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Background Urban air pollution is involved in the progress of idiopathic pulmonary fibrosis (IPF). Its potential role on the devastating event of Acute Exacerbation of IPF (AE-IPF) needs to be clarified. This study examined the association between long-term personal air pollution exposure and AE- IPF risk taking into consideration inflammatory mediators and telomere length (TL). Methods All consecutive IPF-patients referred to our Hospital from October 2013-June 2019 were included. AE-IPF events were recorded and inflammatory mediators and TL measured. Long-term personal air pollution exposures were assigned to each patient retrospectively, for O 3 , NO 2 , PM 2.5 [and PM 10 , based on geo-coded residential addresses. Logistic regression models assessed the association of air pollutants’ levels with AE-IPF and inflammatory mediators adjusting for potential confounders. Results 118 IPF patients (mean age 72 ± 8.3 years) were analyzed. We detected positive significant associations between AE-IPF and a 10 μg/m 3 increase in previous-year mean level of NO 2 (OR = 1.52, 95%CI:1.15–2.0, p  = 0.003), PM 2.5 (OR = 2.21, 95%CI:1.16–4.20, p  = 0.016) and PM 10 (OR = 2.18, 95%CI:1.15–4.15, p  = 0.017) independent of age, gender, smoking, lung function and antifibrotic treatment. Introduction of TL in all models of a subgroup of 36 patients did not change the direction of the observed associations. Finally, O 3 was positively associated with %change of IL-4 ( p  = 0.014) whilst PM 2.5 , PM 10 and NO 2 were inversely associated with %changes of IL-4 ( p  = 0.003, p  = 0.003, p  = 0.032) and osteopontin ( p  = 0.013, p  = 0.013, p  = 0.085) respectively. Conclusions Long-term personal exposure to increased concentrations of air pollutants is an independent risk factor of AE-IPF. Inflammatory mediators implicated in lung repair mechanisms are involved.

The association of ozone exposure with respiratory outcomes has been investigated in epidemiologic studies mainly including asthmatic children. The findings reported had methodological gaps and inconsistencies. We aimed to investigate effects of personal ozone exposure on various respiratory outcomes in school-age children generally representative of the population during their normal activities. We conducted a panel study in a representative sample of school-age children in the two major cities of Greece, Athens and Thessaloniki. We followed 188, 10- to 11-y-old, elementary school students for 5 wk spread throughout the 2013–2014 academic year, during which ozone was measured using personal samplers. At the end of each study week, spirometry was performed by trained physicians, and the fractional concentration of nitric oxide in exhaled air ( ) was measured. Students kept a daily time–activity–symptom diary and measured PEF (peak expiratory flow) using peak flow meters. Mixed models accounting for repeated measurements were applied. An increase of 10 μg/m in weekly ozone concentration was associated with a decrease in FVC (forced vital capacity) and FEV (forced expiratory volume in 1 s) of 0.03 L [95% confidence interval (CI): −0.05, −0.01] and 0.01 L (95% CI: −0.03, 0.003) respectively. The same increase in exposure was associated with a 11.10% (95% CI: 4.23, 18.43) increase in and 19% (95% CI: −0.53, 42.75) increase in days with any symptom. The effect estimates were robust to PM adjustment. No inverse association was found between ozone exposure and PEF. The study provides evidence that airway inflammation and the frequency of respiratory symptoms increase, whereas lung function decreases with increased ozone exposure in schoolchildren. https://doi.org/10.1289/EHP635.

Background Ambient particulate matter (PM) has an adverse effect on respiratory morbidity. Desert dust outbreaks contribute to increased PM levels but the toxicity of desert dust mixed with anthropogenic pollutants needs clarification. Methods We identified 132 days with desert dust episodes and 177 matched days by day of the week, season, temperature and humidity between 2001 and 2006 in Athens, Greece. We collected data on regulated pollutants and daily emergency outpatient visits and admissions for respiratory causes. We applied Poisson regression models adjusting for confounding effects of seasonality, meteorology, holidays and influenza epidemics. We evaluated the sensitivity of our results to co-pollutant exposures and effect modification by age and sex. Results A 10 μg/m 3 increase in PM 10 concentration was associated with 1.95% (95% confidence interval (CI): 0.02%, 3.91%) increase in respiratory emergency room visits. No significant interaction with desert dust episodes was observed. Compared with non-dust days, there was a 47% (95% CI: 29%, 68%) increase in visits in dust days not adjusting for PM 10 . Desert dust days were associated with higher numbers of emergency room visits for asthma, chronic obstructive pulmonary disease and respiratory infections with increases of 38%, 57% and 60%, respectively ( p  < 0.001 for all comparisons). Analyses of respiratory hospital admissions provided similar results. PM 10 effects decreased when adjusting for desert dust days and were further confounded by co-pollutants. Conclusions Desert dust episode days are associated with higher respiratory emergency room visits and hospital admissions. This effect is insufficiently explained by increased PM 10 levels.

Background and objectives In epidemiological research, spirometry is commonly used to estimate prevalence of COPD, as reliance on imprecisely delineated symptoms may introduce bias. Actually, the prevalence of airflow limitation in adults with no prior asthma diagnosis was studied using two different cut-offs for the FEV₁/FVC ratio: the fixed ratio (FR) and the lower limit of normal (LLN), based on data from the EMENO survey. Our objective was to estimate COPD prevalence in Greece under both definitions and to compare associated clinical features and comorbidities. Methods The EMENO study was a population-based survey (2014–2016) of 6,006 adults (≥18 years). This analysis included 2,450 participants aged 30–91 years, with high-quality spirometry and no prior asthma diagnosis. Airflow limitation indicative of COPD was defined by pre-bronchodilator FEV1/FVC < 0.70 (FR) and FEV1/FVC < LLN; self-reported COPD (SRPD) was also analyzed. Comorbidities and demographics were assessed through interviews and medical exams. Results COPD prevalence was 8.51% (FR), 5.33% (LLN), and 1.97% (SRPD). It was more common in men (13.2% FR+ and 8.5% LLN+), with the highest prevalence among current smokers (11.6%, FR; 9.1%, LLN). Prevalence was also higher in participants reporting respiratory symptoms. The FR+/LLN− (discordant) group was strongly associated with older age, blue-collar occupations, and comorbidities. Concordant cases (FR+/LLN+) had a higher prevalence of smoking and respiratory symptoms compared to discordant cases. Obesity was inversely associated with COPD under the LLN criterion, while sleep apnea syndrome increased the odds of concordant COPD. Conclusion COPD prevalence in Greece differed according to the obstructive threshold applied, with discordant and concordant cases showing distinct demographic and clinical risk profiles. The higher prevalence of obstruction among symptomatic participants further supports the use of spirometry as a valid surrogate in epidemiological studies. Overall, reliance on a single definition may misrepresent the true burden and heterogeneity of the disease.

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 μg/m 3 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.

Background: The coronavirus disease (COVID-19) pandemic has posed an unprecedented challenge to health systems, and has significantly affected the healthcare of lung cancer patients. The aim of our study was to assess the impact of COVID-19 on early lung cancer patients’ surgical treatment. Methods: All consecutive patients with early-stage non-small cell lung cancer eligible for surgical treatment stage I/II and resectable stage III, referred to our department during the first wave of COVID-19 between February to May 2020, were included and compared with those on the exact corresponding quarter in 2019, one year before the pandemic. Waiting time to surgical treatment, increase of tumor’s size and increase on lung cancer stage were recorded and compared. All subjects were followed up for 12 months. Multiple linear and logistic regression models were applied to assess the differences in the management of the studied groups adjusting for potential confounders. Results: Sixty-one patients with early-stage lung cancer were included in the study; 28 (median age 67 years, SD: 7.1) during the pandemic and 33 (median age 67.1 years, SD: 7.5) one year earlier. A significantly longer period of waiting for treatment and an increase in tumor size were observed during the pandemic compared to before the pandemic [median time 47 days, interquartile rate (IQR): 23–100] vs. [median time 18 days, IQR: 11–23], p < 0.001. No significant differences were detected in the increase of the stage of lung cancer between the subgroups. Conclusion: The COVID-19 pandemic had a significant impact on surgical and oncological care, leading to significant delays on treatment and an increase in tumor size in early-stage lung cancer patients.

Background Idiopathic pulmonary fibrosis acute exacerbation (IPF-AE) constitutes IPF’s most devastating event, representing the unexpected superimposition of diffuse alveolar damage of unknown etiology. Guidelines recommend high-dose steroids treatment despite unproven benefit. We hypothesized that previous immunosuppression and the administration of high-dose steroids adversely affect IPF-AE outcome. Methods We studied all consecutive patients hospitalized in our department for IPF deterioration from 2007 to June 2013. Our protocol consisted of immediate cessation of immunosuppression (if any), best supportive care, broad-spectrum antimicrobials and thorough evaluation to detect reversible causes of deterioration. Patients were followed-up for survival; post-discharge none received immunosuppression. Results Twenty-four out of 85 admissions (28 %) fulfilled IPF-AE criteria. IPF-AE were analyzed both as unique events and as unique patients. As unique events 50 % survived; 3 out of 12 (25 %) in the group previously treated with immunosuppression whereas nine out of 12 (75 %) in the group not receiving immunosuppression ( p  = 0.041). As unique patients 35.3 % survived; 3 out of 6 (50 %) in the never treated group whereas three out of 11 (27.3 %) in the group receiving immunosuppression ( p  = 0.685). The history of immunosuppression significantly and adversely influenced survival ( p  = 0.035). Survival was greater in the never treated group compared to the immunosuppressed patients ( p  = 0.022). Post-discharge, our IPF-AE survivors had an 83 % 1-year survival. Conclusions By applying the above mentioned protocol half of our patients survived. The history of immunosuppression before IPF-AE adversely influences survival. Avoiding steroids in IPF patients may favor the natural history of the disease even at the moment of its most devastating event.

René Théophile Hyacinthe Laënnec (1781–1826), a French physician, is considered one of the pioneers of respiratory medicine. His contribution to the invention of the stethoscope and to the development of clinical auscultation played a key role in the progress of the diagnosis of chest diseases. Almost two centuries after his invention of the stethoscope, his achievements continue to be widely appreciated and used by modern physicians in current pulmonology.

PurposePost-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique.MethodsThe patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction.Results30-day mortality was 5.4 %. Most patients (72 %) were treated in two stages, while vacuum therapy was used in 20 % of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes.ConclusionsPectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.

Introduction: School-based tobacco control programs exhibit great variety. Our study aimed to evaluate the effectiveness of an experiential learning smoking prevention program in facilitating knowledge acquisition, forging healthy attitudes, and decreasing intention to smoke. Methods: A school-based intervention-control study was implemented during the 2016 – 2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths, Aesop fables and ancient classical literature (Aristotle, Herodotus, Plutarch, Xenophon, Homer’s Epics), with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous selfadministered questionnaire was used at baseline and at follow-up at 3 months to evaluate program effectiveness. Results: A total of 351 students participated in our study; 181 (51.6%) in the intervention group and 170 (48.4%) in the control group. The mean age of student participants was 13 years (SD=0.96). Students in the intervention group were more likely to improve their knowledge of the adverse effects of smoking, develop attitudes against smoking and report a negative intention to smoke in the first year following the intervention, compared to the control group. Conclusions: This study provides evidence that school-based experiential learning smoking prevention programs improve smoking-related knowledge, enhance anti-smoking attitudes and reinforce negative intentions toward tobacco products.