as well as to pollutants. Air pollution has both short-term (peak exposures) and long-term adverse effects, which can involve not only the pulmonary system but also the cardiovascular system.

Background: asthma underdiagnosis was reported in many recent studies, in particular in older subjects. Aim: to assess the risk factors associated with asthma underdiagnosis in two Italian general population samples. Methods: two general population samples living in Pisa (Central Italy, urban/suburban area) and Po Delta (North Italy, rural area) participated in some cross-sectional studies between 1980 and 2011. Through a questionnaire on health status and risk factors, Pisa sample was investigated in 1985-1988, 1991-1993 and 2009-2011; Po Delta sample was investigated in 1980-1982 and 1988-1991. Individuals reporting asthma symptoms or diagnosis in the previous studies were recently enrolled in a study about severe/uncontrolled asthma (AGAVE study, 2011-2014) using the same study tool. For these analyses, subjects were classified as: remittent (if they didn’t report asthma symptoms in the AGAVE study) (REM); persistent symptomatic (if they reported asthma symptoms but not diagnosis in both previous and AGAVE studies) (SPERS); persistent asthmatic (if they reported asthma diagnosis and symptoms in both previous and AGAVE studies) (APERS). Statistical analyses were performed to assess the risk factors associated with SPERS, a condition interpreted as asthma underdiagnosis. Results: 668 subjects participated in the AGAVE study: 18.6% SPERS, 55.1% REM, 26.3% APERS. Through bivariate analyses, with respect to REM and APERS, SPERS showed a significantly higher frequency of older age, obesity, smoking habits, passive smoke exposure, sleep apnea; moreover, they had a significantly lower level of education. APERS and SPERS, with respect to REM, had a significantly higher frequency of occupational exposure. APERS, with respect to REM and SPERS, showed a significantly higher frequency of living in Pisa area (than in Po Delta area), recurrent respiratory infections, allergic rhinitis, COPD, bronchiectasis, anxiety/depression. A multinomial logistic regression analysis, taking into account REM as reference category, confirmed a strong relationship among SPERS and smoking habits (OR, 95% CI 2.66, 1.42-4.99), older age (2.14, 1.04-4.40 for age >65 yrs), recurrent respiratory infections (2.55, 1.23-5.30), passive smoke exposure (2.57, 1.43-4.62) and sleep apnea (2.60, 1.36-4.99). Moreover, APERS showed a strong relationship with living in Pisa area (vs Po Delta area), (2.22, 1.28-3.83), current respiratory infections (3.92, 2.07-7.41) and allergic rhinitis (3.86, 2.48-5.99). Conclusions: in general population there is higher risk of asthma underdiagnosis in smokers, older subjects, subjects with passive smoke exposure, respiratory infections and sleep apnoea; living in urban/suburban area, respiratory infections and allergic rhinitis are related to persistent asthma. These notions should influence prevention and management strategies.

Background: Several studies have indicated that tobacco smoking changes the intrauterine environment that largely affects fetal growth. Low birth weight due to maternal smoking has been found to increase with maternal diseases like diabetes, maternal weight gain and other associated complications. Additional plausible confounders such as, socio-economic status, ethnic groups, sex of the child, alcohol consumption etc. are also found to have a synergistic effect on birth- weight. The aim of this study was to assess the potential impact of maternal smoking during pregnancy on birth- weight, taking into account clinical information and other related factors. Methods: The study included 17383 individuals from different pre- existing cohorts ( EPITeen, Generation 21, REPROPL, CCM, PHIME and EDEN) across multi- centers of six European countries, namely Portugal, Poland, Italy, Croatia, Slovenia and France respectively. A stratified logistic regression analysis was performed to determine the association between birth-weight and maternal smoking habits. In addition to maternal diseases during pregnancy, the effect of maternal smoking on birth weight was simultaneously controlled for sex of child, maternal weight at the end of pregnancy, maternal drinking habits, ethnic group, work position and educational level of mother, and socio-economic crowding index. Due to the presence of missing values, maximum- likelihood method has been used for multiple imputation in the data. Results: 15.79% of the pregnant mothers were regular smokers, 8.15% of newborns weighed less than 2.5 kg at birth. 7.05% of infants were born with low birth-weight (LBW) in case of non-smoking mothers, whereas 12.44% of LBW infants were documented for mothers who smoked during pregnancy. The number of infants with LBW was found to rise with the increasing number of cigarettes smoked by the mothers during pregnancy. 8.02%, 8.92% and 9.25% of LBW was observed when mothers smoked up to 5, 11 and greater than 11 cigarettes per day respectively. Maternal weight was also found to affect birth weight prominently (OR= 1.06 ; 95% CI = 1.02, 1.11), along with other factors like infectious diseases during pregnancy. After adjusting for confounders, maternal smoking during pregnancy had a significant association with LBW (OR= 1.95 ; 95% CI=1.58, 2.22). Similar findings were observed when sub-samples of the data were considered on the basis of geographic origins. Conclusions: Using large data from pre-existing cohorts of different European countries, our study confirms a prominent birth weight reduction with maternal smoking. This finding supports the biological explanation of placental deformation due to smoking that leads to reduced birth weight and other neonatal complications.

Aim: To evaluate the impact of a medical education course (MEC) on the behaviour of general practitioners (GPs) to treat asthma and allergic rhinitis (AR). Methods: Data on 1820 patients (mean age 41yrs ± 17yrs) with asthma or AR were collected by 107 Italian GPs: 50% attended a MEC and 50% didn't (group B). The adherence for AR and asthma treatment was evaluated according to ARIA and GINA guidelines (GL). Results: AR and asthma were diagnosed in 78% and 56% of patients; 34% had concomitant AR and asthma. Regardless of the MEC, the adherence to GL was significantly higher for AR than for asthma treatment (52 versus 19%). Group B GPs were more compliant to ARIA guidelines in the treatment of mild AR, whereas group A were more compliant in the treatment of moderate-severe AR; the adherence didn't differ between the groups for AR patients with comorbid asthma. Adherence to GINA GL for asthma treatment did not differ between GPs of groups A and B, independently from concomitant AR. Though insignificantly, group A were more compliant to GINA GL in the treatment of patients with only severe persistent asthma (63 versus 46%) as group B were for patients with severe persistent asthma and concomitant AR. Conclusions: GPs often tend to treat patients independently from GL. The impact of a single MEC did not improve adherence to GL in treating less severe AR and asthma patients, while there was a trend towards the opposite attitude in more severe AR patients without concomitant asthma. © 2012 Elsevier Ltd. All rights reserved.

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 (RA), 39.4 had asthma alone. The latter, compared to those with RA, 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 RA 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. © 2012 Informa Healthcare USA, Inc.

Most health care systems consider continuing medical education a potential tool to improve quality of care and reduce disease management costs. Its efficacy in general practitioners needs to be further explored.This study assesses the effectiveness of a one-year continuing medical education/continuing professional development course for general practitioners, regarding the improvement in knowledge of ARIA and GINA guidelines and compliance with them in asthma management.Sixty general practitioners, covering 68,146 inhabitants, were randomly allocated to continuing medical education/continuing professional development (five residential events +four short distance-learning refresher courses over one year) or no training. Participants completed a questionnaire after each continuing medical education event; key questions were repeated at least twice. The Local Health Unit prescription database was used to verify prescription habits (diagnostic investigations and pharmacological therapy) and hospitalizations over one year before and after training.Fourteen general practitioners (46.7%) reached the cut-off of 50% attendance of the training courses. Knowledge improved significantly after training (p0.001, correct answers to key questions +13%). Training resulted in pharmaceutical cost containment (trained general practitioners +0.5% vs. controls +18.8%) and greater attention to diagnosis and monitoring (increase in spirometry +63.4%, p0.01).This study revealed an encouraging impact of educational events on improvement in general practitioner knowledge of guidelines and daily practice behavioral changes. Long-term studies of large populations are required to assess the effectiveness of education on the behavior of physicians in asthma management, and to establish the best format for educational events.

AIM: To evaluate the impact of a medical education course (MEC) on the behaviour of general practitioners (GPs) to treat asthma and allergic rhinitis (AR). METHODS: Data on 1820 patients (mean age 41 yrs ± 17 yrs) with asthma or AR were collected by 107 Italian GPs: 50% attended a MEC and 50% didn't (group B). The adherence for AR and asthma treatment was evaluated according to ARIA and GINA guidelines (GL). RESULTS: AR and asthma were diagnosed in 78% and 56% of patients; 34% had concomitant AR and asthma. Regardless of the MEC, the adherence to GL was significantly higher for AR than for asthma treatment (52 versus 19%). Group B GPs were more compliant to ARIA guidelines in the treatment of mild AR, whereas group A were more compliant in the treatment of moderate-severe AR; the adherence didn't differ between the groups for AR patients with comorbid asthma. Adherence to GINA GL for asthma treatment did not differ between GPs of groups A and B, independently from concomitant AR. Though insignificantly, group A were more compliant to GINA GL in the treatment of patients with only severe persistent asthma (63 versus 46%) as group B were for patients with severe persistent asthma and concomitant AR. CONCLUSIONS: GPs often tend to treat patients independently from GL. The impact of a single MEC did not improve adherence to GL in treating less severe AR and asthma patients, while there was a trend towards the opposite attitude in more severe AR patients without concomitant asthma.

Objective:to analyse the associations between exposure to marine aerosol and/or industrial air pollution and the prevalence of asthma and asthma-like symptoms in a population sample living in Livorno(Tuscany). Methods:using GlS, subjects were geocoded on the basis of their own home address and classified as follows. First classification: distance of the residence from the coastline: 0-300m(more exposed), 300m-1000m(less exposed) and 1000m (controls). Second classification also includes the analysis of the distance from the main industrial pollution sources (thermoelectric power plant,waste incinerator, oil refinery)Subjects were classified in 4 groups:exposed to aerosol and industrial pollution, exposed to aerosol,exposed to industrial pollution,controls. Results:significant associations between living near the coastline(within 300m)and attacks of asthma were reported for women(OR=3.75,95%IC 1.34-10.48 in the first classification, OR =4.51, 95%IC 1.44-14.12 in the second one).In the second classification exposure to aerosol and industrial pollution resulted associated with severe asthma (OR=3.44,95%IC 0.91-12.93)and with chest tightness (OR=2.52,95%IC 1.04-6.12),in women. Living exposed to industrial pollution is associated with chronic cough and phlegm(OR=1.99,95%IC 1.09-3.68),in females. Conclusions:exposure to marine aerosol is associated with asthma,whilst exposure to industrial pollution is associated with bronchitic symptoms.GIS provides added value to environmental epidemiology research. Abstract: In this epidemiological survey a general population sample of Livorno was analysed to study the relationship between living near the sea and health status. In fact exposure to marine aerosol is considered to be a potential risk of respiratory diseases, as pollutants accumulated in the surface micro-layer are conveyed to the atmosphere. By means of GIS technology subjects participating to the survey were geocoded with reference to their home addresses, then they were classified considering zones homogeneous by distance from the coastline. In a second classification we also considered distance from the main industrial pollution sources. Bivariate and multivariate analyses were performed to compare the prevalence of asthma and asthma-like symptoms between exposed and non exposed people. Exposure to marine aerosol resulted associated with asthma, whilst exposure to industrial pollution is associated with bronchitic symptoms. GIS provides added value to environmental epidemiology research.

Objective: traffic-related air pollution is considered to be a potential risk factor for respiratory health. To examine whether distance from main roads has an effect on the incidence of respiratory symptoms/diseases, an approach based on Geographical Information System (GIS) was applied to the epidemiological survey conducted in Pisa-Cascina area (Tuscany) in 1991-93 (2062 subjects, aged 8-97 years).