Clinical standards for diagnosis, treatment and prevention of post-COVID-19 lung disease

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice' care for the diagnosis, treatment and prevention of post-COVID-19 lung disease.METHODS: A panel of international experts representing scientific societies, associations and groups active in post-COVID-19 lung disease was identified; 45 completed a Delphi process. A 5-point Likert scale indicated level of agreement with the draft standards. The final version was approved by consensus (with 100% agreement).RESULTS: Four clinical standards were agreed for patients with a previous history of COVID-19: Standard 1, Patients with sequelae not explained by an alternative diagnosis should be evaluated for possible post-COVID-19 lung disease; Standard 2, Patients with lung function impairment, reduced exercise tolerance, reduced quality of life (QoL) or other relevant signs or ongoing symptoms ≥4 weeks after the onset of first symptoms should be evaluated for treatment and pulmonary rehabilitation (PR); Standard 3, The PR programme should be based on feasibility, effectiveness and cost-effectiveness criteria, organised according to local health services and tailored to an individual patient's needs; and Standard 4, Each patient undergoing and completing PR should be evaluated to determine its effectiveness and have access to a counselling/health education session.CONCLUSION: This is the first consensus-based set of clinical standards for the diagnosis, treatment and prevention of post-COVID-19 lung disease. Our aim is to improve patient care and QoL by guiding clinicians, programme managers and public health officers in planning and implementing a PR programme to manage post-COVID-19 lung disease.

Global Asthma Network Phase I Syria asthma surveillance and the impact of the war

Background

Asthma is the most prevalent chronic respiratory disease (CRD) in children. It causes extensive morbidity and mortality worldwide. Since the International Study of Asthma and Allergies in Childhood (ISAAC Phase III 2001-3), there have been no worldwide standardised surveys of prevalence and severity of asthma in school children. The Global Asthma Network (GAN) Phase I aims to provide this information. We participated in GAN with the aim of tracking changes in Syria and comparing the results to those of ISAAC Phase III. We also aimed to track the impact of war pollutants and stress.

Methods

GAN Phase I, following the same methodology of ISAAC in a cross-sectional study. The same ISAAC questionnaire translated into Arabic was repeated. We added questions about displacement from home, and the impact of war pollutants. We also added the Depression, Anxiety and Stress Scale (DASS Score). In this article, we focused on the prevalence of 5 core asthma indicators (wheezing in the past 12 months, wheezing ever, severe wheeze, exercise wheeze and night cough) in adolescents from two centres in Syria: Damascus and Latakia. Additionally, we investigated the impact of the war on our two centres, while the DASS score was investigated only in Damascus. We surveyed 1,100 adolescents from 11 schools in Damascus and 1,215 adolescents from 10 schools in Latakia.

Results

In Syria, which is a low-income country, wheeze prevalence before the war in ISAAC III was 5.2% for 13-14-year-old, whilst it was 19.28% in GAN during the war. Prevalence of severe asthma symptoms was 2.5% in ISAAC III and 12.8% in GAN. Wheezing appearing after the war or becoming more severe was statistically significant p=0.0001. War is associated with higher exposure to new environmental chemicals and pollutants and higher anxiety and depression scores.

Conclusions

It is paradoxical to note that in Syria, current wheeze and severity are much higher in GAN (19.8%) than in ISAAC III (5.2%), which seems positively associated with war pollution and stress.

Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study

BACKGROUND

Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings.

METHODS

We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015-20). A validated, written questionnaire was distributed via schools to three age groups (children, 6-7 years; adolescents, 13-14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group.

FINDINGS

Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3-85·3% participants) and inhaled corticosteroids (12·6-51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40-3·15] for children; 2·45 [2·25-2·67] for adolescents; and 2·75 [2·38-3·16] for adults) or any type of oral medicine (1·86 [1·63-2·12] for children; 1·53 [1·40-1·68] for adolescents; and 1·78 [1·55-2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32-4·14] for children; 3·46 [1·83-6·54] for adolescents; and 4·86 [2·55-9·26] for adults).

INTERPRETATION

Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries.

FUNDING

International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca, UK National Institute for Health Research, UK Medical Research Council, European Research Council, the Spanish Instituto de Salud Carlos III.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

The World Organization of Family Doctors Air Health Train the Trainer Program: lessons learned and implications for planetary health education

The World Organization of Family Doctors (WONCA) Air Health Train the Trainer Program was a pilot educational programme that focused on a key aspect of planetary health: the intersection of air pollution, human health, and climate change. In this Viewpoint, we-the coordinators of the training programme and some of the most active trainers-briefly describe the programme and discuss implementation successes, challenges, and lessons learned, which relate to the creation and use of training materials appropriate for health professionals in low-income and middle-income countries, strategies to improve the retention of trainers to deliver activities in their communities, and the development of stronger networks and further tools to support trainers. These findings could be applied to future education and training programmes.

PROPENSIX: pressure garment therapy using compressive dynamic Lycra® sleeve to improve bi-manual performance in unilateral cerebral palsy: a multicenter randomized controlled trial protocol

Background

Upper limb impairment affects activity and participation in children with unilateral cerebral palsy (UCP). Pressure garment therapy (PGT) using compressive dynamic Lycra^® garments is an innovative intervention proposed for the management of cerebral palsy consequences. The PROPENSIX study aims to evaluate the efficacy of a therapy using a Lycra^® sleeve as compared to a placebo sleeve to improve bi-manual performance measured by the Assisting Hand Assessment (AHA) in children with unilateral cerebral palsy.

Methods

The PROPENSIX trial is a multicenter, prospective, placebo-controlled, double-blinded, randomized study. One hundred children with UCP, aged from 5 to 10, are randomly assigned as soon as they are recruited in a 1:1 ratio to perform usual daily activities, especially activities involving bimanual performances, with Lycra^® sleeve or placebo sleeve during 6 months. The primary endpoint is the change in bimanual performance from inclusion to 6 months, evaluated by AHA. The secondary endpoints evaluate changes from inclusion to 6 months in other dimensions of the International Classification of Functioning (ICF), upper limb movement capacity assessed by Quality of Upper Extremity Skill Test (QUEST), and health-related quality of life evaluated by Pediatric Quality of Life Inventory 3.0 Cerebral Palsy Module (PedsQLTM 3.0 CP Module) and in body structures and functions domain assessed by neuro-orthopedic examination and somatosensory evoked potentials (SEP).

Discussion

The PROPENSIX study is the largest randomized controlled trial (RCT) aiming to evaluate the efficacy of a PGT using compressive dynamic Lycra^® sleeve in UCP. Enhancement of children’s bimanual performance at the end of the 6 months wear of the Lycra^® sleeve should improve evidence regarding this type of treatment and expand discussion about their recommendation in clinical practice. Data from secondary outcomes assessments should bring interesting arguments to discuss the Lycra^® sleeve action on mobility, tonus, and sensory impairments in children with unilateral cerebral palsy.

Trial registration

ClinicalTrials.govNCT02086214. Retrospectively registered on March 13, 2014

Trial status

Study start data: December 2012. Recruitment status: completed. Primary completion date: April 2021. Estimated study completion date: December 2022. Protocol version 10 (date: February 2018).

Differentiation of COVID-19 signs and symptoms from allergic rhinitis and common cold: An ARIA-EAACI-GA2 LEN consensus

Background

Although there are many asymptomatic patients, one of the problems of COVID‐19 is early recognition of the disease. COVID‐19 symptoms are polymorphic and may include upper respiratory symptoms. However, COVID‐19 symptoms may be mistaken with the common cold or allergic rhinitis. An ARIA‐EAACI study group attempted to differentiate upper respiratory symptoms between the three diseases.

Methods

A modified Delphi process was used. The ARIA members who were seeing COVID‐19 patients were asked to fill in a questionnaire on the upper airway symptoms of COVID‐19, common cold and allergic rhinitis.

Results

Among the 192 ARIA members who were invited to respond to the questionnaire, 89 responded and 87 questionnaires were analysed. The consensus was then reported. A two‐way ANOVA revealed significant differences in the symptom intensity between the three diseases (p < .001).

Conclusions

This modified Delphi approach enabled the differentiation of upper respiratory symptoms between COVID‐19, the common cold and allergic rhinitis. An electronic algorithm will be devised using the questionnaire.

Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin‐converting enzyme 2 (ACE2). As a result of SARS‐CoV‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT₁R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT₁R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects, helpful in mitigating COVID‐19 severity.

ARIA digital anamorphosis: Digital transformation of health and care in airway diseases from research to practice

Digital anamorphosis is used to define a distorted image of health and care that may be viewed correctly using digital tools and strategies. MASK digital anamorphosis represents the process used by MASK to develop the digital transformation of health and care in rhinitis. It strengthens the ARIA change management strategy in the prevention and management of airway disease. The MASK strategy is based on validated digital tools. Using the MASK digital tool and the CARAT online enhanced clinical framework, solutions for practical steps of digital enhancement of care are proposed.

A global respiratory perspective on the COVID-19 pandemic: commentary and action proposals

The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1, 2]. The World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on 11 March, 2020, demanding effective national and global mitigation measures, strong public health response and coordination. To date, the SARS-CoV-2 pandemic has affected over 5 million individuals worldwide with an overall 7.02% (median 3.41%, ranges 0.06% to 31.25%) case fatality ratio (European Center for Disease Prevention and Control dashboard: www.ecdc.europa.eu , as of 22 May, 2020) [3]. This ratio may be overstated since it is based primarily on hospitalised or notified cases.

This paper offers practical and feasible actions to be implemented at patient, healthcare provider and community level to combat COVID-19 while attending, maintaining and strengthening ongoing health management in people with lung diseases https://bit.ly/30yNyhP

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Comparison of autofluorescence and white-light bronchoscopies performed with the Evis Lucera Spectrum for the detection of bronchial cancers: a meta-analysis

Background

Many recent studies have reported that autofluorescence bronchoscopy (AFB) has a superior sensitivity and decreased specificity in the diagnosis of bronchial cancers when compared with white-light bronchoscopy (WLB). We specifically analyzed the diagnostic performances of autofluorescence imaging video bronchoscopy (AFI) performed with the Evis Lucera Spectrum from Olympus, which is a relatively novel approach in detecting and delineating bronchial cancers, and compared it to the older WLB method.

Methods

We searched the PubMed, Embase, Web of Science, and CNKI databases from inception to July 12^th, 2018 for trials in which patients were diagnosed with lung cancer via concurrent or combined use of AFI and WLB. The included studies were required to have a histologic diagnosis as the gold standard comparison, and a sufficient amount of data was extracted to assess the diagnostic capacity. A 2×2 table was constructed, and the area under the receiver-operating characteristic curve (AUC) of AFI and WLB was estimated by using a stochastic model for diagnostic meta-analysis using STATA software.

Results

A total of 10 articles were eligible for the meta analysis, comprising 1,830 patients with complete data included in the analysis. AFI showed a superior sensitivity of 0.92 (95% CI, 0.88-0.95) over WLB's 0.70 (95% CI, 0.58-0.80) with P<0.01, and a comparable specificity of 0.67 (95% CI, 0.51-0.80) compared with WLB's 0.78 (95% CI, 0.68-0.86) with P=0.056. Egger's test P value (0.225) demonstrated that there was no publication bias.

Conclusions

Our research showed that in the evaluation of bronchial cancers, AFI was superior to conventional WLB. With its higher sensitivity, AFI could be valuable for avoiding misdiagnosis.

Helsinki by nature: The Nature Step to Respiratory Health

Background

The Nature Step to Respiratory Health was the overarching theme of the 12th General Meeting of the Global Alliance against Chronic Respiratory Diseases (GARD) in Helsinki, August 2018. New approaches are needed to improve respiratory health and reduce premature mortality of chronic diseases by 30% till 2030 (UN Sustainable Development Goals, SDGs). Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends. Planetary health and human health are interconnected, and both need to be considered by individuals and governments while addressing several SDGs.

Results

The concept of the Nature Step has evolved from innovative research indicating, how changed lifestyle in urban surroundings reduces contact with biodiverse environments, impoverishes microbiota, affects immune regulation and increases risk of NCDs. The Nature Step calls for strengthening connections to nature. Physical activity in natural environments should be promoted, use of fresh vegetables, fruits and water increased, and consumption of sugary drinks, tobacco and alcohol restricted. Nature relatedness should be part of everyday life and especially emphasized in the care of children and the elderly. Taking “nature” to modern cities in a controlled way is possible but a challenge for urban planning, nature conservation, housing, traffic arrangements, energy production, and importantly for supplying and distributing food. Actions against the well-known respiratory risk factors, air pollution and smoking, should be taken simultaneously.

Conclusions

In Finland and elsewhere in Europe, successful programmes have been implemented to reduce the burden of respiratory disorders and other NCDs. Unhealthy behaviour can be changed by well-coordinated actions involving all stakeholders. The growing public health concern caused by NCDs in urban surroundings cannot be solved by health care alone; a multidisciplinary approach is mandatory.

How to manage asthma during Ramadan?

When Muslims fast in Ramadan, they abstain from eating, drinking and smoking from sunrise (sehour) to sunset (Fetour or Iftar). Many Muslims also abstain from taking prescription medication during the fasting hours. This has significant implications for asthma management since to maintain asthma control patients should continue to take their preventer inhalers (ICS±LABA) as prescribed or risk acute exacerbations and even death. Islamic jurisprudence is not unanimous on whether inhalers invalidate fasting or not. The controversy is related to how the inhalers are classified. Some Muslim scholars believe that inhalers do not break the fast because of the gaseous nature of the inhaled agents. Other scholars disagree. They state that since the inhaled gases pass through the mouth and precipitate on the mucosa, they mimic food products. Consequently, they believe the use of the inhalers breaks the fast. It is important to assist patients deal with this dilemma. One approach is to help patients with the timing of their inhaler use. Most preventer asthma medications are prescribed twice daily. With good timing, patients can stick to their therapeutic regimens and still observe fasting. They can take daily preventer inhalers of ICS or ICS+LABA at Sehour and Fetour. Another approach is to remind patients that Islam is flexible and allows special consideration for patients suffering from serious illnesses or conditions, including uncontrolled asthma, asthmatic attacks, and other chronic diseases. These individuals, according to the holy Qur'an, are allowed not to fast or to break their fast and take their medications if they develop acute attacks or complications. Patients can make these days up by fasting later during the year a number of days equivalent to the number of days they had not fasted. Alternatively, if they still are not able to fast, they get redemption by feeding a poor person. Physicians should educate patients about the importance of adherence to preventer therapy during the month of Ramadan .The latter may be a golden opportunity for patients to stop smoking, a process that can be enhanced by compassionate education from the physician. Asthma in Ramadan should be considered in curriculum of nursing, pharmacy, and Medical schools.

Next-generation ARIA care pathways for rhinitis and asthma: a model for multimorbid chronic diseases

BACKGROUND

In all societies, the burden and cost of allergic and chronic respiratory diseases are increasing rapidly. Most economies are struggling to deliver modern health care effectively. There is a need to support the transformation of the health care system into integrated care with organizational health literacy.

MAIN BODY

As an example for chronic disease care, MASK (Mobile Airways Sentinel NetworK), a new project of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, and POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure. Three aspects of care pathways are being developed: (i) Patient participation, health literacy and self-care through technology-assisted "patient activation", (ii) Implementation of care pathways by pharmacists and (iii) Next-generation guidelines assessing the recommendations of GRADE guidelines in rhinitis and asthma using real-world evidence (RWE) obtained through mobile technology. The EU and global political agendas are of great importance in supporting the digital transformation of health and care, and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care.

CONCLUSION

In 20 years, ARIA has considerably evolved from the first multimorbidity guideline in respiratory diseases to the digital transformation of health and care with a strong political involvement.

Improving the quality of hospital care provided for asthma out-patients in a country in turmoil: a report from Syria

Background

In low resources settings, especially during periods of turmoil, asthma care becomes emergency-oriented, and adherence to international asthma management guidelines such as long-term inhaled corticosteroids (ICS) prescription is limited. The role of education for inhaler technique to guarantee treatment efficacy is neglected and follow up is hampered by war-related displacement. In Syria, asthma care is not included in primary care, and frequently, internal medicine general hospital outpatient clinics are the first contact. The main objective of our study was to evaluate the adequacy of prescription of controller medications (ICS/LABA) by residents on initial contact with patients, and the effect of regular onsite personalized supervision and coaching by a trainer pulmonologist on improving their practice. The second objective was to evaluate the efficacy of mobile training for inhaler technique, and asthma mobile follow up.

Methods

We developed an audit form to assess initial prescription of ICS/LABA by residents. Filled forms were reviewed by a trainer pulmonologist for compliance with international guidelines. When discrepancies were noted, onsite training was provided. Auditing of new presenting asthma patients is continual to evaluate improvement of initial prescription by the same residents. In parallel, video-mobile education of patients for inhaler technique, and mobile interviewing follow up were tested.

Results

Implementation of these strategies resulted in improved adherence of residents to ICS dosing guidelines (P=0.002), optimal inhaler technique by patients, and efficacy of mobile follow up.

Conclusions

WHO programs for CRD in developing countries, especially in regions of conflict and war, should include auditing of care by residents with onsite coaching by trainer pulmonologists, and mobile education for technology of inhaler and patient follow up.

Erratum to uncontrolled and under-diagnosed asthma in a Damascus shelter during the Syrian crisis

[This corrects the article DOI: 10.21037/jtd.2017.08.86.].

Uncontrolled and under-diagnosed asthma in a Damascus shelter during the Syrian crisis

Background

Studies have shown that poor shelter or dwelling conditions may lead to deteriorations in health. Those with asthma may be more susceptible to compromised living conditions and stress leading to a higher risk of asthma exacerbations. To describe the asthma control and quality of life of individuals with diagnosed asthma living in a shelter in Damascus, Syria and estimate the prevalence of respiratory symptoms in shelter dwellers without diagnosed asthma.

Methods

In this cross-sectional study, all individuals 5 years and older living in Al-Herjalleh shelter with diagnosed asthma were recruited to complete a questionnaire, which included items related to their respiratory symptoms, asthma exacerbations, exposure to asthma triggers, medication use, and health-related quality of life before and since entering the shelter. A representative sample of shelter dwellers without diagnosed asthma also completed a questionnaire to establish their demographics, respiratory symptoms, environment and chronic disease co-morbidities, in order to identify factors associated with under-diagnosed asthma. All participants underwent spirometry to measure their lung function. Descriptive statistics were calculated, and chi-square tests and Student's t-tests were used to compare individuals with asthma before and since entering the shelter, as well as to compare those with under-diagnosed asthma and individuals without asthma.

Results

The prevalence of asthma at the Al-Herjalleh shelter in those aged 5 years and older was approximately 8.5%. Nearly 70% of the asthma group felt their asthma had worsened since entering the shelter, and there was a significant drop in the proportion of individuals using inhaled corticosteroids (ICS), with only 4.3% using daily ICS in the shelter (P<0.0001). The proportion of individuals experiencing a severe asthma attack did not change after entering the shelter (P=0.97), but almost all individuals with asthma (94.4%) reported worsening in their health-related quality of life. In the non-asthma group, 44.2% of participants reported episodes of wheezing, coughing and breathlessness at night, consistent with under-diagnosed asthma. A higher proportion of those with under-diagnosed asthma had allergic rhinitis (57.1%), symptoms of post-traumatic stress disorder (PTSD) (35.1%), and abnormal spirometry (60.0%), compared to those without asthma.

Conclusions

The findings of our study highlight the need for asthma programs in Syrian shelters as significant gaps exist in both the screening and management of chronic respiratory diseases to minimize asthma deterioration in Syrian shelter dwellers.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

The role of serum surfactant protein D as a biomarker of exacerbation of chronic obstructive pulmonary disease

BACKGROUND

The exacerbation of chronic obstructive pulmonary disease (COPD) is a major factor for the high mortality associated with the disease. There is a paucity in the lung-specific biomarkers which diagnose these exacerbations. Surfactant protein D (SP-D) is a promising biomarker in predicting clinical outcomes for patients with COPD, is lung-specific and can be detected in serum. However, the profile in which serum concentrations of SP-D change during acute exacerbation is still unclear. This study aims to estimate and compare the concentrations of serum SP-D in patients with stable disease and during the exacerbation.

METHODS

A cross-sectional study was conducted which composed of apparently healthy individuals (n = 28), which included 14 smokers and 14 nonsmokers, patients with stable COPD (n = 28), and patients experiencing acute exacerbations (n = 28). Pulmonary functions were performed for all groups. Serum SP-D concentrations were measured using enzyme-linked immunosorbent assay (ELISA). These concentrations were compared by analysis of variance.

RESULTS

Serum SP-D levels were significantly elevated in patients with acute exacerbations (508.733 ± 102.813 ng/ml) compared to patients with stable COPD (337.916 ± 86.265 ng/ml) and healthy subjects (177.313 ± 46.998 ng/ml; p <  0.001). Serum SP-D levels correlated inversely with lung function parameters including FEV1%pred, FVC%pred and FEV1/FVC.

CONCLUSION

Serum SP-D levels are raised early on during acute exacerbations of COPD, which could be a potential early diagnostic biomarker for COPD exacerbations.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.

Respiratory effects in children from passive smoking of cigarettes and narghile: ISAAC Phase Three in Syria

BACKGROUND

The association between environmental tobacco smoke (ETS) and asthma symptoms is well documented, but a causal relationship is inconclusive. International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three was the first to report a dose-response relationship between current wheezing and exposure to parental cigarette smoke. As exposure of children to water pipe (narghile) smoke is of concern in Syria, in the ISAAC Phase Three Tartous Centre we also examined the role of parental smoking of the narghile.

METHODS

Parents of children aged 6-7 years completed core written questionnaires about the prevalence of symptoms, and an environmental questionnaire for other risk factors, including parental cigarette smoking. We added questions about narghile to the questionnaire.

RESULTS

Among 2 734 pupils (49% females) surveyed, we found an association between exposure to ETS of the mother smoking cigarette or narghile and ever wheezing, nocturnal cough and severe wheeze; however, the strongest association was found when the mother smoked narghile. Mother smoking narghile was also associated with exercise wheeze. Father smoking narghile, but not cigarettes, was associated with nocturnal cough, severe wheeze and exercise wheeze. The association with current wheeze became significant when mother smoked both cigarettes and narghile; however, the effect was addititive and not synergic.

CONCLUSION

We recommend that international studies investigating ETS include questions on narghile smoking.

Co-morbidities in 99 COPD patients: A case series from Syria

Objectives

To assess the most frequent co-morbidities in chronic obstructive pulmonary disease (COPD) patients.

Patients and Methods

We studied 99 patients, including 72 males and 67 smokers, presented to our University Hospital in Lattakia, Syria in 2012, with a mean age of 63 years.

Results

Overall, there were 61% hypertension, 37% ischemic heart disease, 25% diabetes, 45% anemia, and 47% pulmonary hypertension. Other diseases were less significant. Patients who had more severe Global Initiative for Chronic Obstructive Lung Disease stage had a greater number of co-morbidities.

Conclusions

We recommend as a general practice, to assess cardiac co-morbidities, hypertension, and other co-morbidities in all COPD patients and vice versa. We also recommend performing spirometry in smokers complaining of chronic cough, sputum, or dyspnea for early diagnosis of COPD.

Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group

Background

The burden of chronic respiratory disease (CRD) is alarming. International studies suggest that women with CRD are undersurveyed and underdiagnosed by physicians worldwide. It is unclear what the prevalence of CRD is in the general population of Syria, particularly among women, since there has never been a survey on CRD in this nation. The purpose of this study was to investigate the impact of different patterns of smoking on CRD in women.

Materials and methods

We extracted data on smoking patterns and outcome in women from the Global Alliance Against Chronic Respiratory Diseases survey. Using spirometric measurements before and after the use of inhaled bronchodilators, we tracked the frequency of CRD in females active and passive narghile or cigarette smokers presenting to primary care. We administered the questionnaire to 788 randomly selected females seen during 1 week in the fiscal year 2009–2010 in 22 primary care centers in six different regions of Syria. Inclusion criteria were age >6 years, presenting for any medical complaint. In this cross-sectional study, three groups of female subjects were evaluated: active smokers of cigarettes, active smokers of narghiles, and passive smokers of either cigarettes or narghiles. These three groups were compared to a control group of female subjects not exposed to active or passive smoking.

Results

Exposure to active cigarette smoke but not narghile smoke was associated with doctor-diagnosed chronic obstructive pulmonary disease (COPD). However, neither cigarette nor narghile active smoking was associated with increased incidence of spirometrically diagnosed COPD. Paradoxically, exposure to passive smoking of either cigarettes or narghiles resulted in association with airway obstruction, defined as forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) < 70% according to the Global initiative for chronic Obstructive Lung Disease criteria; association with FEV₁ < 80% predicted, evidencing moderate to severe GOLD spirometric grade, and doctor-diagnosed COPD. Physicians tend to underdiagnose COPD in women who present to primary care clinics. Whereas around 15% of enrolled women had evidence of COPD with FEV₁/FVC < 70% after bronchodilators, only 4.8% were physician-diagnosed. Asthma did not appear to be a significant spirometric finding in these female subjects, although around 11% had physician-diagnosed asthma. One limitation is FEV₁/FVC < 70% could have also resulted from uncontrolled asthma. The same limitation has been reported by the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study.

Conclusion

Contrary to popular belief in developing countries, women exposed to tobacco smoke, whether active or passive, and whether by cigarettes or narghiles, like men are at increased risk for the development of COPD, although cultural habits and taboos may decrease the risk of active smoking in some women.

Recommendations

These findings will be considered for country and region strategy for noncommunicable diseases, to overcome underdiagnosis of CRD in women, fight widespread female cigarette and narghile smoking, and promote behavioral research in this field.

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

[ARIA (Allergic Rhinitis and its Impact on Asthma) achievements in 10 years and future needs]

Allergic rhinitis and asthma represent global health problems for all age groups. Asthma and rhinitis frequently co-exist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization (WHO) workshop in 1999 and was published in 2001. ARIA has reclassified allergic rhinitis as mild/moderate-severe and intermittent/persistent. This classification schema closely reflects the impact of allergic rhinitis on patients. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of allergic rhinitis and asthma co-morbidities based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation). ARIA has been disseminated and implemented in over 50 countries of the world. In Turkey, it is important to make a record of ARIA achievements and to identify the still unmet clinical, research and implementation needs in order to strengthen the 2011 EU Priority on allergy and asthma in children.

Reperfusion rates following intra-arterial thrombolysis for acute ischemic stroke: the influence of the method for alteplase delivery

BACKGROUND AND PURPOSE

Because alteplase does not penetrate thrombus effectively, this study examined whether a method thought to maximize surface distribution of alteplase on the offending thrombus during IATT would result in greater reperfusion rates in acute ischemic stroke.

MATERIALS AND METHODS

Clinical information, arteriograms, and CT scans following treatment from 85 consecutive patients who underwent IATT by using alteplase within 6 hours of stroke symptom onset were reviewed. Alteplase was delivered through a microcatheter embedded within the thrombus at 1 mg per minute in all cases, and the delivery never exceeded 100 mg of alteplase. Patients who underwent microcatheter contrast injections confirming that alteplase surrounded the thrombus were compared with patients who did not.

RESULTS

Greater than 50% vascular territory reperfusion occurred in 82.2% of patients who underwent IATT with the intention of optimizing alteplase delivery versus 30.0% in patients without this intention (P < .0001, Pearson correlation) with an odds ratio of 15.8 based on nominal regression analysis. Hemorrhagic complication rates between methods were similar. The mRS at 1-3 months, infarct volume, change in NIHSS score by 24 hours, and hospital discharge were positively affected by optimizing alteplase delivery.

CONCLUSIONS

A method that intends to evenly distribute alteplase around a thrombus resulted in better reperfusion rates and clinical outcomes compared with methods without this intention. Other predictors positively influencing reperfusion included the presence of slow antegrade flow distal to the clot, earlier time to treatment, lower presenting NIHSS score, and proximal occlusion site.