Exhaled nitric oxide : Variability and association with bronchial hyperresponsiveness and atopy

Airway inflammation is a key feature of bronchial asthma. In asthma management, according to international guidelines, the gold standard is anti-inflammatory treatment. Currently, only conventional procedures (i.e., symptoms, use of rescue medication, PEF-variability, and lung function tests) were used to both diagnose and evaluate the results of treatment with anti-inflammatory drugs. New methods for evaluation of degree of airway inflammation are required. Nitric oxide (NO) is a gas which is produced in the airways of healthy subjects and especially produced in asthmatic airways. Measurement of NO from the airways is possible, and NO can be measured from exhaled air. Fractional exhaled NO (FENO) is increased in asthma, and the highest concentrations are measured in asthmatic patients not treated with inhaled corticosteroids (ICS). Steroid-treated patients with asthma had levels of FENO similar to those of healthy controls. Atopic asthmatics had higher levels of FENO than did nonatopic asthmatics, indicating that level of atopy affected FENO level. Associations between FENO and bronchial hyperresponsiveness (BHR) occur in asthma. The present study demonstrated that measurement of FENO had good reproducibility, and the FENO variability was reasonable both short- and long-term in both healthy subjects and patients with respiratory symptoms or asthma. We demonstrated the upper normal limit for healthy subjects, which was 12 ppb calculated from two different healthy study populations. We showed that patients with respiratory symptoms who did not fulfil the diagnostic criteria of asthma had FENO values significantly higher than in healthy subjects, but significantly lower than in asthma patients. These findings suggest that BHR to histamine is a sensitive indicator of the effect of ICS and a valuable tool for adjustment of corticosteroid treatment in mild asthma. The findings further suggest that intermittent treatment periods of a few weeks’ duration are insufficient to provide long-term control of BHR in patients with mild persistent asthma. Moreover, during the treatment with ICS changes in BHR and changes in FENO were associated. FENO level was associated with BHR measured by a direct (histamine challenge) or indirect method (exercise challenge) in steroid-naïve symptomatic, non-smoking asthmatics. Although these associations could be found only in atopics, FENO level in nonatopic asthma was also increased. It can thus be concluded that assessment of airway inflammation by measuring FENO can be useful for clinical purposes. The methodology of FENO measurements is now validated. Especially in those patients with respiratory symptoms who did not fulfil the diagnostic criteria of asthma, FENO measurement can aid in treatment decisions. Serial measurement of FENO during treatment with ICS can be a complementary or an alternative method for evaluation in patients with asthma.Astma on tulehdus keuhkoputkien limakalvolla ja inhaloitava kortikosteroidi (ICS)on hoidon kulmakivi. Jos astman seurantaan käytetään vain spirometriaa, PEF-seurantaa, oirekyselyä sekä avaavan lääkkeen tarvetta, ei astmaan liittyvä tulehdusta pystytä arvioimaan. Siis kaivataan uusia menetelmiä, joilla voidaan mitata myös astmaan liittyvä tulehdus. Uloshengitysilman typpioksidin (FENO) määrä on lisääntynyt astmassa ja ICS-hoidetuilla potilailla FENO on samaa luokkaa kuin terveillä. Kuitenkin, atooppisten astmaatikkojen arvot ovat selvästi korkeammat ja näin ollen atopian merkitys FENO-pitoisuuteen on tärkeä. Kirjallisuuden perusteella FENO ja keuhkoputkien supistumisherkkyys (BHR) assosioituvat vaihtelevasti. Tutkimus koostui viidestä osatyöstä, joissa kahdessa keskityttiin metodologisiin tekijöihin. FENO-mittauksen toistettavuus on hyvä terveillä ja mahdollista astmaa sairastavilla sekä lyhyellä että pitkällä aikavälillä. FENO-pitoisuuden normaaliarvon yläraja oli 12 ppb. FENO-pitoisuus oli korkeampi mahdollista astmaa sairastavilla kuin terveillä, mutta matalampi kuin astmaa sairastavilla. Tutkimus osoitti, että BHR on herkkä mittari osoittamaan hengitettävän flutikasonihoidon vaikutusta 26 astmaatikolla. Lisäksi, tulos viittaa siihen, että muutaman viikon hoito ICS:lla on riittämätön pitkällä aikavälillä. Kahden viikon ICS-hoidon jälkeen nähtiin merkittävä assosiaatio FENO-tason vähenemisessä ja BHR-tason paranemisessa. 181 potilaalla, joilla epäiltiin astmaa, FENO ja BHR mitattuna sekä rasitusastmareaktiolla että histamiinialtistuksella korreloivat vain atoopikoilla. Lisäksi, tutkimus osoitti, että FENO-taso oli korkeampi ei-atooppista astmaa sairastavilla kuin terveillä ja matalampi kuin atooppista astmaa sairastavilla. Kun atooppinen astma jaettiin vähän ja paljon herkistyneisiin potilaisiin, niin tulosten perusteella voitiin osoittaa, että ei-atooppisten ja vähän herkistyneiden astmaatikkojen FENO-taso sekä BHR mitattuna sekä rasitusastmareaktiolla että histamiinialtistuksella ovat samanlaisia. Tulokset viittaavat siihen, että astmaan liittyvää tulehdusta kannattaa tutkia FENO-mittauksella myös kliinisessä tarkoituksessa. Metodologia on nyt validoitu. Kun epäillään astmaa, FENO-mittaus voi auttaa kliinisessä päätöksenteossa. Toistuvat FENO-mittaukset ICS-hoidon aikana voivat olla täydentävä tai vaihtoehtoinen menetelmä astman hoidossa

GOLD-suositus on unohtunut

Kommentt

Tupakasta vieroitus tulee hallita

Koko hoitoketju on saatava ylläpitämään vieroitusosaamista

Weak smoking cessation awareness in primary health care before surgery : a real-world, retrospective cohort study

Objective: Tobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce. Design: This was a retrospective cohort study. Setting: The Stop Smoking before Surgery Project (SSSP) started in Porvoo, Finland, in May of 2016, involving both primary health care and specialized health care. The goals of the project were smoking awareness and preoperative smoking cessation. Subjects: Our study involved 1482 surgical patients operated at Porvoo Hospital between May and December of 2016. Main outcome measures: We studied the recording of smoking status in all patients, and ICD-10 diagnosis of nicotine dependency and the initiation of preoperative smoking cessation in current smokers. Variables were studied from electronic patient records, comparing primary health care referrals and surgical outpatient clinic records. Results: Smoking status was visible in 14.2% of primary health care referrals, and in 18.4% of outpatient clinic records. Corresponding rates for current smokers (n = 275) were 0.0 and 8.7% for ICD-10 diagnosis of nicotine dependence, and 2.2 and 15.3% for initiation of preoperative smoking cessation. The differences between primary health care referrals and outpatient clinic records were statistically significant for all three variables (pPeer reviewe

Smoking is a predictor of complications in all types of surgery : a machine learning-based big data study

Background: Machine learning algorithms are promising tools for smoking status classification in big patient data sets. Smoking is a risk factor for postoperative complications in major surgery. Whether this applies to all surgery is unknown. The aims of this retrospective cohort study were to develop a machine learning algorithm for clinical record-based smoking status classification and to determine whether smoking and former smoking predict complications in all surgery types. Methods: All surgeries performed in a Finnish hospital district from 1 January 2015 to 31 December 2019 were analysed. Exclusion criteria were age below 16 years, unknown smoking status, and unknown ASA class. A machine learning algorithm was developed for smoking status classification. The primary outcome was 90-day overall postoperative complications in all surgeries. Secondary outcomes were 90-day overall complications in specialties with over 10 000 surgeries and critical complications in all surgeries. Results: The machine learning algorithm had precisions of 0.958 for current smokers, 0.974 for ex-smokers, and 0.95 for never-smokers. The sample included 158 638 surgeries. In adjusted logistic regression analyses, smokers had increased odds of overall complications (odds ratio 1.17; 95 per cent c.i. 1.14 to 1.20) and critical complications (odds ratio 1.21; 95 per cent c.i. 1.14 to 1.29). Corresponding odds ratios of ex-smokers were 1.09 (95 per cent c.i. 1.06 to 1.13) and 1.09 (95 per cent c.i. 1.02 to 1.17). Smokers had increased odds of overall complications in all specialties with over 10 000 surgeries. ASA class was the most important complication predictor. Conclusion: Machine learning algorithms are feasible for smoking status classification in big surgical data sets. Current and former smoking predict complications in all surgery types.Peer reviewe

Remdesiviiri sairaalahoitoisessa COVID-19-taudissa : pragmaattinen, adaptiivinen, satunnaistettu Solidarity Finland -monikeskustutkimus

Lähtökohdat : Remdesiviiriä tutkittiin Solidarity Finland -tutkimuksessa. Menetelmät : COVID-19-taudin takia sairaalahoitoon joutuneet potilaat satunnaistettiin saamaan standardihoitoa tai sen lisäksi remdesiviiriä. Solidarity-tutkimuksessa ja satunnaistettujen ­tutkimusten meta-analyysissä ensisijainen päätetapahtuma oli sairaalahoitoajan kuolleisuus. Tulokset : Rekrytoimme 208 potilasta yhdestätoista sairaalasta. Sairaalahoidon aikana ­remdesiviiriryhmässä (n = 114) kuoli 1 % ja standardihoitoryhmässä (n = 94) 4 %. Invasiiviseen hengityslaitehoitoon joutui 5 % molemmissa ryhmissä. Tehohoitoa sai 11 % remdesiviiri- ja 12 % standardihoitoryhmässä. Maksaentsyymit nousivat merkittävästi 5 %:lla remdesiviiri- ja 2 %:lla standardihoitoryhmässä. Meta-analyysin alaryhmäanalyysissä remdesiviiri vähensi kuoleman riskiä potilailla, jotka eivät sairaalahoidon alkaessa saaneet hengityslaitehoitoa (RR 0,85, 95 % LV 0,75­–0,96). Päätelmät : Suomessa on pandemian aikana mahdollista rekrytoida merkittävä määrä potilaita suuriin, satunnaistettuihin tutkimuksiin, joilla voidaan saada luotettavia tuloksia nopeasti. Remdesiviiristä voi olla apua sairaalahoitoisessa COVID-19-taudissa varhain aloitettuna.publishedVersionPeer reviewe

Effect of remdesivir post hospitalization for COVID-19 infection from the randomized SOLIDARITY Finland trial

We report the first long-term follow-up of a randomized trial (NCT04978259) addressing the effects of remdesivir on recovery (primary outcome) and other patient-important outcomes one year after hospitalization resulting from COVID-19. Of the 208 patients recruited from 11 Finnish hospitals, 198 survived, of whom 181 (92%) completed follow-up. At one year, self-reported recovery occurred in 85% in remdesivir and 86% in standard of care (SoC) (RR 0.94, 95% CI 0.47-1.90). We infer no convincing difference between remdesivir and SoC in quality of life or symptom outcomes (p > 0.05). Of the 21 potential long-COVID symptoms, patients reported moderate/major bother from fatigue (26%), joint pain (22%), and problems with memory (19%) and attention/concentration (18%). In conclusion, after a one-year follow-up of hospitalized patients, one in six reported they had not recovered well from COVID-19. Our results provide no convincing evidence of remdesivir benefit, but wide confidence intervals included possible benefit and harm.Peer reviewe