[Show abstract][Hide abstract] ABSTRACT: Background:
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 (p < 0.001, 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%, p < 0.01).
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.
European annals of allergy and clinical immunology 10/2012; 44(5):193-9.
[Show abstract][Hide abstract] ABSTRACT: The present study aimed to develop a short validated patient-completed questionnaire, the RhinAsthma Patient Perspective (RAPP), to assess the health-related quality of life (HRQoL) in patients with asthma and comorbid allergic rhinitis in clinical practice.
A provisional RAPP questionnaire was formed from candidate items identified through retrospective analysis of 333 RHINASTHMA questionnaires. This was then tested on 150 asthma patients with allergic rhinitis.
Psychometric analyses identified eight items fitting a unidimensional model to form RAPP. Internal consistency (Cronbach's alpha coefficient > 0.8) and agreement with RHINASTHMA (r = -0.31, P = 0.0001) were excellent. Criterion, discriminant, and convergent validity were good. Reliability in 47 stable patients was very good (intra-class and concordance correlation coefficients were 0.90 and 0.89, respectively). Responsiveness in 103 patients with health improvement or deterioration was significantly associated with changes in Global Rating Scale (r = -0.4965, P < 0.01), Rhinitis Visual Analogue Scale (r = 0.5722, P < 0.01) and asthma control test (r = -0.6483, P < 0.01). Minimal clinical difference in the analyzed population was 2.
RhinAsthma Patient Perspective is a simple eight-question questionnaire with good measurement properties and sensitivity to health changes, which will provide a valid, reliable and standardized HRQoL measurement in patients with asthma and comorbid allergic rhinitis in clinical practice.
[Show abstract][Hide abstract] ABSTRACT: It has been demonstrated that Leukotriene modifiers reduce rhinitis symptoms, but montelukast preventive effect on inflammatory cells pattern in intranasal challenge studies has not been already assessed. This pilot study has been designed to explore the montelukast effects in preventing early/late inflammatory cells response to specific allergen challenge in persistent rhinitis. After a 4 week wash-out period, patients were randomised to receive montelukast/placebo for 4 weeks. Pre-post treatment nasal washing and scraping before and after specific nasal challenge were performed. No difference in baseline inflammatory cells count before and after treatment was shown between groups. Despite at a basal level a decrease of inflammatory cells in active group after treatment was observed, the statistical significance was not reached. The generalised mixed model showed that, after therapeutic interventions, the inflammatory cells increased 30' and 6 hour after challenge but, only in the active group the cells amounting was less for eosinophils (-34%), macrophages (-56%), lymphocytes (-45%) and neutrophils (-46%; p = 0.001). The longitudinal generalised linear model with just one time variable showed a decrease of all inflammatory cellular types although a significant relevance was reached only for macrophages (p = 0.038) and neutrophils (p = 0.001). The modulatory effect on neutrophils and macrophages could lead to montelukast still unexplored effects. Specific trials, sized according to the results of this pilot exploratory study, could add relevant evidences concerning the leukotrienes receptors antagonist treatment of specific rhinitis and asthma phenotypes.
European annals of allergy and clinical immunology 04/2012; 44(2):48-53.
[Show abstract][Hide abstract] ABSTRACT: A historical mortality cohort study was conducted in Genoa, Italy among public transport workers ever employed between 1949 and 1980, to estimate overall and cause-specific mortality from January 1970 to December 2005 and to examine associations between exposure to urban air pollutants and overall and cause-specific mortality.
Causes of death for 9267 males (6510 bus drivers, 2073 maintenance workers and 601 white collar workers) were coded according to ICD-9. Standardised mortality ratios (SMRs) and 95% CIs were computed by applying Italian and regional male death rates to person-years of observation for the entire cohort and following stratification by longest held job title and length of and time since first employment using the Poisson regression model.
There were 2916 deaths and 230,009 person-years of observation; 17 subjects were lost to follow-up. SMRs for all causes, diseases of the circulatory, respiratory, digestive and genitourinary systems, and for accidents were lower than expected. SMRs (95% CI) were increased for lung cancer (1.16, 1.05 to 1.28), non-Hodgkin's lymphoma (1.23, 0.85 to 1.78), Hodgkin's lymphoma (2.14, 1.19 to 3.87) and diabetes mellitus (1.16, 1.05 to 1.28). The SMR for leukaemia was 0.77 (0.51 to 1.16). Hodgkin's lymphoma mortality was significantly increased among bus drivers (1.62, 1.37 to 5.04). Lung cancer risk was significantly increased among all workers after 30 years' employment and among maintenance workers.
The study failed to show any increased risk for leukaemias. The increased mortality from Hodgkin's lymphoma and lung cancer may be associated with long-term exposure to urban air pollution.
Occupational and environmental medicine 09/2010; 67(9):611-9. DOI:10.1136/oem.2009.050377 · 3.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of asthma therapy is to achieve and maintain disease control. Clinicians' behavior is crucial in terms of prescribing the best possible treatment, carrying out appropriate follow-up, and ensuring adherence to treatment. Although clinical trials have demonstrated that asthma control is an achievable goal, real-life data show that this objective is still far from being reached.
To investigate physician-related factors that can influence successful asthma management.
In 2008, 811 general practitioners (GPs) and 230 respiratory medicine specialists attending a continuous medical education program completed a questionnaire prior to beginning the course on aspects related to asthma pathogenesis and control, applicability of research and guidelines in daily practice, and doctor-patient relations.
The level of knowledge among GPs and specialists regarding the use of control tools was not optimal, with the Asthma Control Test used by 20.15% of GPs and 42.92% of specialists. The respondents were also largely unable to correctly identify level of asthma control, with approximately just 20% providing correct answers. Although chronic inflammation was considered the main feature of asthma by more than 90% of the 2 groups, they inexplicably believed that up to 40% of patients might not require long-term treatment. Both GPs and specialists preferred a continuous fixed-dose regimen (57.69% and 54.21%, respectively) and did not tend to favor self-management plans, believing that these were only feasible in a very small percentage of patients.
Our findings provide one possible explanation of why asthma control levels are currently unsatisfactory in real life.
Journal of investigational allergology & clinical immunology: official organ of the International Association of Asthmology (INTERASMA) and Sociedad Latinoamericana de Alergia e Inmunología 01/2010; 20(1):9-12. · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Only few studies have examined early hematological effects in human populations exposed to low benzene levels and their findings are controversial. We evaluated hematological outcomes (WBC, neutrophils, lymphocytes, monocytes, eosinophils, basophils, RBC, Hb, HCT MCV, platelets and MPV) in a population of 153 Bulgarian petrochemical workers exposed to benzene (range 0.01-23.9 ppm) and 50 unexposed subjects.
Written informed consent was obtained and a self-administered questionnaire used to collect information on current smoking habits, lifestyle, and occupational activities. Exposure assessment was based on personal monitoring sampling the day before phlebotomy. Urinary trans-trans-muconic acid (t,t-MA) was determined at the beginning and end of the work shift. Based on individual airborne benzene measurements, study subjects were categorized in three exposure categories (referents, <1 and > or =1 ppm). Mean values of each hematologic outcomes in each exposure category were compared with the referent group using a multiple linear regression model adjusted for age, gender, current smoking habits and environmental toluene level. The influence of the CYP2E1 (RsaI and DraI) and NQO1 609C>T genetic polymorphisms on differential hematological parameters was also investigated.
No dose-response effect was observed for most of the examined hematological outcomes (WBC, lymphocytes, neutrophils, monocytes, RBC, Hb, HCT, MCV, platelets and MPV). The eosinophil count was inversely related to benzene exposure only among smokers. Conversely, basophils increased with increasing exposure. No effect on benzene hematotoxicity was found for any of the investigated polymorphisms.
In our study we did not find a decline in WBC and lymphocytes related to benzene exposure. A myeloproliferative effect of benzene is highly unlikely to explain the observed reduction in eosinophils and increase in basophils as it would lead to a concordant depression in all granulocyte subpopulations. Whether benzene effects at low doses are present in Caucasian populations remains uncertain, thus warranting further investigations.
La Medicina del lavoro 03/2009; 100(2):83-90. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The goal of asthma therapy is to achieve an optimal level of disease control, but the relationship between asthma control, impact of comorbid rhinitis and health related quality of life (HRQoL) in real life remains unexplored.
The aims of this real life study were to evaluate asthma control, the impact of asthma (with and without rhinitis) on HRQoL, the relationship between asthma control and HRQoL, and the role of rhinitis on asthma control and HRQoL.
122 asthma patients completed the Asthma Control Test, Rhinitis Symptoms score (T5SS) and RHINASTHMA.
Asthma control was unsatisfactory (44.27% of uncontrolled patients), as well as HRQoL. Controlled patients controlled showed significantly lower scores in all the RHINASTHMA domains compared to uncontrolled. Irrespective of their level of control, patients with rhinitis symptoms showed worse HRQoL in Upper Airways (UA) (P < 0.0001), Lower Airways (LA) (P < 0.001), and Global Summary (GS) (P < 0.0001). In patients with symptomatic rhinitis, RHINASTHMA were lower in controlled asthma patients (UA P = 0.002; LA P < 0.0001; RAI P < 0.01; GS P < 0.0001). Asthma control was associated with lower T5SS score (P = 0.034).
Asthma control in real life is unsatisfactory. Rhinitis and asthma influence each other in terms of control and HRQoL. The control of rhinitis in asthma patients can lead to an optimization of HRQoL related to the upper airways, while this phenomenon is not so evident in asthma. These results suggest to strengthen the ARIA recommendation that asthma patients must be evaluated for rhinitis and vice versa.
[Show abstract][Hide abstract] ABSTRACT: Field studies conducted in children exposed to ionizing radiation and industrial chemicals have consistently reported increased frequencies of chromosome aberrations in those environmentally exposed than in referent subjects. Exposure(s) occurring during childhood--as well as in utero--may continue for several years, become chronic, and eventually play a relevant role in the etiology of childhood as well as adulthood cancers. Indeed the statistical association between CA frequency in peripheral blood lymphocytes and cancer risk detected in occupationally exposed adults supports the hypothesis that CA is a predictor of cancer. These facts suggest the usefulness of including CA as biomarkers of genetic damage in epidemiologic studies of children exposed to environmental pollutants. As reported for other cytogenetic biomarkers, CA frequency may vary with gender and age in children as well as in adults. Estimates of the baseline frequency of CA in a pediatric population is a prerequisite in planning epidemiologic investigations of children exposed to low level of environmental genotoxic agents. The CA baseline levels were estimated from 16 published epidemiologic studies and from a large sample of Czech children aged 7-16 years (n=1214) and 206 newborns, all serving as referents (not exposed individuals). For the whole referent population (age range 0-19 years) the mean CA frequency estimated from the published findings was 1.24% (95%CI=1.05-1.47). Similar baseline levels were found for chromosome breaks frequency in boys and girls: 1.22% (95%CI=1.12-1.32) and 1.21% (95%CI=1.10-1.31), respectively. Among newborns CA baseline frequency was 1.14% (95%CI=0.96-1.32). Based on the reviewed studies and the reanalysed data, CA baseline levels were similar in boys and girls and failed to show any increase with age.