Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis.

BACKGROUND: High exhaled nitric oxide fraction (F ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F ENO to guide ICS reductions. METHODS: Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. RESULTS: We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). CONCLUSION: In patients with mild-to-moderate asthma, gradual ICS reduction when F ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.

How we did the Question Time Forum (QTF).

BACKGROUND: We piloted a new method of feedback to supplement online surveys and student representation. METHODS: The face-to-face feedback session enabled all Year 5 students to ask questions directly to a faculty panel, regarding their curriculum. Questions were gathered in advance so the panel could review and prepare appropriate responses. "Ask the audience" questions were also included. EVALUATION: The panel and a convenience sample of 25 students (attenders and non-attenders) were interviewed. All interviews were recorded, transcribed and themed using long table technique. QTF was also evaluated on-the-day by using "Ask the Audience" questions. RESULTS: Sixty-three Year 5 students attended (from a cohort of 337), of whom 96% felt it was a useful addition to current methods of feedback and 93% would attend again. Students felt QTF was "brilliant" and a "triumph in transparency" while the faculty hailed the "novel" event and "honest discussion". CONCLUSION: QTF was well-received by students and faculty. Both encouraged repetition of the event, thought to enhance the transparency of decisions about the running of the course and promote more in-depth dialogue between staff and students.