• Antonia Stazi1

  1. Istituto superiore di sanità, Roma

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Ricerca bibliografica 25 settembre 2010 -17 gennaio 2011

Di ogni articolo è disponibile l'abstract. Per visualizzarlo basta cliccare sul titolo.

1. Sicolo M, Tringali M, Fumagalli P, Santagostino A. Columba livia as a sentinel species for the assessment of urban air genotoxicity. Arch Environ Contam Toxicol. 2010 Oct;59(3):484-91. Epub 2010 Mar 13.
Department of Environmental Sciences, University of Milan-Bicocca,
This study explored the comet assay as a possible tool to assess genotoxicity in erythrocytes of Columba livia to detect genotoxic effects induced by exposure to urban air pollution. Fieldwork was conducted between June 2004 and June 2005 in the city of Milan, Italy, by sampling pigeons in different areas almost twice a week. Six air contaminants-CO, PM10, NO(2), O(3) (ozone), SO(2), and C6H6-plus polycyclic aromatic hydrocarbons (PAHs) in fine particles, temperature, and ultraviolet index, were considered. Genotoxicity levels, expressed as %DNA migrated, tail moment, and damage index (DI), were always higher in wild pigeons than in pigeons living indoors (controls). Animals exposed to urban air showed significant differences from season to season, and the genotoxic parameters presented the highest values in summer (45.30% +/- 1.40% %DNA migrated, 12.73 +/- 0.80 tail moment, and 22.30 +/- 0.15 x DI x 10(-1)); regression analyses showed a positive relation between DI and O(3) concentrations (P < 0.001). The use of the comet assay DI parameter as a rapid assessment of incipient genotoxic risk by pollution, as measured in C. livia living in urban areas, is also discussed.

Commento a cura di Antonia Stazi
In questo studio, condotto a Milano tra giugno 2004 e giugno 2005, gli autori propongono l’utilizzo di un animale sentinella, il piccione o columba livia, per monitorare i possibili effetti genotossici dell’inquinamento urbano in diverse aree della città. Per quantificare i danni al DNA delle cellule nucleate del sangue di piccioni campionati nelle quattro stagioni in sei aree di Milano e di piccioni di controllo “indoor” è stato utilizzato il comet test, che misura in maniera rapida, semplice e altamente sensibile le rotture del DNA. Per le stesse sei aree e nello stesso giorno di campionamento dei piccioni sono stati resi disponibili dall’ARPA i livelli dei principali contaminanti dell’aria. I risultati indicano una sostanziale differenza tra i risultati del test eseguiti negli animali outdor rispetto ai controlli, mentre le differenze tra le sei aree sono minime. C’è invece un effetto importante della stagione di campionamento, che si esplica sostanzialmente con i livelli di ozono a livello stradale, prodotto della interazione tra NO2 e calore. L’effetto genotossico dell’ozono è stato già dimostrato in studi animali e sulle piante. Questo studio, oltre ad essere estremamente interessante per il tipo di modello proposto, pone il problema del possibile rumore di fondo “stagionale” nei risultati dei test genotossici, dal momento che il comet test viene sempre più spesso usato in tossicologia per valutare il rischio carcinogenico da esposizioni ambientali e occupazionali a agenti mutageni.

2. Gigli F, Zattoni F, Valotto C, Bernardin L, Pozzi R, Zattoni F. Correlation between pathologic features and perfusion CT of renal cancer: a feasibility study. Urologia. 2010 Oct-Dec;77(4):223-31.
Clinica Urologica, Università di Padova, Padova - Italy.

Objectives. The computerized tomography with perfusion technique (pCT) has proved to have some potentialities in the oncologic field as a possible tool to identify neoangiogenesis in vivo. The purpose of the present job is to test the correlations existing between perfusion data and pathologic features in the evaluation of vascularization in kidney cancer.
Methods. 6 patients with clinical diagnosis of renal tumor awaiting surgical treatment underwent preoperatively pCT scans. Axial images encompassing the greatest diameter of the cancer were compared with the respective histological sections.
Results. A correlation between tumor histological subtype and perfusion index was observed and shown. Moreover, clear cell RCC of different Fuhrman grades showed statistically significant differences in perfusion values (T test). Specifically, high perfusion indexes were associated with high density of microvessels with abnormal architecture at the microscopic evaluation of tumor specimen. Conversely, lower perfusion index were detected in tumors with lower microvascular density?
Conclusions. pCT scans can provide significant data on tumor angiogenesis and, eventually, suggest tumor histological subtype. The possibility of identifying preoperatively tumor histotype can be of particular relevance in patients with small renal tumors, suitable for minimally-invasive surgery or active surveillance program.

3. Dorigo W, Pulli R, Nesi M, Alessi Innocenti A, Pratesi G, Inzitari D, Pratesi C. Urgent Carotid Endarterectomy in Patients with Recent/Crescendo Transient Ischaemic Attacks or Acute Stroke. Eur J Vasc Endovasc Surg. 2010 Dec 31. [Epub ahead of print]
Department of Vascular Surgery, University of Florence, Florence, Italy.
OBJECTIVES: Objective of this study was to review the results of urgent carotid endarterectomy (CEA) performed in patients with recent (<24 h) or crescendo (at least 2 episodes in 24 h) transient ischaemic attack (TIA) or with acute stroke in a single centre experience.
MATERIALS AND METHODS: From January 2000 to December 2008, 75 patients underwent urgent CEA for severe internal carotid artery stenosis and recent/crescendo TIA (51 patients, TIA group) or acute stroke (24 patients, stroke group). In patients with acute stroke the intervention was proposed on the basis of clinical and instrumental features (patient conscious, patency of middle cerebral artery, no lesions or limited brain infarction at CT scan) according to neurologists' suggestion. Data from all the interventions were prospectively collected in a dedicated database, which included main pre-, intra- and postoperative parameters. Independent neurological assessment with National Institute of Health Stroke Scale (NIHSS) score calculation was performed before the operation and within the 30th postoperative day. Early (<30 days) results were evaluated in terms of mortality, modifications in NIHSS values and stroke and death rates. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6 and 12 months and yearly thereafter. Follow-up results (survival, occurrence of ipsilateral stroke in TIA group, recurrence of stroke in stroke group) were analysed by Kaplan-Meier curves.
RESULTS: Among patients presenting with TIA, 28 had crescendo TIAs and 23 had a recent TIA; In stroke group, two patients had a stroke in evolution, eight patients had a recent major non-disabling stroke and 14 patients had a recent minor stroke. Preoperative mean value of NIHSS score in stroke group was 4.7 (SD 3.2). There were 2 perioperative (<30 days) deaths, both in stroke group, in one case due to acute respiratory failure and to fatal stroke in the other one (preoperative NIHSS value 9, postoperative 17), with a cumulative 30-day mortality rate of 2.7%, significantly higher in stroke group (8.3%) than in TIA group (no death, p = 0.03). No postoperative cerebral haemorrhage occurred. In TIA group one postoperative major stroke occurred, with a 30-day stroke and death rate of 1.9%. In surviving patients of stroke group NIHSS value improved in 13 cases, with a mean improvement of 2 points (SD 0.9); in 8 cases the value remained unchanged, while in the remaining case it increased from 2 to 4. Mean postoperative NIHSS score in stroke group was 3.9 (SD 3.7), significantly reduced in comparison with preoperative value (p < 0.001). Mean duration of follow-up was 34 months (SD 28.1). No ipsilateral stroke in patients of TIA group occurred; in stroke group a recurrent fatal stroke at 1 postoperative month was recorded. Estimated 48-month stroke-free survival rate TIA group was 95% and 79% in stroke group (p = 0.02).
CONCLUSIONS: Urgent CEA in patients with recent/crescendo TIA provided in our experience excellent results, with low rates of perioperative and late stroke. In selected patients with acute stroke early surgery seems to provide acceptable results.
4. Ansaldi F, Canepa P, de Florentiis D, Bandettini R, Durando P, Icardi G. Increasing incidence of serotype 19A Streptococcus pneumoniae and emergence of vaccine escape recombinants ST695 in Liguria, Italy, seven years after PCV7 implementation. Clin Vaccine Immunol. 2010 Dec 22. [Epub ahead of print]
Department of Health Sciences University of Genoa, Italy; "San Martino" University Hospital, Genoa, Italy; I.R.C.C.S. "Giannina Gaslini", Genoa, Italy.
Two serotype 19A (ST695) Streptococcus pneumoniae vaccine escape recombinant strains due to capsular switching events were detected by a laboratory surveillance system, integral part of vaccination programme starting in Liguria, Italy, in May 2003, an Italian administrative region with long-lasting high coverage, unusual in Europe. To our knowledge, this is the first detection of capsular switching occurrence outside USA.
5. Baldissera S, Campostrini S, Binkin N, Minardi V, Minelli G, Ferrante G, Salmaso S; PASSI Coordinating Group. Features and initial assessment of the Italian Behavioral Risk Factor Surveillance System (PASSI), 2007-2008. Prev Chronic Dis. 2011 Jan;8(1):A24. Epub 2010 Jun 15.
Collaborators: D'Argenio P, De Mei B, Fontana G, Perra A, Possenti V, Bertozzi N,Carrozzi G, D'Argenzio A, Fateh-Moghadam P, Trinito MO, Vasselli S, Benelli E,Menna S. National Institute of Public Health, Rome, Italy.
INTRODUCTION: Surveillance systems for health status and behaviors of populations are fundamental for planning, implementing, and monitoring preventive interventions. In 2006, the Italian Ministry of Health provided funding to the National Institute of Public Health to develop an ongoing surveillance system for adult behavioral risk factors. We describe the main features of the system (known as PASSI) and provide a preliminary assessment of its activity.
METHODS: PASSI is conducted by participating local health units, which use a common questionnaire and methods. Each month, local health unit staff conduct telephone interviews of a random sample of resident adults aged 18 to 69 years. Data are transmitted to the national coordinating center, where they are cleaned, managed, and made available for local, regional, and national analysis. Training, data analysis, and communications are centrally supervised, and data quality is routinely monitored.
RESULTS: In 2007 and 2008, nearly 60,000 interviews were completed. The demographic characteristics of survey participants closely corresponded to census data in the surveyed areas. The response rate was 82%; the refusal rate was 10% or less. Communications activities have been conducted to disseminate the results and encourage their use.
CONCLUSION: PASSI is administered by the public health system with limited human and financial resources. In the first 2 years of activity, the data quality was good, and information collected was useful. The organizational model of PASSI may be of interest to countries that are developing surveillance systems as well as those with systems already in place.
6. Baracchini C, Tonello S, Meneghetti G, Ballotta E. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology. 2010 Nov 23;75(21):1864-70. Epub 2010 Oct 20.
Department of Neurological Sciences, School of Medicine, University of Padua, Padova, Italy.
Comment in: Neurology. 2010 Nov 23;75(21):1858-9.
OBJECTIVE: To monitor the sonographic course of spontaneous cervical artery dissections (sCADs) and investigate their recanalization and recurrence rates.
METHODS: All consecutive patients with an MRI-proven sCAD were prospectively evaluated by neurovascular ultrasound (nUS) daily while in hospital, then monthly for the first 6 months after discharge and every 6 months thereafter, for a mean follow-up period of 58 months (range, 28-96 months).
RESULTS: A total of 105 sCADs were detected in 76 patients: 61 (58.1%) involved the internal carotid artery and 44 (41.9%) the vertebral artery, while multiple sCADs were found in 4 patients (5.3%). Follow-up was obtained in 74 patients (97.3%, 103 vessels). The complete and hemodynamically significant (<50% stenosis) recanalization rates were 51.4% (53/103) and 20.4% (21/103). All but one complete recanalization occurred within the first 9 months. There were early recurrences (while in hospital) in 20 previously unaffected arteries (26.3%) and late recurrences in 2 arteries (2.7%), site of a previous sCAD. All patients (n = 6) with a family history of arterial dissection had a sCAD recurrence (4 early and 2 late) as opposed to 16 (22.8%) among those with no known familial disease (p < 0.001).
CONCLUSIONS: These results suggest that most lumen changes occur within the first few months after the initial event, but recanalization may occur even after 1 year. Early recurrence is not uncommon and usually involves arteries previously unaffected by dissection, while the risk of late recurrence is low. A family history of arterial dissection is strongly associated with sCAD recurrence.
7. Degrate L, Garancini M, Misani M, Poli S, Nobili C, Romano F, Giordano L, Motta V, Uggeri F. Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections. Int J Colorectal Dis. 2011 Jan;26(1):61-9. Epub 2010 Oct 5.
Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy,
PURPOSE: Surgical site infections (SSIs) are the most common infections in colorectal surgery. Although some studies suggest that rectal surgery differs from colon surgery for SSI incidence and risk factors, the National Nosocomial Infection Surveillance system categorizes all colorectal surgeries into only one group. The aim of this study was to determine incidence, characteristics, and risk factors of SSIs according to the subclassification of colorectal surgery into right colon surgery (RCS), left colon surgery (LCS), and rectum surgery (RS).
METHODS: From November 2005 to July 2009, all patients requiring colorectal resectioning were enrolled into our program. The outcome of interest was an SSI diagnosis. Univariate and multivariate analyses were performed to determine SSI predictors in each group.
RESULTS: Two hundred seventy-seven consecutive colorectal resections were analyzed. SSI rates were 8% in RCS, 18.4% in LCS, and 17.6% in RS. LCS and RS showed significantly higher SSI incidences (p = 0.022) and greater rates of organ/space infections compared to RCS (p = 0.029). Predictors of SSI were steroid use among RCS, age greater than 70 years, multiple comorbidities, steroid use, non-neoplastic colonic disease, urgent operation, ostomy creation, postoperative intensive care among LCS, preoperative chemoradiation, heart disease, and prolonged operation among RS patients. On multivariate analysis, the coupled LCS and RS groups showed an increased risk for SSI compared to RCS (OR, 2.57).
CONCLUSIONS: SSI incidences, characteristics, and risk factors seem to be different among RCS, LCS, and RS. A tailored SSI surveillance program should be applied for each of the three groups, leading to a more competent SSI recognition and reduction of SSI incidence and related costs.
8. Camilloni L, Rossi PG, Farchi S, Chini F, Borgia P, Guasticchi G. Triage and Injury Severity Scores as predictors of mortality and hospital admission for injuries: a validation study. Accid Anal Prev. 2010 Nov;42(6):1958-65. Epub 2010 Jul 2.
Public Health Agency of Lazio Region. Via di Santa Costanza, 53, 00198 Rome, Italy.
BACKGROUND: Many emergency departments use a rating system to establish priority based on urgency: "triage". The aim of this study was to evaluate the validity of triage in predicting hospitalizatio
n and mortality compared to that of the ICD-9-CM based Injury Severity Score (ISS).
METHODS: Sources: The Emergency Information System 2000, the Hospital Information System 2000-2001 and the Mortality Register 2000-2001, of the Lazio Region. Case selection: Emergency department visits for traumas that occurred on the road or at home. Outcomes: Hospitalization and 30-day mortality. For each case, trauma diagnoses from the ICD-9-CM were given a corresponding ISS value. We performed logistic models, including age, sex and, alternatively, triage or ISS. We compared discrimination measures and calibration of the models.
RESULTS: Out of 264,709 emergency department visits, 22,249 (8.4%) were followed by a hospitalization and 655 (0.2%) died within 30 days. ISS scores were calculated for 72,179 (27%) cases. Of the most urgent triage (840 patients), 78.3% (658) were hospitalized and 9% (76) died, while among patients with ISS > or = 16 value (1276) 36.4% (464) of were hospitalized and 1.8% (23) died. Measures of discrimination and calibration showed similar results. The triage model had a better fitness in predicting hospitalization probability for home accidents (Hosmer-Lemeshow statistic: chi(2)(triage)=5.5 vs chi(2)(ISS)=34.3) and had a better performance for road accidents (ROC(triage)=0.71 vs ROC(ISS)=0.66). There were no differences between the models in predicting the probability of death.
CONCLUSIONS: The agreement between the two scales confirms the validity of triage as a clinical management tool in the emergency department, and as a proxy of trauma severity.
9. Storelli MM, Barone G, Cuttone G, Giungato D, Garofalo R. Occurrence of toxic metals (Hg, Cd and Pb) in fresh and canned tuna: public health implications. Food Chem Toxicol. 2010 Nov;48(11):3167-70. Epub 2010 Aug 20.
Pharmacological-Biological Department, Veterinary Medicine Faculty, University of Bari, Valenzano (Ba), Italy.
Hg, Pb and Cd levels in fresh and canned tuna were determined and assessed by comparing element levels in these samples with maximum permissible limits set by European legislation. The estimated weekly intakes by human consuming both fresh and canned tuna were also evaluated for possible consumer health risks. Among tested metals, Hg had the highest concentrations, followed by Pb and Cd either in fresh tuna or canned tuna. None of the tested samples surpassed the European regulatory limits fixed for Cd and Pb, whereas 8.9% of the tuna cans and 20% of fresh tuna samples exceeded standard for Hg. The size of tuna was a determining factor of Hg burden. A high intake of Hg surpassing the toxicological reference value established by WHO, was associated with consumption of larger size tuna specimens. Also canned tuna consumption with Hg concentrations higher than 1 μg kg(-1), strongly increased the consumer exposure. In contrast, Cd and Pb weekly intakes through consumption either of fresh tuna or canned tuna did not exceed the toxicological reference values established by WHO, and consequently there was no human health risk. A continuous surveillance system of Hg content in these fishery products is crucial for consumer protection.
10. Masia MD, Barchitta M, Liperi G, Cantù AP, Alliata E, Auxilia F, Torregrossa V, Mura I, Agodi A; Italian Study Group of Hospital Hygiene (GISIO). Validation of intensive care unit-acquired infection surveillance in the Italian SPIN-UTI network. J Hosp Infect. 2010 Oct;76(2):139-42. Epub 2010 Jul 14.
Hygiene and Preventive Medicine Institute, University of Sassari, Italy.
Validity is one of the most critical factors concerning surveillance of nosocomial infections (NIs). This article describes the first validation study of the Italian Nosocomial Infections Surveillance in Intensive Care Units (ICUs) project (SPIN-UTI) surveillance data. The objective was to validate infection data and thus to determine the sensitivity, specificity, and positive and negative predictive values of NI data reported on patients in the ICUs participating in the SPIN-UTI network. A validation study was performed at the end of the surveillance period. All medical records including all clinical and laboratory data were reviewed retrospectively by the trained physicians of the validation team and a positive predictive value (PPV), a negative predictive value (NPV), sensitivity and specificity were calculated. Eight ICUs (16.3%) were randomly chosen from all 49 SPIN-UTI ICUs for the validation study. In total, the validation team reviewed 832 patient charts (27.3% of the SPIN-UTI patients). The PPV was 83.5% and the NPV was 97.3%. The overall sensitivity was 82.3% and overall specificity was 97.2%. Over- and under-reporting of NIs were related to misinterpretation of the case definitions and deviations from the protocol despite previous training and instructions. The results of this study are useful to identify methodological problems within a surveillance system and have been used to plan retraining for surveillance personnel and to design and implement the second phase of the SPIN-UTI project.
11. Ajelli M, Merler S, Pugliese A, Rizzo C. Model predictions and evaluation of possible control strategies for the 2009 A/H1N1v influenza pandemic in Italy. Epidemiol Infect. 2011 Jan;139(1):68-79. Epub 2 010 Jun 14.
Predictive Models for Biomedicine & Environment, Bruno Kessler Foundation, Trento, Italy.
We describe the real-time modelling analysis conducted in Italy during the early phases of the 2009 A/H1N1v influenza pandemic in order to estimate the impact of the pandemic and of the related mitigation measures implemented. Results are presented along with a comparison with epidemiological surveillance data which subsequently became available. Simulated epidemics were fitted to the estimated number of influenza-like syndromes collected within the Italian sentinel surveillance systems and showed good agreement with the timing of the observed epidemic. On the basis of the model predictions, we estimated the underreporting factor of the influenza surveillance system to be in the range 3·3-3·7 depending on the scenario considered. Model prediction suggested that the epidemic would peak in early November. These predictions have proved to be a valuable support for public health policy-makers in planning interventions for mitigating the spread of the pandemic.
12. De Lisi S, Peralta S, Arini A, Simone F, Craxì A. Oesophagogastroduodenoscopy in patients with cirrhosis: Extending the range of detection beyond portal hypertension. Dig Liver Dis. 2011 Jan;43(1):48-53. Epub 2010 May 14.
Di.Bi.M.I.S., University of Palermo, Italy.
BACKGROUND: Oesophagogastroduodenoscopy is currently recommended for the screening of varices in cirrhosis. In addition to the assessment of varices, oesophagogastroduodenoscopy can detect conditions that, while unrelated to portal hypertension, may require treatment.
AIMS: We evaluated in a large cohort of cirrhotic patients the prevalence of upper digestive findings other than oesophagogastric varices, the associations between upper gastrointestinal findings, portal hypertension and features of cirrhosis, and the incidence of new lesions in the course of a surveillance program.
METHODS: Analysis of the records of 611 consecutive cirrhotic patients undergoing oesophagogastroduodenoscopy for screening and surveillance.
RESULTS: 232 patients (38%) presented endoscopic lesions not related to portal hypertension: peptic diseases (n=193), proliferative diseases (n=27) and vascular diseases (n=12). In the screening group, 127 patients (39.4%) had pathologic lesions. At multivariate analysis, an association was found between peptic diseases and the absence of portal hypertensive gastropathy (RR 3.3; 95% CI 2.2-4.8); vascular diseases were associated with endoscopic signs of portal hypertension (p=0.01). During surveillance, 9/55 patients (16.3%) in the group without previous pathologic findings developed new lesions.
CONCLUSIONS: Oesophagogastroduodenoscopy in patients with cirrhosis undergoing endoscopy for screening diagnosed pathologic lesions unrelated to portal hypertension requiring a change in management in 39.4% of asymptomatic subjects.
13. Calzolari M, Bonilauri P, Bellini R, Caimi M, Defilippo F, Maioli G, Albieri A, Medici A, Veronesi R, Pilani R, Gelati A, Angelini P, Parco V, Fabbi M, Barbieri I, Lelli D, Lavazza A, Cordioli P, Dottori M. Arboviral survey of mosquitoes in two northern Italian regions in 2007 and 2008. Vector Borne Zoonotic Dis. 2010 Nov;10(9):875-84. Epub 2010 Apr 6.
Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna B.Ubertini, Brescia, Italy.
Recently, Italy-particularly the Emilia-Romagna region-was the location of consecutive outbreaks of human diseases caused by the arboviruses chikungunya virus and West Nile virus. The two outbreaks, spread by different species of mosquitoes, were not related, but pointed out the lack of an arboviral surveillance program in this region. Beginning in 2007 entomological surveillance was initiated in the Emilia-Romagna region, and in 2008 the program was improved and extended at Lombardia region. Using CO(2)-baited traps, 65,292 mosquitoes were collected; pooled by date of collection, location, and species; macerated manually; and tested by reverse transcription (RT)-polymerase chain reaction for the presence of alphaviruses, orthobunyaviruses, and flaviviruses. Amplicons were sequenced and employed for identification of viral RNA by basic local alignment search tool search in GenBank. Results of these assays showed (1) the presence of West Nile virus in two pools of Culex pipiens mosquitoes, (2) the presence of RNA of two orthobunyaviruses, Tahyna virus in a pool of Ochlerotatus caspius mosquitoes and Batai virus in a pool of Anopheles maculipennis mosquitoes, and (3) the presence of flavivirus RNAs in pools of Oc. caspius, Aedes albopictus, and Aedes vexans mosquitoes; the sequences of these amplicons were most closely related to flaviviruses that have been detected only in mosquitoes and had no recognized vertebrate host (Aedes flavivirus, Culex flavivirus, and Kamiti River virus).

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14. Di Novi C. The influence of traffic-related pollution on individuals' life-style: results from the BRFSS. Health Econ. 2010 Nov;19(11):1318-44.
University of Eastern Piedmont, Polis-Public Policy and Choice, Alessandria, Italy.
This paper employs the Behavioral Risk Factor Surveillance System (2001) data in conjunction with the Environmental Protection Agency's Air Quality System data to investigate how air pollution caused by motor vehicle emissions affects the likelihood of good health and the amount of health investments. Models are estimated using three different measures of overall health: a measure of self-assessed health and two health outcome indicators (asthma and blood pressure). A multivariate probit approach is used to estimate recursive systems of equations for self-assessed health, health outcomes and life-styles. The most interesting result concerns the influence of pollution on health-improving life-style choices: only if traffic pollution is in the 'satisfactory range' (AQI level at or below 100), individuals will have incentive to invest in health.