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Acute exacerbation of Idiopathic Pulmonary Fibrosis (AE-IPF) represents an acute, clinically significant respiratory deterioration of unidentifiable cause with high mortality. The potential role of air pollution on this devastating event in the progress of IPF has not been yet elucidated. This study aims to determine the association between air pollution exposure and AE-IPF. All consecutive IPF patients referred to our department from October-2013 to October-2016 were studied. Demographic, functional data and AE-IPF events were recorded. Blood levels of IL-6 and IL-8 were measured. Air pollution exposures were assigned to each patient retrospectively, for ozone, nitrogen dioxide and particulate matter, based on geo-coded residential addresses. Logistic regression models and Spearman correlation were used to assess air pollutants’ association with AE-IPF and pro-inflammatory mediators. A total of 94 IPF (43 AE-IPF) patients were included in the analysis. AE-IPF patients presented significantly higher levels of IL-6 and IL-8 compared to stables. A positive, non-significant association, between AE-IPF and a 10 μg/m 3 increase in previous year mean level of NO 2 (OR=1.021, 95% CI 0.825-1.265) and O 3 (OR=1.002, 95% CI 0.769-1.305) as well as short-term exposure to NO 2 (OR Lag0-1 =3.024, 95% CI 0.631-14.498; OR antecedent month =3.586, 95% CI 0.565-22.741; OR antecedent 6weeks =3.554, 95% CI 0.470-26.860) was found. A significant positive association was observed between IL-8 and NO 2 whilst a negative one with O 3 for all patients. There is some indication that short as well as long term exposure to increased concentrations of air pollutants is associated to AE-IPF. Studies with more patients to achieve appropriate statistical power are needed.

Background There have been contradicting reports in the literature regarding the impact of pleural fluid aspiration on patients’ oxygenation. The aim of this study was to assess the role of the initial size of effusion on post-drainage oxygenation. Methods We studied 122 patients, aged (mean±SD) 61.2±16.8 years, with unilateral pleural effusion and no remarkable parenchymal lesion, by determining PaO2, PaCO2 and [A−a] PaO2 just before thoracocentesis (T1), 30 min after its completion (T2) and 48 hours after the procedure (T3). Patients were divided into group A (75 patients) with small and moderate sized effusions and group B (47 patients) with large and massive effusions. The position of the meniscus line on the posteroanterior film, being arbitrarily set at just above the upper costal margin of the sixth anterior rib, was used to divide the two groups. Patients were studied at rest, breathing room air in the sitting position. Repeated measures ANOVA (related samples) and the Friedman test when the normality assumption was violated were used. Results In group A, at T3, PaO2(mm Hg) showed a statistically significant increase versus T1 (p Conclusion Patients with smaller effusions showed a small improvement in their oxygenation 48 hours post-thoracocentesis (T3). Patients with larger effusions exhibited a transient reduction in their oxygenation immediately after fluid removal (T2).

Following the implementation of three successive European Directives during the 1990s to reduce the sulphur content of fuels, background SO2 concentrations in European cities have fallen substantially. We investigated the magnitude of the short-term associations between daily SO2 concentrations and mortality during the various phases of legislation. Daily counts of all-cause and cause-specific mortality, SO2 concentration, temperature and humidity were obtained for 20 European cities participating in the Aphekom project during 1990–2008. Poisson regression was used to estimate the city-specific risks of death associated with changes in SO2 concentrations for the time periods before legislation and subsequent periods following the implementation of the three European Directives. City-specific risk estimates were pooled using meta-regression. We also estimated the health impact associated with changes in SO2 concentrations during these pre-and post-implementation periods. During the study period, 10 μg/m3 increases in SO2 levels were associated with increases in all-cause (0.53 %), respiratory (0.49 %) and cardiovascular (0.72 %) mortality. We found no evidence of changes in the SO2 concentration–response function across the implementation periods. We estimated, annually, a total of 639, 1,093 and 1,616 premature deaths across the 14 EU cities as result of respective reductions in SO2 concentrations in each of the three implementation periods. Our study suggests that the linear relationship between daily SO2 concentrations and mortality has remained unaltered despite substantial reductions in ambient concentrations in recent years arising from EU directives to limit sulphur content in fuel. This linearity suggests that new legislation to reduce SO2 concentrations further will bring about additional public health benefits.

This study reports on the assessment of a multivariate heat wave vulnerability index (HVI) developed for London, United Kingdom. The HVI is assessed in terms of its ability to predict whether mortality and ambulance callout attain above average levels during heat wave events. Three approaches to assessment were adopted: 1) calculation of categorical statistics and associated skill scores for the dichotomous situation that above average mortality or ambulance callout occurred or not, 2) the degree to which relative risk of the aforementioned health outcomes changed with an increase in heat vulnerability as established using Poisson regression analysis, and 3) an independent samples test of the difference of mean mortality and ambulance callout between census units with and without high heat exposure and high vulnerability. The assessment results reveal that the HVI and a simple single variable index that represents age as a heat risk factor (the elderly index) offer potential as a priori indicators of the level of ambulance callout and mortality for all summer days and heat wave events, respectively. Based on the assessment results the utility of the HVI for heat risk management is discussed.

Heat waves and air pollution are both associated with increased mortality. Their joint effects are less well understood.We explored the role of air pollution in modifying the effects of heat waves on mortality, within the EuroHEAT project. Daily mortality, meteorologic, and air pollution data from nine European cities for the years 1990-2004 were assembled. We defined heat waves by taking both intensity and duration into account. The city-specific effects of heat wave episodes were estimated using generalized estimating equation models, adjusting for potential confounders with and without inclusion of air pollutants (particles, ozone, nitrogen dioxide, sulphur dioxide, carbon monoxide). To investigate effect modification, we introduced an interaction term between heat waves and each single pollutant in the models. Random effects meta-analysis was used to summarize the city-specific results.The increase in the number of daily deaths during heat wave episodes was 54% higher on high ozone days compared with low, among people age 75-84 years. The heat wave effect on high PM10 days was increased by 36% and 106% in the 75-84 year and 85+ year age groups, respectively. A similar pattern was observed for effects on cardiovascular mortality. Effect modification was less evident for respiratory mortality, although the heat wave effect itself was greater for this cause of death. The heat wave effect was smaller (15-30%) after adjustment for ozone or PM10.The heat wave effect on mortality was larger during high ozone or high PM10 days. When assessing the effect of heat waves on mortality, lack of adjustment for ozone and especially PM10 overestimates effect parameters. This bias has implications for public health policy.

Introduction Controversy exists about the pathogenesis of idiopathic pulmonary fibrosis acute exacerbations (IPF-AEs). According to one hypothesis IPF-AEs represent the development of any etiology diffuse alveolar damage (DAD) upon usual interstitial pneumonia (UIP), whilst other researchers argue that an accelerated phase of the intrinsic fibrotic process of unknown etiology prevails, leading to ARDS. Different cytokines might be involved in both processes. The aim of this study was to assess pro-inflammatory and pro-fibrotic cytokines in the peripheral blood from stable and exacerbated IPF patients. Methods Consecutive IPF patients referred to our department were included. Diagnoses of IPF and IPF-AE were based on international guidelines and consensus criteria. The interleukins (IL)-4, IL-6, IL-8, IL-10, and IL-13 as well as active transforming growth factor-beta (TGF-β) were measured in blood from both stable and exacerbated patients on the day of hospital admission for deterioration. Subjects were followed for 12 months. Mann-Whitney test as well as Tobit and logistic regression analyses were applied. Results Among the 41 patients studied, 23 were stable, and 18 under exacerbation; of the latter, 12 patients survived. The IL-6 and IL-8 levels were significantly higher in exacerbated patients (p = 0.002 and p = 0.046, respectively). An increase in either IL-6 or IL-8 by 1 pg/ml increases the odds of death by 5.6% (p = 0.021) and 6.7% (p = 0.013), respectively, in all patients. No differences were detected for the other cytokines. Conclusion High levels of IL-6 and IL-8 characterize early-on IPF-AEs and an increase in the levels of IL-6 and IL-8 associates with worse outcome in all patients. However, as the most representative pro-fibrotic cytokines, TGF-β, IL-10, IL-4 and IL-13 were not increased and given the dualistic nature, both pro-inflammatory and pro-fibrotic of IL-6 further studies are necessary to clarify the enigma of IPF-AEs etiopathogenesis.

The precise pathogenetic mechanisms and the potential role of uncontrolled fibroblastic proliferation or occult infection in IPF acute exacerbations need clarification. The aim of the study was the assessment of profibrotic and proinflammatory profile in both stable and excacerbated patients and their association to outcome. Stable or exacerbated patients referred to our department from October 2013 until November 2014 were included. IL-6, IL-8 and TGF-b were measured. All patients were followed up for 12 months. Tobit and logistic regression analysis were applied. Forty-one patients were included in the study [18 exacerbated, median age (IQR) 68.5 (67.0, 78.0) and 23 with stable IPF, median age (IQR) 71.0 (69.0, 74.0)]. Exacerbated patients presented higher plasma levels of IL-6 and IL-8 compared to those with stable IPF [median (IQR) 6.2 (3.2, 26.5) vs 2.1 (1.0, 4.4) pg/ml, p=0.002; median (IQR) 16.5 (12.9, 44.8) vs 10.1 (7.9, 13.2) pg/ml, p=0.046, respectively]. Most of the differences were independent to age, smoking status, procalcitonin, CRP, corticosteroid and oxygen treatment. No significant differences were observed in the profibrotic cytokine TGF-b between the two groups. An increase of IL-6 or IL-8 by 1 pg/ml increased the odds of death by 5,6% (p=0.021) and 6,7% (p=0.013) respectively in all patients and by 3,8% (p=0.093) and 4,3% (p=0.078) in exacerbated patients. The increased plasma levels of IL-6 and IL-8 found in exacerbated patients compared to stable suggest the presence of inflammation that may also relate to occult infection. Furthermore, our results indicate that plasma levels of IL-6 and IL-8 are associated with increased risk of death in all.

Introduction: High temperatures and heat waves are associated with large increases in mortality, especially among susceptible individuals living in urban areas. Although large multi-city studies ha...

Cardiovascular events may occur even after complete revascularization in patients with coronary artery disease. We measured preoperative osteopontin (OPN) levels in 131 consecutive patients (66.5±10years old, 117 men and 14 women) with left ventricular ejection fraction of50.7±9.2%and low logistic EuroScore (3.5±3.2%) undergoing elective Coronary Artery Bypass Grafting (CABG) surgery. Patients were prospectively followed up for a median of 12 months (range 11–24). The primary study endpoint was the composite of cardiovascular death, nonfatal myocardial infarction, need for repeat revascularization, and hospitalization for cardiovascular events. Pre-op OPN plasma levels were 77.9 (49.5, 150.9). Patients with prior acute myocardial infarction (AMI) had significantly higher OPN levels compared to those without [131.5 (52.2, 219) versus 73.3 (45.1, 125),p=0.007]. OPN levels were positively related to EuroScore (r=0.2,p=0.031). Pre-op OPN levels did not differ between patients who had a major adverse event during follow-up compared to those with no event (p=0.209) and had no effect on the hazard of future adverse cardiac events [HR (95% CI): 1.48 (0.43–4.99),p=0.527]. The history of AMI was associated with increased risk of subsequent cardiovascular events at follow-up (p=0.02). OPN is associated with preoperative risk assessment prior to low-risk CABG but did not independently predict outcome.

Background: Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients. Methods: Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. Results: The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68–5.95] (first meta-analysis) and 5.26% (95% CI: 3.47–7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P

Particulate matter (PM) from traffic and other sources has been associated with adverse health effects. One unifying theory is that PM, whatever its source, acts on the human body via its capacity to cause damaging oxidation reactions related to its content of pro-oxidants components. Few epidemiological studies have investigated particle oxidative potential (OP) and health. We conducted a time series analysis to assess associations between daily particle OP measures and numbers of deaths and hospital admissions for cardiovascular and respiratory diseases.During 2011 and 2012 particles with an aerodynamic diameter less than 2.5 and 10μm (PM2.5 and PM10 respectively) were collected daily on Partisol filters located at an urban background monitoring station in Central London. Particulate OP was assessed based on the capacity of the particles to oxidize ascorbate (OP(AA)) and glutathione (OP(GSH)) from a simple chemical model reflecting the antioxidant composition of human respiratory tract lining fluid. Particulate OP, expressed as % loss of antioxidant per μg of PM, was then multiplied by the daily concentrations of PM to derive the daily OP of PM mass concentrations (% loss per m(3)). Daily numbers of deaths and age- and cause-specific hospital admissions in London were obtained from national registries. Poisson regression accounting for seasonality and meteorology was used to estimate the percentage change in risk of death or admission associated with an interquartile increment in particle OP.We found little evidence for adverse associations between OP(AA) and OP(GSH) and mortality. Associations with cardiovascular admissions were generally positive in younger adults and negative in older adults with confidence intervals including 0%. For respiratory admissions there was a trend, from positive to negative associations, with increasing age although confidence intervals generally included 0%.Our study, the first to analyse daily particle OP measures and mortality and admissions in a large population over two years, found little evidence to support the hypothesis that short-term exposure to particle OP is associated with adverse health effects. Further studies with improved exposure assessment and longer time series are required to confirm or reject the role of particle OP in triggering exacerbations of disease.

Dental implants in partially edentulous patients are a predictable therapeutic option. In patients with reduced bone volume, tooth-to-implant connected prostheses have been described as a treatment option. In this systematic review, the incidence of biologic and technical complications and the long-term survival rates of tooth-implant supported fixed partial dentures (FPDs) are analyzed. In cases where a natural tooth is connected with an implant to support a FPD, a rigid connection should be preferred.

The climate and vegetation of the greater Athens area (population over three million) make forest fires a real threat to the environment during the summer. A few studies have reported the adverse health effects of forest fires, mainly using morbidity outcomes. The authors investigated the short-term effects of forest fires on non-accidental mortality in the population of Athens, Greece, during 1998-2004.The authors used generalised additive models to investigate the effect of forest fires on daily mortality, adjusting for time trend and meteorological variables, taking into account air pollution as measured from fixed monitors. Forest fires were classified by size according to the area burnt.Small fires do not have an effect on mortality. Medium sized fires are associated with an increase of 4.9% (95% CI 0.3% to 9.6%) in the daily total number of deaths, 6.0% (95% CI -0.3% to 12.6%) in the number of cardiovascular deaths and 16.2% (95% CI 1.3% to 33.4%) in the number of respiratory deaths. Cardiovascular effects are larger in those aged75 years, while respiratory effects are larger in older people. The corresponding effects of the one large fire are: 49.7% (95% CI 37.2% to 63.4%), 60.6% (95% CI 43.1% to 80.3%) and 92.0% (95% CI 47.5% to 150.0%). These effects cannot be completely explained by an increase in ambient particle concentrations.Forest fires have an immediate effect on mortality, not associated with accidental deaths, which is a significant public health problem, especially if the fire occurs near a densely populated area.

BACKGROUND: Epidemiologic studies show that high temperatures are related to mortality, but little is known about the exposure-response function and the lagged effect of heat. We report the associations between daily maximum apparent temperature and daily deaths during the warm season in 15 European cities. METHODS: The city-specific analyses were based on generalized estimating equations and the city-specific results were combined in a Bayesian random effects meta-analysis. We specified distributed lag models in studying the delayed effect of exposure. Time-varying coefficient models were used to check the assumption of a constant heat effect over the warm season. RESULTS: The city-specific exposure-response functions have a V shape, with a change-point that varied among cities. The meta-analytic estimate of the threshold was 29.4 degrees C for Mediterranean cities and 23.3 degrees C for north-continental cities. The estimated overall change in all natural mortality associated with a 1 degrees C increase in maximum apparent temperature above the city-specific threshold was 3.12% (95% credibility interval = 0.60% to 5.72%) in the Mediterranean region and 1.84% (0.06% to 3.64%) in the north-continental region. Stronger associations were found between heat and mortality from respiratory diseases, and with mortality in the elderly. CONCLUSIONS: There is an important mortality effect of heat across Europe. The effect is evident from June through August; it is limited to the first week following temperature excess, with evidence of mortality displacement. There is some suggestion of a higher effect of early season exposures. Acclimatization and individual susceptibility need further investigation as possible explanations for the observed heterogeneity among cities.

The authors investigated whether neutrophil to lymphocyte ratio (N/L) can contribute to the diagnosis and risk assessment in patients with type A acute aortic dissection (AAD).The authors studied 120 consecutive patients with type A AAD (group I) and compared them with 121 consecutive patients with chronic aneurysms (group II) and 121 age- and sex-matched healthy subjects (group III).It was found that white blood cell count, N/L, D-dimer and C-reactive protein were significantly higher in group I versus both groups II and III (p0.001 for all comparisons). White blood cell count and D-dimer were much higher in patients who died compared to survivors in group I (p = 0.023 and p = 0.033, respectively). A cutoff value of N/L4.6 was associated with 0.89 sensitivity and 0.91 specificity for AAD.High N/L may contribute to the diagnostic evaluation and prompt immediate therapy in patients with type A AAD.

Epidemiological studies have linked daily concentrations of urban air pollution to mortality, but few have investigated specific traffic sources that can inform abatement policies. We assembled a database of >100 daily, measured and modelled pollutant concentrations characterizing air pollution in London between 2011 and 2012. Based on the analyses of temporal patterns and correlations between the metrics, knowledge of local emission sources and reference to the existing literature, we selected, a priori, markers of traffic pollution: oxides of nitrogen (general traffic); elemental and black carbon (EC/BC) (diesel exhaust); carbon monoxide (petrol exhaust); copper (tyre), zinc (brake) and aluminium (mineral dust). Poisson regression accounting for seasonality and meteorology was used to estimate the percentage change in risk of death associated with an interquartile increment of each pollutant. Associations were generally small with confidence intervals that spanned 0% and tended to be negative for cardiovascular mortality and positive for respiratory mortality. The strongest positive associations were for EC and BC adjusted for particle mass and respiratory mortality, 2.66% (95% confidence interval: 0.11, 5.28) and 2.72% (0.09, 5.42) per 0.8 and 1.0 μg/m3, respectively. These associations were robust to adjustment for other traffic metrics and regional pollutants, suggesting a degree of specificity with respiratory mortality and diesel exhaust containing EC/BC.

Background: Particulate air pollution is associated with increased mortality. There is a need for European results from multicountry databases concerning cause-specific mortality to obtain more accurate effect estimates.Methods: We report the estimated effects of ambient particle concentrations (black smoke and particulate matter less than 10 Am [PM10]) on cardiovascular and respiratory mortality, from 29 European cities, within the Air Pollution and Health: a European Approach (APHEA2) project. We applied a 2-stage hierarchical modeling approach assessing city-specific effects first and then overall effects. City characteristics were considered as potential effect modifiers.Results: An increase in PM10 by 10 mu g/m(3) (lag 0 + 1) was associated with increases of 0.76% (95% confidence interval = 0.47 to 1.05%) in cardiovascular deaths and 0.58% (0.21 to 0.95%) in respiratory deaths. The same increase in black smoke was associated with increases of 0.62% (0.35 to 0.90%) and 0.84% (0.11 to 1.57%), respectively.Conclusions: These effect estimates are appropriate for health impact assessment and standard-setting procedures.

In the Air Pollution and Health: A European Approach (APHEA2) project, the effects of ambient ozone concentrations on mortality were investigated. Data were collected on daily ozone concentrations, the daily number of deaths, confounders, and potential effect modifiers from 23 cities/areas for at least 3 years since 1990. Effect estimates were obtained for each city with city-specific models and were combined using second-stage regression models. No significant effects were observed during the cold half of the year. For the warm season, an increase in the 1-hour ozone concentration by 10 mug/ml was associated with a 0.33% (95% confidence interval [CI], 0.17-0.52) increase in the total daily number of deaths, 0.45% (95% CI, 0.22-0.69) in the number of cardiovascular deaths, and 1.13% (95% CI, 0.62-1.48) in the number of respiratory deaths. The corresponding figures for the 8-hour ozone were similar. The associations with total mortality were independent of SO2 and particulate matter with aerodynamic diameter less than 10 mum (PM10) but were somewhat confounded by NO2 and CO. Individual city estimates were heterogeneous for total (a higher standardized mortality rate was associated with larger effects) and cardiovascular mortality (larger effects were observed in southern cities). The dose-response curve of ozone effects on total mortality during the summer did not deviate significantly from linearity.

Purpose Breastfeeding is the best way to feed all infants, but not all infants can be (exclusively) breastfed. Cow's milk based infant formula is the second choice infant feeding. Methods The safety of a new synbiotic infant formula, supplemented with Bifidobacterium lactis and fructo-oligosaccharides, with lactose and a whey/casein 60/40 protein ratio was tested in 280 infants during 3 months. Results The median age of the infants at inclusion was 0.89 months. Weight evolution was in accordance with the World Health Organization growth charts for exclusive breastfed infants. The evolution of all anthropometric parameters (weight-for-length z score and body mass index-for-age z score) was within the normal range. The incidence of functional constipation (3.2%), daily regurgitation (10.9%), infantile crying and colic (10.5%) were all significantly lower than the reported median prevalence for a similar age according to literature (median value of 7.8% for functional constipation, 26.7% for regurgitation, 17.7% for infantile colic). Conclusion The new synbiotic infant starter formula was safe, resulted in normal growth and was well tolerated. Functional gastro-intestinal manifestations (functional constipation, regurgitation and colic) were significantly lower than reported in literature. Synbiotics (Bifidobacterium lactis and fructo-oligosaccharides) in cow's milk based infant formula bring the second choice infant feeding, formula, closer to the golden standard, exclusive breastfeeding.

PURPOSE: The purpose of this paper is to evaluate the efficacy of a lactose- reduced synbiotic partial whey hydrolysate in formula fed infants presenting with colic and the impact of this dietary intervention in mean crying time and quality of life. METHODS: Forty infants with infantile colic were treated during one month with parental reassurance and the intervention formula (partial whey hydrolysate, reduced lactose, Bifidobacterium lactis BB12 and galacto-oligosaccharides) and were compared to a control group of 20 infants with infantile colic treated with parental reassurance and a standard infant formula. Parents completed a quality of life (QoL) questionnaire assessing the burden of infantile colic. Wilcoxon test, t-test and Mann-Whitney test were used to compare QoL scores before and after intervention as well as between the intervention and control group. RESULTS: At inclusion, duration of crying did not differ between both groups. Crying duration decreased with 2.7 hours (from 3.2 to 0.5 hours) in the intervention group while duration of crying decreased only with 1.2 hours in the control group (p

Background: Although numerous studies have shown that high temperatures are related to increases in mortality, little research has investigated how the effect varies over time in response to change...

ACL-3; International audience; Since the 1970s, legislation has led to progress in tackling several air pollutants. We quantify the annual monetary benefits resulting from reductions in mortality from the year 2000 onwards following the implementation of three European Commission regulations to reduce the sulphur content in liquid fuels for vehicles. We first compute premature deaths attributable to these implementations for 20 European cities in the Aphekom project by using a two-stage health impact assessment method. We then justify our choice to only consider mortality effects as short-term effects. We rely on European studies when selecting the central value of a life-year estimate (€2005 86 600) used to compute the monetary benefits for each of the cities. We also conduct an independent sensitivity analysis as well as an integrated uncertainty analysis that simultaneously accounts for uncertainties concerning epidemiology and economic valuation. Results: The implementation of these regulations is estimated to have postponed 2212 (95% confidence interval: 772–3663) deaths per year attributable to reductions in sulphur dioxide for the 20 European cities, from the year 2000 onwards. We obtained annual mortality benefits related to the implementation of the European regulation on sulphur dioxide of €2005 191.6 million (95% confidence interval: €2005 66.9–€2005 317.2). Conclusion: Our approach is conservative in restricting to mortality effects and to short-term benefits only, thus only providing the lower-bound estimate. Our findings underline the health and monetary benefits to be obtained from implementing effective European policies on air pollution and ensuring compliance with them over time.

AIM: To present and integrate findings of studies investigating the effects of laparoscopic cholecystectomy on various aspects of lung function. METHODS: We extensively reviewed literature of the past 24 years concerning the effects of laparoscopic cholecystectomy in comparison to the open procedure on many aspects of lung function including spirometric values, arterial blood gases, respiratory muscle performance and aspects of breathing control, by critically analyzing physiopathologic interpretations and clinically important conclusions. A total of thirty-four articles were used to extract information for the meta-analysis concerning the impact of the laparoscopic procedure on lung function and respiratory physiopathology. The quality of the literature reviewed was evaluated by the number of their citations and the total impact factor of the corresponding journals. A fixed and random effect meta-analysis was used to estimate the pooled standardized mean difference of studied parameters for laparoscopic (LC) and open (OC) procedures. A crude comparison of the two methods using all available information was performed testing the postoperative values expressed as percentages of the preoperative ones using the Mann-Whitney two-sample test. RESULTS: Most of the relevant studies have investigated and compared changes in spirometric parameters.The median percentage and interquartile range (IQR) of preoperative values in forced vital capacity (FVC), forced expiratory volume in 1 s and forced expiratory flow (FEF) at 25%-75% of FVC (FEF25%-75%) expressed as percentage of their preoperative values 24 h after LC and OC were respectively as follows: [77.6 (73.0, 80.0) L vs 55.4 (50.0, 64.0) L, P < 0.001; 76.0 (72.3, 81.0) L vs 52.5 (50.0, 56.7) L, P < 0.001; and 78.8 (68.8, 80.9) L/s vs 60.0 (36.1, 66.1) L/s, P = 0.005]. Concerning arterial blood gases, partial pressure of oxygen [PaO2 (kPa)] at 24 or 48 h after surgical treatment showed reductions that were significantly greater in OC compared with LC [LC median 1.0, IQR (0.6, 1.3); OC median 2.4, IQR (1.2, 2.6), P = 0.019]. Fewer studies have investigated the effect of LC on respiratory muscle performance showing less impact of this surgical method on maximal respiratory pressures (P < 0.01); and changes in the control of breathing after LC evidenced by increase in mean inspiratory impedance (P < 0.001) and minimal reduction of duty cycle (P = 0.01) compared with preoperative data. CONCLUSION: Laparoscopic cholecystectomy seems to be associated with less postoperative derangement of lung function compared to the open procedure.

Heat stress is a current public health concern during the warm months in many urban areas. Climate change and increasing urbanization are expected to worsen this concern, with some locations being more vulnerable than others. The aim of this study was to determine the short-term effect of heat on mortality in the two most populated cities in Portugal: Lisbon and Oporto. Each city was assessed for specific heat stress threshold above which heat-related mortality becomes significant. A Poisson generalized estimating equations (GEE) model was used to estimate the impact of maximum apparent temperature (ATmax) and maximum temperature (Tmax) on daily mortality, in the summer season. Data show ATmax thresholds of 30.4°C for Lisbon and 26.3°C for Oporto, and Tmax thresholds of 29.3°C and 25.0°C, respectively. For every 1°C elevation in ATmax above the city-specific threshold, all-cause mortality rate rose by 7.13% (95% CI: 5.9; 8.4) in Lisbon and 4.31% (95% CI: 3.2; 5.4) in Oporto. The Tmax threshold increases were 5.6% (95% CI: 4.6; 6.6) in Lisbon and 3% (95% CI: 2.0, 3.9) in Oporto. In both cities, stronger associations were found for respiratory diseases and the elderly group was the most vulnerable. This study confirmed that elevated temperatures have a considerable impact on daily mortality frequency in the two most urbanized areas in Portugal. Our results also provide useful data for policymakers to better prepare local actions to mitigate and reduce the health risks associated with high temperatures.

Mean platelet volume (MPV) and platelet size distribution width (PDW) are markers of platelet (PLT) size and variability in PLT size as well as PLT activation [1–3]. Reduced PLT count and increased MPV values have been reported in unruptured abdominal aortic aneurysms [4,5]. Others, however, have noted lower PLT indices (MPV and PDW) in patients with aortic aneurysm compared to age-matched controls [6]. High-grade inflammation is associated with low MPV whereas low-grade inflammation is associated with high MPV; inflammation may play a role in pathogenesis of aneurysm formation and rupture [3]. We studied PLT indices in patients with acute aortic dissection (AAD), chronic aortic aneurysms and age and sex matched normal subjects. We studied, prospectively, 100 consecutive patients with AAD admitted to our hospital for emergency surgery (group I), 100 patients with chronic aneurysms of the ascending aorta scheduled for coronary angiography prior to elective surgical repair (group II) and 100 age and sex matched normal subjects who served as controls (group III). The diagnosis was confirmed for all patients with computed tomography. Dissection was classified according to the Stanford criteria. In patients with AAD, blood samples were obtained as soon as the patient came to hospital and for patients in group II the morning of the admission, prior to catheterization. All patients gave informed consent and the study protocol was approved by the Ethics Committee of our institution. The authors of this manuscript have certified that they comply with the PrinciplesofEthicalPublishingintheInternationalJournalofCardiology. PLT indices were evaluated with anautomatic counter, including PLT count, MPV, PDW and MPV/PLT ratio (Coulter LH780, Hematology Analyzer, Beckman, Miami, USA).Bloodsamples were collected in tubes with potassium ethylenediaminetetraacetate and were analyzed 1 h after venipuncture. We also measured D-dimers with Elisa (Vidas Ddimer, Biomerieux, France) and CRP with an immunoturbidimetric method (Cobas Integra, Roche, Mannheim, Germany). The groups were compared by means of chi-square or Fishers' exact test, Kruskal Wallis test or non-parametric one-way analysis of variance, Mann–Whitney test and Spearman rank correlation coefficient, as appropriate. Baseline characteristics for all three groups are presented in Table 1. In type A dissection, 8 patients died before surgery and the remaining were all but one operated; this patient declined surgery. There were 3 deaths in the operating room and 7 post-operative deaths. In type B dissection, 2 patients died on arrival to our unit; 2 patients were transferred elsewhere for vascular surgery and 1 was operated on site; the remaining 10 were managed conservativelyand did well. Ingroup II, there were 2 deaths. As expected, aortic cross clamping time and cardiopulmonary bypass time were significantly longer in group I than in group II (p b 0.001) whereas the duration of hospitalization was similar in the 2 groups (p = 0.192). Table 2 illustratestheresultsofstudiedbiochemicalvariablesamong groups. Within group I, PLT count was lower [186 (146,212) vs 222 (195,264)] and the MPV/PLT ratio was higher [0.047(0.036, 0.059) vs 0.037(0.033, 0.04)] in type A dissection compared to type B (p = 0.009 and p = 0.008, respectively). In addition, MPV as well as the MPV/PLT ratiowere significantlylowerinpatientswithmore extensivedissection with involvementof the abdominal aorta and the iliacarteries; in detail, when comparing thoracic vs thoracic–abdominal vs thoracic–abdominal–iliacdissection,MPVwas8.7(8.1,9.5),7.9(7.4,8.4)and8.1(7.1,8.7), respectively (p = 0.013) and MPV/PLT ratio was 0.05 (0.037, 0.062), 0.041 (0.036, 0.047) and 0.038 (0.034, 0.048), respectively (p = 0.042).

Background: The Mediterranean region is particularly vulnerable to the effect of summer temperature. Within the CIRCE project this time-series study aims to quantify for the first time the effect of summer temperature in Eastern-Southern Mediterranean cities and compared it with European cities around the Mediterranean basin, evaluating city characteristics that explain between-city heterogeneity. Methods: The city-specific effect of maximum apparent temperature (Tappmax) was assessed by Generalized Estimation Equations, assuming a linear threshold model. Then, city-specific estimates were included in a random effect meta-regression analysis to investigate the effect modification by several city characteristics. Results: Heterogeneity in the temperature-mortality relationship was observed among cities. Thresholds recorded higher values in the warmest cities of Tunis (35.5 degrees C) and Tel-Aviv (32.8 degrees C) while the effect of Tappmax above threshold was greater in the European cities. In Eastern-Southern Mediterranean cities a higher effect was observed among younger age groups (0-14 in Tunis and 15-64 in Tel-Aviv and Istanbul) in contrast with the European cities where the elderly population was more vulnerable. Climate conditions explained most of the observed heterogeneity and among socio-demographic and economic characteristics only health expenditure and unemployment rate were identified as effect modifiers. Conclusions: The high vulnerability observed in the young populations in Eastern-Southern Mediterranean cities represent a major public health problem. Considering the large political and economic changes occurring in this region as well future temperature increase due to climate change, it is important to strengthen research and public health efforts in these Mediterranean countries., Commission of the European Communities, Research Directorate General (6th Framework Program, Priority 1.1.6.3 Global Change and Ecosystem)

To evaluate the therapeutic effect of bevacizumab (Avastin) on corneal neovascularization (NV).Systematic review and meta-analysis of the literature was performed. Seven eligible clinical human studies and 18 eligible experimental animal studies examining the effectiveness of bevacizumab treatment on corneal NV were included in the meta-analysis. Pertinent publications were identified through a systematic search of PubMed. All references of relevant reviews and eligible articles were also screened, and data were extracted from each eligible study. The random-effects model (of DerSimonian and Laird) was used to combine the results from the selected studies. Heterogeneity was explored using available data. Publication bias was also assessed.A significant reduction of corneal neovascularized area was seen in clinical human studies, with a pooled reduction of 36% [95% confidence interval (CI), 18%-54%] overall, of 32% (95% CI, 10%-54%) for subconjunctival anti-vascular endothelial growth factor injections, and 48% (95% CI, 32%-65%) for topical treatment. Pooled mean change in best-corrected visual acuity showed an improvement in best-corrected visual acuity by 0.04. The summary standardized mean difference in animal studies indicated a statistically significant reduction in the area of corneal NV when treated with bevacizumab compared with the control group by -1.71 (95% CI, -2.12 to -1.30). The subtotal pooled standardized mean differences were -1.83 (95% CI, -2.38 to -1.28) for subconjunctival anti-vascular endothelial growth factor injections and -1.50 (95% CI, -1.88 to -1.12) for topical treatment.Our results suggest that both topical and subconjunctival bevacizumab achieve significant reduction in the area of corneal NV. This meta-analysis provides an evidential basis for the new therapeutic concept of treating corneal NV with antiangiogenic therapy.

Background Biomarkers for monitoring progression and prognosis of thoracic aneurysm are of great interest. Homocysteine (Hcy) induces elastolysis in arterial media and may directly affect fibrillin-1 or collagen whereas lipoprotein (Lp) (a) inhibits elastolysis by reducing activation of matrix metallopeptidase-9. Methods We studied 31 consecutive patients with acute aortic dissection (AAD) admitted for emergency surgery (group I, 60±13years old, 25 men), 30 consecutive patients with chronic aneurysms of the ascending aorta (group II, 67±12years old, 24 men) and 20 healthy controls (group III, 58±15years old, 14 men). We evaluated Hcy, folate, B12, Lp(a) and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism at baseline. Results Hcy, folate and B12 differed significantly among the 3 studied groups ( P =0.016, P =0.004 and P =0.001, respectively). The levels of Hcy and B12 were significantly higher in group I compared to both groups II and III ( P =0.05 and P =0.002, P P =0.017, respectively) and without significant differences between groups II and III ( P =0.083 and P =0.124). Folate was significantly lower in group I compared to both groups II and III ( P =0.001 and P =0.006, respectively) and without marked difference between groups II and III ( P =0.409). No significant difference was found in serum levels of Lp (a) ( P =0.074) or among the frequency of MTHFR C677T genotypes. Conclusions Patients with AAD present with higher Hcy and lower folate compared to both chronic aneurysms and controls.

Contains fulltext : 108972.pdf (Publisher’s version ) (Open Access) ABSTRACT: BACKGROUND: Particulate matter air pollution has been associated with adverse health effects. The fraction of ambient particles that are mainly responsible for the observed health effects is still a matter of controversy. Better characterization of the health relevant particle fraction will have major implications for air quality policy since it will determine which sources should be controlled.The RUPIOH study, an EU-funded multicentre study, was designed to examine the distribution of various ambient particle metrics in four European cities (Amsterdam, Athens, Birmingham, Helsinki) and assess their health effects in participants with asthma or COPD, based on a detailed exposure assessment. In this paper the association of central site measurements with respiratory symptoms and restriction of activities is examined. METHODS: At each centre a panel of participants with either asthma or COPD recorded respiratory symptoms and restriction of activities in a diary for six months. Exposure assessment included simultaneous measurements of coarse, fine and ultrafine particles at a central site. Data on gaseous pollutants were also collected. The associations of the 24-hour average concentrations of air pollution indices with the health outcomes were assessed in a hierarchical modelling approach. A city specific analysis controlling for potential confounders was followed by a meta-analysis to provide overall effect estimates. RESULTS: A 10 mug/m3 increase in previous day coarse particles concentrations was positively associated with most symptoms (an increase of 0.6 to 0.7% in average) and limitation in walking (OR= 1.076, 95% CI: 1.026-1.128). Same day, previous day and previous two days ozone concentrations were positively associated with cough (OR= 1.061, 95% CI: 1.013-1.111; OR= 1.049, 95% CI: 1.016-1.083 and OR= 1.059, 95% CI: 1.027-1.091, respectively). No consistent associations were observed between fine particle concentrations, nitrogen dioxide and respiratory health effects. As for particle number concentrations negative association (mostly non-significant at the nominal level) was observed with most symptoms whilst the positive association with limitation of activities did not reach the nominal level of significance. CONCLUSIONS: The observed associations with coarse particles are in agreement with the findings of toxicological studies. Together they suggest it is prudent to regulate also coarse particles in addition to fine particles.

Item does not contain fulltext OBJECTIVES: Studies of individual inflammatory responses to exposure to air pollution are few but are important in defining the most sensitive markers in better understanding pathophysiological pathways in the lung. The goal of this study was to assess whether exposure to airborne particles is associated with oxidative stress in an epidemiological setting. METHODS: The authors assessed exposure to particulate matter air pollution in four European cities in relation to levels of nitrite plus nitrate (NOx) in exhaled breath condensate (EBC) measurements in 133 subjects with asthma or chronic obstructive pulmonary disease using an EBC capture method developed for field use. In each subject, three measurements were collected. Exposure measurements included particles smaller than 10 mum (PM(10)), smaller than 2.5 mum (PM(2.5)) and particle number counts at a central site, outdoors near the subject's home and indoors. RESULTS: There were positive and significant relationships between EBC NOx and coarse particles at the central sampling sites (increase of 20.4% (95% CI 6.1% to 36.6%) per 10 mug/m(3) increase of coarse particles of the previous day) but not between EBC NOx and other particle measures. Associations tended to be stronger in subjects not taking steroid medication. CONCLUSIONS: An association was found between exposure to ambient coarse particles at central sites and EBC NOx, a marker of oxidative stress. The lack of association between PM measures more indicative of personal exposures (particularly indoor exposure) means interpretation should be cautious. However, EBC NOx may prove to be a marker of PM-induced oxidative stress in epidemiological studies.

Background and Aims: The implementation of three EU directives to reduce sulphur content in fuel was assessed for mortality impacts in 20 European cities, between 1990 and 2007 in the APHEKOM proje...

Background and Aims: Intervention studies play an important role in supporting and complementing scientific validation of results of epidemiological non-intervention studies linking air pollution a...

Numerous epidemiological studies have found a link between air pollution and health. We are reviewing a collection of published intervention studies with particular focus on studies assessing both improvements in air quality and associated health effects.Interventions, defined as events aimed at reducing air pollution or where reductions occurred as a side effect, e.g. strikes, German reunification, from the 1960s onwards were considered for inclusion. This review is not a complete record of all existing air pollution interventions. In total, 28 studies published in English were selected based on a systematic search of internet databases.Overall air pollution interventions have succeeded at improving air quality. Consistently published evidence suggests that most of these interventions have been associated with health benefits, mainly by the way of reduced cardiovascular and/or respiratory mortality and/or morbidity. The decrease in mortality from the majority of the reviewed interventions has been estimated to exceed the expected predicted figures based on the estimates from time-series studies.There is consistent evidence that decreased air pollution levels following an intervention resulted in health benefits for the assessed population.

The present study investigated the possible effects of south winds on daily mortality in Athens during the period 1983-1991. The mortality data were assembled from the Athens city registry and registries of the adjacent municipalities. The mean daily dry bulb and dew point temperature, as well as the wind speed and duration for which the south winds were blowing, were recorded by the Institute of Meteorology and Physics of the Atmospheric Environment of the National Observatory of Athens. Temperature, dew point temperature, seasonal and long-term patterns, as well as other potential confounders, have been adjusted for. Synoptic circulation patterns over Athens have been taken into account. Regression modelling was used for the analysis adjusting for autocorrelation where appropriate. When the south winds were added to the basic model (adjusting for year, season, day of the week, temperature, dew point temperature and black smoke), an increase of 3.2% in the daily mortality (95% CI: 1.4 to 4.8%) was observed on the days when south winds were blowing, compared to the days without a south wind. When a variable for southwesterly synoptic flow was also included in the model, the effect of south winds remained approximately the same: a 2.9% increase in daily mortality (95% CI: 1.9 to 4.7%), whilst the effect of the southwesterly synoptic flow was also significant and of similar magnitude (a 3.4% increase in the daily number of deaths, 95% CI: 1.1 to 5.8%). Longer duration and higher wind speed were also associated with increased mortality. In conclusion, adjusting for all known confounders, it was found that the days on which south winds blow are characterized by increased mortality in Athens. Climate Research

Recent reports investigate whether windblown desert dust may exacerbate the short-term health effects associated with particulate pollution in urban centers. We have tested this hypothesis by using daily air pollution and mortality data for Athens, Greece during the period 2001-2006. We investigated the effects of exposure to particulate matter with aerodynamic diameter = 75years of age, while for total mortality higher effects were observed among females. The main effect of desert dust days and its interaction with PM(10) concentrations were significant in all cases except for respiratory mortality and cardiovascular mortality among those

Weather-related health effects have attracted renewed interest because of the observed and predicted climate change. The authors studied the short-term effects of cold weather on mortality in 15 European cities. The effects of minimum apparent temperature on cause- and age-specific daily mortality were assessed for the cold season (October-March) by using data from 1990-2000. For city-specific analysis, the authors used Poisson regression and distributed lag models, controlling for potential confounders. Meta-regression models summarized the results and explored heterogeneity. A 1 degrees C decrease in temperature was associated with a 1.35% (95% confidence interval (CI): 1.16,1.53) increase in the daily number of total natural deaths and a 1.72% (95% CI: 1.44, 2.01), 3.30% (95% CI: 2.61, 3.99), and 1.25% (95% CI: 0.77, 1.73) increase in cardiovascular, respiratory, and cerebrovascular deaths, respectively. The increase was greater for the older age groups. The cold effect was found to be greater in warmer (southern) cities and persisted up to 23 days, with no evidence of mortality displacement. Cold-related mortality is an important public health problem across Europe. It should not be underestimated by public health authorities because of the recent focus on heat-wave episodes.