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Slowing global warming: benefits for patients and the planet.

Global warming will cause significant harm to the health of persons and their communities by compromising food and water supplies; increasing risks of morbidity and mortality from infectious diseases and heat stress; changing social determinants of health resulting from extreme weather events, rising sea levels, and expanding flood plains; and worsening air quality, resulting in additional morbidity and mortality from respiratory and cardiovascular diseases.

Vulnerable populations such as children, older persons, persons living at or below the poverty level, and minorities will be affected earliest and greatest, but everyone likely will be affected at some point.

Family physicians can help reduce greenhouse gas emissions, stabilize the climate, and reduce the risks of climate change while also directly improving the health of their patients. Health interventions that have a beneficial effect on climate change include encouraging patients to reduce the amount of red meat in their diets and to replace some vehicular transportation with walking or bicycling.

Patients are more likely to make such lifestyle changes if their physician asks them to and leads by example. Medical offices and hospitals can become more energy efficient by recycling, purchasing wind-generated electricity, and turning off appliances, computers, and lights when not in use. Moreover, physicians can play an important role in improving air quality and reducing greenhouse gas emissions by advocating for enforcement of existing air quality regulations and working with local and national policy makers to further improve air quality standards, thereby improving the health of their patients and slowing global climate change.

Passive smoking and respiratory allergies in adolescents.

OBJECTIVE: The aim of our study was to investigate impact of active and passive smoking on total and specific serum IgE levels and on incidence of developing allergic diseases (i.e. asthma, rhinitis) in a group of Croatian adolescents.

METHODS: Our study consisted of random sample of one hundred fifty-five (155) voluntary pupils (80 males and 75 females), with mean age of 16.72 +/- 1.25 years, from one high school in the city of Varazdin (north-west part of Croatia). Their smoking habits were examined by interview administered by a single trained survey worker while diagnosis of allergic disease (i.e. asthma and allergic rhinits) had to be previously confirmed by physician. Total and specific serum IgE levels were determined using enzyme-linked immunosorbent assay (ELISA) method in Central Laboratory of Clinic for lung diseases Jordanovac, Zagreb (Croatia).

RESULTS: Statistically significant higher prevalence of allergic diseases was found in the group of passive smokers as opposed to nonsmokers (chi2=9.29, p=0.002) as well as in active smokers compared to nonsmokers (chi2=4.45, p=0.034). Also, total IgE (IU/ml) was significantly higher in passive smokers when compared to non-smokers (t=13.039, p<0.01), and in passive smokers as opposed to active smokers as well (t=4.960, p<0.01), while difference in its level between active smokers and non-smokers was not statistically significant. The level of specific IgE to Dermatophagoides pteronyssinus between active smokers, passive smokers and non-smokers resulted to be not statistically significant.

CONCLUSIONS: Results of the study indicate that clinical manifestations of allergic diseases are more frequent in smokers (both active and passive) than in nonsmokers. Our investigation leads us to a presumption of a possibly more harmful effect of passive than active smoking in the adolescent high school population. Statistically highest IgE level in passive smokers as opposed to non-smokers or smokers could be attributed to longer duration of exposure to tobacco smoke in passive smokers and tobacco's potential cumulative effect on allergic senzitisa-tion, although investigations with more precised and detailed mesures including higher number of participants are warranted.

Influenza: epidemiology, clinical features, therapy, and prevention.

Influenza A and B are important causes of respiratory illness in all age groups. Influenza causes seasonal outbreaks globally and, less commonly, pandemics. In the United States, seasonal influenza epidemics account for >200,000 hospitalizations and >30,000 deaths annually. More than 90% of deaths occur in the elderly population. Interestingly, in the novel 2009 H1N1 influenza pandemic, attack rates were highest among children and young adults. Fewer than 10% of cases occurred in adults >60 years old, likely because preexisting antibodies against other H1N1 viruses afforded protection.

Despite concerns about a high lethality rate with the novel 2009 H1N1 strain, most illnesses caused by the 2009 H1N1 viruses were mild (overall case fatality rate <0.5%). Clinical features of influenza infection overlap with other respiratory pathogens (particularly viruses). The diagnosis is often delayed due to low suspicion and the limited use of specific diagnostic tests. Rapid diagnostic tests are widely available and allow detection of influenza antigen in respiratory secretions within 1 hour; however, sensitivity ranges from 50 to 90%. Neuraminidase inhibitors (NAIs) (eg, oseltamivir and zanamivir) are effective for treating influenza A or B and for prophylaxis in selected adults and children. Resistance to NAIs is rare, but influenza strains resistant to oseltamivir have been detected. Vaccines are the cornerstone of influenza control. Currently, trivalent inactivated vaccine (TIV) and live attenuated influenza vaccine (LAIV) are available.

These agents reduce mortality and morbidity in high-risk patients (i.e., the elderly or patients with comorbidities), and expanding the use of vaccines to healthy children and adults reduces the incidence of influenza, pneumonia, and hospitalizations due to respiratory illnesses in the community.

Human metapneumovirus.

Human metapneumovirus (hMPV) is a common pathogen that can cause both upper and lower respiratory tract infections, particularly in children, elderly adults, and immunocompromised hosts. Since its initial identification in 2001, hMPV has been isolated from individuals with acute respiratory tract infections (ARTIs) in virtually every continent. Serological studies indicate that it has caused human infection since 1958 or earlier.

The epidemiology and clinical manifestations of hMPV are similar to those of the human respiratory syncytial virus (hRSV). HMPV has a seasonal variation: it circulates in late winter to early spring in temperate climates; late spring and summer in tropical regions. In young children, symptoms range from mild upper respiratory tract infections to severe lower respiratory tract infections (eg, bronchiolitis, croup, and pneumonia).

In adults, hMPV reinfection typically presents with colds and flulike clinical manifestations. The disease is more severe (sometimes lethal) in immunocompromised hosts. Reverse transcription polymerase chain reaction (RT-PCR) is the most sensitive test with which to detect hMPV infection. Direct detection of hMPV antigens with an immunofluorescent antibody test is available but is less sensitive than PCR. Antibody testing is used mainly for retrospective diagnosis (≥ fourfold increase in titer or seroconversion) and for epidemiological studies. The mainstay of treatment of hMPV infections is supportive. Ribavirin has similar activity in vitro and in animal models against hRSV and hMPV, but its efficacy in vivo is unproven. Monoclonal antibodies have activity in murine models but are not available in humans.

Several vaccines are promising in animal models, but their safety and efficacy have not yet been evaluated in humans.

Progress in respiratory virus vaccine development.

Viral respiratory infections cause significant morbidity and mortality in infants and young children as well as in at-risk adults and the elderly. Although many viral pathogens are capable of causing respiratory disease, vaccine development has to focus on a limited number of pathogens, such as those that commonly cause serious lower respiratory illness (LRI). Whereas influenza virus vaccines have been available for some time (see the review by Clark and Lynch in this issue), vaccines against other medically important viruses such as respiratory syncytial virus (RSV), the parainfluenza viruses (PIVs), and metapneumovirus (MPVs) are not available.

This review aims to provide a brief update on investigational vaccines against RSV, the PIVs, and MPV that have been evaluated in clinical trials or are currently in clinical development.

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