The Course: “Occupational and environmental diseases of the lung”. What lessons did we learn from Perugia’s lectures?



From March 9th to March 13th, 2014, the course Occupational and environmental diseases of the lung took place in the beautiful city of Perugia, in the heart of Italy, at the Sangallo Palace Hotel.
The aim of the event was to disseminate current scientific knowledge about occupational respiratory diseases and also giving basic information on epidemiological methods.

The course, completely in English, was composed of different sessions with different interactive lectures during each day. Each discussion lasted no more than 30 minutes ending with a break. Participants and Course Faculty gathered together also at lunch and dinner. The event was based on similar cultural experiences well-known in Sweden. Almost all of the 25 participants were resident students from Postgraduate Schools in Occupational Medicine scattered around Italy.

The opening dinner on Sunday 9th of March was the first opportunity for the participants to familiarize with one’s surrounding and to meet each other. At the beginning of the morning session on Monday March 10th there was a welcome speech from Professor Giuseppe Abbritti, Former Director of the Post-graduate School in Occupational Medicine at the University of Perugia.

Almost the entire day was spent in “Epidemiological Methods in Respiratory Research” by Professor Gösta Axelsson from the Dept. of Public Health and Community Medicine, University of Gothenburg, Sweden. The lectures were focused on epidemiological studies, statistical power, aspects on validity in occupational and environmental epidemiology.

The last afternoon lecture was “How to write a scientific paper” taught by Professor Kjell Torén (course leader) and Professor Lars Barregård both from the Sahlgrenska Academy, Gothenburg, Sweden. The main messages dealt with the importance of writing scientific papers and good practice to do it based on the instructions of the science editor Jane Schroeder. The practical session ended with a group exercise.

The first session on March 11th, tried to answer the intriguing question: Asthma and COPD – one syndrome with different phenotypes? At first Professor Anna-Carin Olin from the Sahlgrenska Academy with the lecture “Phenotypes and endotypes of asthma” explained the utility of a better characterization of asthma and his heterogeneity due to differences in airflow obstruction, airflow hyperresponsiveness and airway inflammation.

After Professor Paul D. Blanc from the Division of Occupational and Environmental Medicine, University of San Francisco, USA, in the lecture “COPD” clarified what is in essence Chronic Obstructive Pulmonary Disease, encouraged to get out of rigid old thought patterns about COPD and asthma and taught participants about the role of smoking on the classification of disease.

The second day session was: Importance and assessment of airway inflammation in occupational settings. The lectures “Monitoring inflammation using exhaled nitric oxide (FENO) in occupational setting” and “Particles in exhaled air (PEx) and respiratory disease” by Professor Anna-Carin Olin dealt with FENO and PEx, these methods are non-invasive, relatively simple and safe to collect and they offer surely advantages in measuring airway inflammation (especially in small airways); however both, for different reasons, still require a better standardization for widely screening use in occupational and clinical settings.

After lunch the lecture “Spirometry and Peak Expiratory Flow (PEF)” by Professor Jonas Brisman from the Sahlgrenska Academy focus on the usefulness of serial PEF (in monitoring occupational asthma and in home management of asthma) and spirometry taking into account for the first one the inter-individual and circadian variability and for the second one the importance of good performing.

The lecture “Tests of bronchial hyperreactivity” by Doctor Nicola Murgia from the Dept. of Occupational Medicine, Respiratory Diseases and Toxicology, University of Perugia, starting from the provocative title of a review “Bronchial hyperresponsiveness is not bronchial hyperresponsiveness is not bronchial asthma” (Pauwels 1988*) provided different take home messages on the importance of testing bronchial hyperreactivity (not only with methacholine) in asthma but not just in asthma.

The day session ended with a paper discussion.

The topic of the first morning session on Wednesday March 12th was: Occupation, Asthma and COPD.

Professor Paul D. Blanc with the lecture “Occupational burden of Asthma and COPD” provided a summary of current
data. The main messages were: occupational exposure is causally related to asthma and COPD with a PAR% (Population Attributable Risk %) median value of 15% for each one; smoking habit seems to give an additive effect.

The lecture “Exacerbation of asthma and COPD” by Professor Jonas Brisman dealt with work-exacerbated asthma (WEA) and all the occupational and environmental factors able to cause it.

The following session was: Air Pollution. Professor Lars Barregård taught two lectures about this argument: “Air pollution and cardiovascular disease” and “Air pollution, asthma and COPD”. Exposure to air particulates, above all particles smaller than 2.5 micrometers (PM 2,5), is very harmful and it increases total mortality (especially for cardiovascular diseases, respiratory diseases and lung cancer). Mechanisms involved in pathogenesis are mainly due to 3 biological pathways capable to cause systemic oxidative stress and inflammation highly linked to cardiovascular events. Domestic wood smoke is a common source of PM emission worldwide. Hospital admissions due to respiratory diseases (mainly due to exacerbation of COPD and asthma) increase when outdoor air pollution levels are high. Pulmonary inflammation with oxidative stress in the airways caused by particles seems to be the main pathological mechanism.

After lunch the theme session was Interstitial Lung Diseases. Professor Paul D. Blanc with the lecture “Mineral dusts and fibres” showed an up-to-date of scientific knowledge about well known pathognomonic interstitial diseases (like silicosis, coal worker’s pneumoconiosis, asbestosis), chronic beryllium disease (CBD), hard metal lung disease, and pulmonary fibrosis due to minerals.

The title of the second lecture by Professor Giacomo Muzi, Director of the Post-graduate School of Occupational Medicine at the University of Perugia, was “Hypersensitivity pneumonitis” with a current in-depth analysis of this complex and multifaceted disorder a very intriguing subject in Occupational Medicine.

This afternoon session ended with a case discussion.

On Thursday March 13th there was an historic journey thanks to the last lecture “Occupational lung diseases – From the times of Ramazzini until today” by Professor Paul D. Blanc.

During the closing of the course Professor Kjell Torén and Professor Giacomo Muzi provided certificates of attendance for all participants and it was a good opportunity to say goodbye each other.

This event was without any doubt a novelty in the Italian teaching system. A key point was the opportunity for young physicians to meet and relate to internationally reknowned professors in Occupational Medicine. Another key point of the event was the given opportunity for all participants to socialize (also befriending) and to share ideas,
residency experiences and future expectations.

What were the main lessons from this course?

Probably the main lessons were that there is a place also in Italy for this way of teaching Occupational Medicine and that Italian resident students from different Postgraduate Schools are able to appreciate it and can take advantage of it.

Lucio Fellone ( /


*  Pauwels R, Joos G, Van der Straeten Bronchial hyperresponsiveness is not bronchial hyperresponsiveness is not bronchial asthma.  M.Clin Allergy. 1988 Jul; 18(4):317-21. []

Organizing Committee of the Course:
Giuseppe Abbritti, MD, Università degli Studi di Perugia, Italy
Paul Blanc, MD, University of California San Francisco,USA
Jonas Brisman, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden
Giacomo Muzi, MD, Università degli Studi di Perugia, Italy
Anna-Carin Olin, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden
Kjell Torén, MD, PhD, University of Gothenburg, Gothenburg, Sweden

Course Faculty:
Gösta Axelsson, PhD, University of Gothenburg, Gothenburg, Sweden
Paul D Blanc, MD, University of California, San Francisco,USA
Jonas Brisman, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden
Nicola Murgia, MD, Università degli Studi di Perugia, Italy
Giacomo Muzi, MD, Università degli Studi di Perugia, Italy
Anna-Carin Olin, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden
Kjell Torén, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden
Lars Barregård, MD, PhD, Sahlgrenska Academy, Gothenburg, Sweden

A link to the programme here.




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