Asthma control in Kazakhstan: need for urgent action.

BACKGROUND: Asthma control, patients' awareness level and adherence to treatment in Kazakhstan have never been studied. The aim of this study was to verify the prevalence of controlled, poorly controlled and uncontrolled asthma in a large sample of three largest cities of Kazakhstan. METHODS: We recruited 600 (median age 54 (interquartile range (IQR) 22) years, 64% females) patients with diagnosis confirmed earlier in the outpatient facilities in Almaty, Astana and Shymkent in 2020-2021. We offered a structured questionnaire on asthma control and risk factors as of GINA and performed spirometry. We report the prevalence of asthma control, knowledge and skills and pharmacological treatment with 95% confidence interval (CI) and the association of selected predictors with asthma control. RESULTS: With the median of 9 (IQR 13) years of diagnosis, 40% of patients had comorbid COPD and 42% had allergic rhinitis, whereas 32% lived with pets. Asthma was well-controlled in only 12.3% (95% CI 9.7-15.0), partly controlled in 29.8% (95% CI 26.2-33.5) and uncontrolled in 57.8% (95% CI 53.9-61.8) patients. ACQ-5 score (range 0-5.8, median 2) equaled 0.2 (IQR 0.85) in well-controlled asthma patients, 1.4 (IQR 1) in partly controlled and 2.8 (IQR 1.4) in uncontrolled asthma patients. Knowledge and skills levels were very low. Only 54% were on inhaled corticosteroids (52.2% of them used budesonide/formoterol and 39.5% used fluticasone/salmeterol). 39% used steroids per os or parenterally within a period of 12 months (51% of patients with uncontrolled asthma). CONCLUSION: Asthma control, knowledge and skills levels of asthma patients in the largest cities of Kazakhstan remain unacceptably low, whereas pharmacological treatment is far from optimal. Urgent action should be taken to support doctors' training, and we call to launch a national asthma program to coordinate asthma care in Kazakhstan.

Exploring medical students' perceptions of family medicine in Kyrgyzstan: a mixed method study.

BACKGROUND: Despite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice. METHODS: This study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review. RESULTS: The interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student's perceptions and prevented students' ability to identify with the practice of family medicine. However, students' awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved. CONCLUSION: This study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools' institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Tobacco use among Kyrgyzstan medical students: an 11-year follow-up cross-sectional study.

BACKGROUND: Medical students are the first line active force to combat tobacco epidemic, but they may suffer from high smoking prevalence and wrong attitude themselves. The aim of the study was to assess the effect of current curriculum on smoking behavior of medical students in Kyrgyzstan. METHODS: 20% random sample of all 6 years of the School of Medicine in Kyrgyz State Medical Academy were interviewed in spring 2016. The questionnaire included sections on tobacco products consumption and knowledge and attitude to counseling. We verified smoking status with exhaled CO measurement using Bedfont Smokelyzer. RESULTS: In 618 students (48% female), the overall daily cigarette smoking prevalence was 21% (34% in males and 6% in females), being highest in years 1 and 3 and least in year 5 (prevalence difference 14%). With very low smokeless products and electronic cigarettes use prevalence, ever-smoking prevalence of waterpipe use was very high, reaching 85% in 6-year male students with alarmingly high prevalence in female students also. Only 74% students responded there was 100% evidence of harmful effects of tobacco, unchanged throughout the course of study. CONCLUSIONS: The use of tobacco products, especially smoking waterpipe, in Kyrgyzstan medical students remains very high. Coupled with poor knowledge and high demand for more information, this demonstrates urgent need for more active and advanced training on tobacco control in medical school.

Smoking increases the risk of acute mountain sickness.

OBJECTIVE: We aimed to ascertain risk factors for acute mountain sickness (AMS) in miners exposed to chronic intermittent high altitude conditions. METHODS: All new hires (2009-2012) for mine employment (4000 m above sea level) were followed up for 12 months after first ascent. Demographics, physiologic data, and cigarette smoking were assessed at preemployment screening. Mine site clinic care for AMS defined incident events. Cox regression analysis estimated risk of AMS associated with smoking and selected covariates. RESULTS: There were 46 AMS cases among 569 individuals during the first 12 months of employment. Adjusted for age, sex, and altitude of permanent residence, cigarettes smoked per day before hiring were prospectively associated with AMS (hazard ratio [HR], 1.9; 95% CI, 1.1 to 3.2 per 10 cigarettes smoked). This risk was higher in the subset of workers with less demanding physical work (n=336; HR, 3.3; 95% CI, 1.7 to 6.3), whereas among those with more physically demanding jobs (n=233), smoking was not associated with increased risk (HR, 0.6; 95% CI, 0.1 to 2.3). CONCLUSIONS: In workers newly hired to work at high altitude, smoking increases the likelihood of AMS, but this effect appears to be operative only among those with less physically demanding work duties.

Morbidity in the Mountainous Province of Kyrgyzstan: Results from a Population-Based Cross-Sectional Study.

Brimkulov, Nurlan, Louis Louton, Salima Sydykova, Denis Vinnikov, and Farida Imanalieva. Morbidity in the mountainous Province of Kyrgyzstan: Results from a population-based cross-sectional study. High Alt Med Biol 18:338-342, 2017.-The aim of this study was to identify the main causes of using primary care facilities in the mountainous Naryn Province of Kyrgyzstan to set resources allocation priorities. We collected data on all admissions to family doctors in three Family Medical Centers (FMCs) in Naryn Province: (1) the city of Naryn (2200 meters above sea level [MASL]); (2) the town of At-Bashy (3200 MASL); and the town of Kochkor (1800 MASL) by using an original questionnaire during one full week (5 days) in spring 2016. Within 1 week, we recorded 1136 cases in Naryn and 782 cases in Bishkek after exclusion of missing data. The top three reasons for admissions were respiratory (23% of all in Naryn and 36% in Bishkek), nonspecific general (19% and 17%), and neurological (13% and 9%). Naryn residents were 3.84 times (confidence interval [95% CI] 2.07-7.11) more likely to apply with musculoskeletal and 3.05 times (95% CI 1.02-9.12) more likely to apply with cardiovascular conditions. This first population-based study in Naryn stresses the need to prioritize cardiovascular and rheumatological care in these mountainous conditions.

Chronic Intermittent Hypoxia and Blood Pressure: Is There Risk for Hypertension in Healthy Individuals?

AIM: The aim of the current study was to assess a year-long impact of chronic intermittent exposure to hypoxia on blood pressure (BP) in healthy working middle-aged adults. MATERIALS AND METHODS: Data from pre-employment and annual screening of high-altitude mining company (elevation 4000 meters above sea level) were obtained for 472 workers aged 34.1 ± 7.8 years, working 2-week shifts, followed by 2 weeks of rest at low altitude (cumulative exposure 6 months). Overall systolic, diastolic BP change (ΔBP) were calculated, and tested in multivariate regression models in the entire group, as well as in different strata of BP. RESULTS: Baseline systolic BP reduced from 123.2 ± 11.3 to 116.3 ± 13.1 mmHg (ΔBP 6.8 mmHg), diastolic BP from 76.7 ± 8.4 to 74.9 ± 8.4 mmHg (ΔBP -1.7 mmHg) (p < 0.001), both measured at low altitude before and after one year of exposure to chronic intermittent hypoxia. The greater the baseline BP, the more pronounced was BP decrease. In the most prevalent combined group of normal and high normal BP, both systolic and diastolic BP reduced after one year of high altitude exposure (p < 0.01). In multivariate adjusted models, none of exposures of interest were associated with ΔBP. CONCLUSIONS: One-year intermittent exposure to hypobaric hypoxia in new hires for high-altitude mining company was not associated with BP increase.

High-altitude alpine therapy and lung function in asthma: systematic review and meta-analysis.

We used meta-analysis to measure the effect of high-altitude climate therapy (HACT) on lung function outcomes in asthma, and systematically searched PubMed, Embase and www.elibrary.ru for publications appearing from 1970 to mid-2015. We included studies carried out with children or adults with an exposure of up to 12 weeks at an altitude of ≥1500 m above sea level. Changes in forced expiratory volume in 1 s (FEV1), FEV1/vital capacity ratio or peak expiratory flow rate as the HACT intervention outcomes were analysed. We included data for 907 participants (age range 4-58 years) from 21 studies, altogether including 28 substrata based on asthma type or severity. Only three of 21 included studies had high quality, whereas 93% of substudies reported lung function improvement with an overall pooled standardised mean difference (SMD) of 0.53 (95% CI 0.43-0.62). The measured effect of HACT was greater in adults (SMD 0.75, 95% CI 0.63-0.88, n=14) than in children (SMD 0.24, 95% CI 0.09-0.38, n=14). Studies at altitude >2000 m above sea level yielded the same effect as those at lower altitude. Based on a cut-point of a 0.50 change in SMD to define a meaningful clinical difference, HACT appears to have efficacy as an intervention. This extent of benefit appears to be limited to adults with asthma.

Five-year lung function observations and associations with a smoking ban among healthy miners at high altitude (4000 m).

OBJECTIVE: To assess the annual lung function decline associated with the reduction of secondhand smoke exposure in a high-altitude industrial workforce. METHODS: We performed pulmonary function tests annually among 109 high-altitude gold-mine workers over 5 years of follow-up. The first 3 years included greater likelihood of exposure to secondhand smoke exposure before the initiation of extensive smoking restrictions that came into force in the last 2 years of observation. RESULTS: In repeated measures modeling, taking into account the time elapsed in relation to the smoking ban, there was a 115 ± 9 (standard error) mL per annum decline in lung function before the ban, but a 178 ± 20 (standard error) mL per annum increase afterward (P < 0.001, both slopes). CONCLUSION: Institution of a workplace smoking ban at high altitude may be beneficial in terms of lung function decline.

Four-year prospective study of lung function in workers in a high altitude (4000 m) mine.

The aim of this study was to determine if work at high altitude is associated with accelerated lung function decline and if smoking could further accelerate this decline. Subjects working at high altitude (3800 to 4500 m) in a gold mine on shift-rotation basis were included, and 7320 spirometry reports were obtained throughout a 4-yr observation period (2005-2009). Out of 3368 selected reports with acceptable quality, for 842 patients aged 38.9 ± 8.6 yr we analyzed annual decline in vital capacity (VC), forced vital capacity (FVC), and forced expiratory volume during the first second (FEV(1)). VC was reduced by 46.5 mL, FVC by 67.8 mL, and FEV(1) by 74.5 mL a year, greater than in historical controls. In those having initial FEV(1)/FVC below 70%, yearly VC decline was 59.4 mL, FEV(1) -58.6 mL. In long-term workers with no initial obstruction, FEV(1) declined slower (67.2 vs. 101.3 mL/yr (p < 0.001); but VC and FVC decline did not differ. Work at high altitude for years may be a factor that accelerates lung function decline, and the rate of decline along with confounding factors should be the subject of future studies.

Exhaled nitric oxide is reduced upon chronic intermittent hypoxia exposure in well-acclimatized mine workers.

The aim of this study was to assess how exhaled nitric oxide (NO) levels in healthy subjects changed upon exposure to intermittent hypoxia at high altitude. Eighty-one healthy subjects with a mean age of 31.8±6.7 years, well acclimatized at altitudes of 3800-4000m above sea level, and employed by a gold-mining company were recruited for the study. Baseline, altitude-corrected partial exhaled NO levels (PE(NO)) were measured in Bishkek, Kyrgyzstan (780m). Measurements were then taken on day 1 of the ascent to the mine, which is located at an altitude of 4000m, on day 3 and finally at the end of the 2- or 3-week shifts. The mean PE(NO) level was 9.49±3.66nmHg in Bishkek and was lower in females than in males (9.76±3.58nmHg vs. 7.03±3.71nmHg). When compared to the first day at altitude, exhaled NO was reduced by 17.2% on day 3 (p=0.001) and 29.6% by the end of the shift (p<0.001). In summary, this study of well-acclimatized high-altitude miners demonstrates that despite the absence of clinical signs of desadaptation, there is an apparent reduction in exhaled NO.

Excessive exposure to secondhand tobacco smoke among hospitality workers in Kyrgyzstan.

The aim of this study was to assess the levels of secondhand smoke (SHS) exposure of men and women in public places in Kyrgyzstan. This cross-sectional study involved 10 bars and restaurants in Bishkek the capital city of Kyrgyzstan. Smoking was allowed in all establishments. Median (interquartile range) air nicotine concentrations were 6.82 (2.89, 8.86) microg/m(3). Employees were asked about their smoking history and exposure to SHS at work. Employees were exposed to SHS for mean (SD) 13.5 (3.6) hours a day and 5.8 (1.4) days a week. Women were exposed to more hours of SHS at work compared to men. Hospitality workers are exposed to excessive amounts of SHS from customers. Legislation to ban smoking in public places including bars and restaurants is urgently needed to protect workers and patrons from the harmful effects of SHS.

Antiinflamatory effect of high-altitude adaption patients with bronchial asthma / Efecto antiinflamatorio de la altura en la adaptación de pacientes con asma bronquial

Durante muchos años hemos elaborado el método de climato-terapia de altura en pacientes con asma bronquial (en la Tuya-Ashu Pass, Northern Tie-Shan, 3,200m). El estudio broncológico complejo que incluye el lavado bronqio-alveolar fue realizado en 62 pacientes con asma bronquial antes del tratamiento (en Bishkek, 760 m) y a 25 días de climatoterapia en la altura. El estudio de lavado alveolar incluyó, la composición citológica, la estimación de la viabilidad y actividad fagocítica de los macrófagos alveolares con partículas de latex, receptores de membrana de los macrófagos alveolares de la fracción del complemento C3, y Fe de la inmunoglobulina, determinación de la IgA secretoria y la actividad de superficie del surfactante. Se encontró que la altura como tratamiento del asma bronquial mejora una serie de parámetros del lavado bronquial demostrando que la altura tiene un efecto anti-inflamatorio.