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.

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.

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 12th, 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.

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.

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.

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.

Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma.

Asthma is a global health problem affecting around 300 million individuals of all ages, ethnic groups and countries. It is estimated that around 250,000 people die prematurely each year as a result of asthma. Concepts of asthma severity and control are important in evaluating patients and their response to treatment, as well as for public health, registries, and research (clinical trials, epidemiologic, genetic, and mechanistic studies), but the terminology applied is not standardized, and terms are often used interchangeably. A common international approach is favored to define severe asthma, uncontrolled asthma, and when the 2 coincide, although adaptation may be required in accordance with local conditions. A World Health Organization meeting was convened April 5-6, 2009, to propose a uniform definition of severe asthma. An article was written by a group of experts and reviewed by the Global Alliance against Chronic Respiratory Diseases review group. Severe asthma is defined by the level of current clinical control and risks as "Uncontrolled asthma which can result in risk of frequent severe exacerbations (or death) and/or adverse reactions to medications and/or chronic morbidity (including impaired lung function or reduced lung growth in children)." Severe asthma includes 3 groups, each carrying different public health messages and challenges: (1) untreated severe asthma, (2) difficult-to-treat severe asthma, and (3) treatment-resistant severe asthma. The last group includes asthma for which control is not achieved despite the highest level of recommended treatment and asthma for which control can be maintained only with the highest level of recommended treatment.