ARIA - One Airway, One Disease: What Links Our Research to the Concept

ARIA (Allergic Rhinitis and its Impact on Asthma) jest javnozdravstvena inicijativa Svjetske zdravstvene organizacije (SZO) koja se temelji na koncepciji jedinstvene alergijske bolesti dišnog sustava. Pokretač inicijative bio je rastući broj dokaza (epidemioloških, anatomskih, patofizioloških, kliničkih, terapijskih) koji je upućivao na pandemijski porast učestalosti alergijskih bolesti dišnog sustava (alergijski rinitis i astma), neadekvatnost mjera primarne i sekundarne prevencije te nemogućnost zadovoljavajuće kontrole tih bolesti postojećim strategijama liječenja. Do sada prikupljeni dokazi (anatomski, histološki, etiološki, patofiziološki mehanizmi, terapijski uspjeh) upućuju na izrazitu povezanost alergijskog rinitisa i astme. Stoga je ARIA kao javnozdravstvena inicijativa usmjerena na zajedničko zbrinjavanje do sada dviju razdvojenih bolesti. U ovom pregledu biti će izneseni dokazi na kojima se temelji koncepcija jedinstvene alergijske bolesti dišnog sustava te doprinos suradnika Instituta za medicinska istraživanja i medicinu rada tim spoznajama.ARIA (Allergic Rhinitis and its Impact on Asthma) is a public health initiative of the World Health Organization (WHO) based on the “one airway, one disease” concept. The trigger for the initiative was a growing evidence (from epidemiology, anatomy, pathophysiology, clinical diagnostics, therapy) of a pandemic increase in the prevalence of allergic disorders of the respiratory tract (allergic rhinitis and asthma), of the deficiency of primary and secondary preventive measures, and of incomplete therapeutic control over these conditions using current management strategies. Evidence gathered so far suggest a strong link between allergic rhinitis and asthma (anatomical and histological features, aetiology, similar pathophysiological mechanisms, related therapeutic results). Therefore, ARIA as a public health initiative aims at uniting the management of these, till now separated disorders. This review discusses the evidence on which the "one airway, one disease" concept and ARIA are based, including a contribution made by scientists from the Institute of Medical Research and Occupational Health, Zagreb, Croatia

Inhaled Corticosteroids

Inhalacijski kortikosteroidi (ICS) prva su linija terapije u liječenju kronične astme. Njihovo djelovanje na različite sastavnice procesa upale pridonosi smanjenju pojave simptoma, smanjenju hiperreaktivnosti dišnih putova, smanjenju potrebe za primjenom sistemskih kortikosteroida i bolničkog liječenja, poboljšava plućnu funkciju te unapređuje kontrolu bolesti i kvalitetu života. Inhalacijski kortikosteroidi jedini su osnovni lijekovi koji smanjuju smrtnost od astme. Najdjelotvorniji su lijekovi trenutačno raspoloživi u liječenju astme. Brojne studije potvrđuju njihov dugotrajni učinak u kontroli astme u djece i odraslih. ICS se razlikuju po svojim farmakokinetskim i farmakodinamskim karakteristikama te po jakosti. Klinička dobrobit ovih pripravaka uvelike nadilazi rizik od njihovih nuspojava. Potrebni su redoviti kontrolni pregledi za ranu detekciju eventualnih nuspojava.Inhaled corticosteroids (ICS) are the first line treatment in chronic asthma. The broad action of ICSs on the inflammatory process may account for their efficacy. Their clinical effects include reduction in severity of symptoms, diminished airway hyperresponsiveness, prevention of exacerbations, reduction in systemic corticosteroid courses and hospitalizations, and improvement in lung function tests, asthma control and quality of life. The ICSs are the only long-term controllers associated with a reduction in the risk of dying from asthma. They are the most effective drugs currently available in asthma treatment. Numerous studies proved their long lasting effects in asthma control in adults and children. Inhaled glucocorticoids manifest different pharmacokinetic and pharmacodynamic characteristics as well as potency. The clinical benefits of these agents by far surpass their side effects. Clinical follow- up is essential for the early detection of side effects

UČINAK SPAJANJA BOLNICA U REPUBLICI HRVATSKOJ PROCJENOM POMOĆU UPITNIKA O STAVOVIMA O SIGURNOSTI

On several occasions hospitals in Croatia have been a subject to consolidation. The purpose of the consolidations was savings gained by merging some of the services, especially in the hospitals which are geographically close to each other. The available published research results have shown that the smallest hospitals in Croatia achieve highest results for safety measured by the Safety Attitudes Questionnaire 2006 Short Form (SAQ). Further investigation and management of the SAQ data obtained in 2016 has proven that the analyzed independent hospitals with up to 500 beds, compared to the consolidated hospitals, achieve significantly better results with regard to Working Conditions, Management’s Attitude, Job Satisfaction and overall SAQ results. In terms of expenditures expressed as the index change of expenditures from year 2006 (2006 having an index of 100), no significant differences were found. However, the highest rise in the expenditures is found for consolidated hospitals with >500 beds, while the hospitals with 500 ležaja, dok bolnice s <500 ležaja, bilo konsolidirane ili ne, pokazuju isti trend promjena rashoda za razdoblje od 2006. do 2015. godine. Prilikom odlučivanja o konsolidaciji bolnica u Hrvatskoj valjalo bi uzeti u obzir i te rezultate

The Importance of Exhaled Breath Condensate Analysis in Diagnostic a Lung Disease

Kondenzat izdahnutog zraka (KIZ) sadržava aerosoliziran sekret dišnih putova i hlapljive sastojke koji pružaju neinvazivan uvid u biokemijske i upalne procese u plućima. Značajan porast interesa za KIZ rezultat je prepoznavanja da u plućnim bolestima ta lako skupljiva tekućina ima mjerljive karakteristike koje se razlikuju od zdravog stanja. KIZ pruža uvid u redoks reakcije unutar pluća, acidobazni status te stupanj i tip upale u akutnoj i kroničnoj fazi astme, kroničnoj opstruktivnoj plućnoj bolesti, adultnom respiratornom distres sindromu, cističnoj fibrozi i drugim bolestima dišnog sustava. Karakteriziran nepoznatim i varijabilnim stupnjevima razrjeđenja, KIZ ne pruža preciznu informaciju o koncentraciji pojedinog markera unutar sekreta dišnih putova, ali pokazuje kada se koncentracija razlikuje između zdravog i bolesnog stanja u dišnom sustavu. Zbog pristupačnosti i jednostavnosti izvođenja, KIZ postaje integralni dio budućih kliničkih istraživanja, a nakon što se prevlada problem standardizacije, on bi se mogao iskoristiti u dijagnosticiranju i praćenju terapije bolesti dišnog sustava.Exhaled breath condensate (EBC) contains aerosolised airway lining fluid and volatile compounds that provide non-invasive insight in biochemical and inflammatory activities in the lung. The interest in EBC has grown rapidly since this easily sampled fluid showed measurable properties that clearly indicate a disease. EBC assays provide evidence of redox deviation, acid-base status, and of the degree and type of inflammation in acute and chronic asthma, chronic obstructive pulmonary disease, cystic fibrosis, adult respiratory distress syndrome, and other lung diseases. Because of uncertain and variable degrees of dilution, EBC does not provide precise assessment of individual solute concentrations within native airway lining fluid. However, it can provide information when concentrations differ substantially between health and disease. Because, EBC assays are approachable and easy to perform, they will become integral components of future clinical studies, and after standardisation is accomplished, they might be used to diagnose and monitor therapy in clinical practice

Promjene učestalosti trovanja psihoaktivnim lijekovima u Hrvatskoj

The aim of this study was to analyse the frequency of poisoning with psychoactive drugs (benzodiazepines, antidepressants and neuroleptics) over the last 15 years in Croatia. The analysis was based on poisoning incidents reported over the phone (hot line) to the Zagreb Poison Control Center and included two periods: 1985–1991 (period I) and 1992–1999 (period II). The data were analysed separately for children and adults. Each phone call was counted as one poisoning incident. Child poisoning with neuroleptics was significantly higher in period II than in period I and so was the adult poisoning with antidepressants, amytriptyline, and combined psychoactive drugs. The frequency of total psychoactive drug poisoning was significantly higher in adults than in children in both periods. From 1992, the frequency of adult poisoning with antidepressants considerably increased as one of the many consequences of war-related stress. The results indicate a need for careful psychiatric evaluation and more critical use of antidepressants in affected individuals.Retrospektivno su analizirani telefonski pozivi vezani uz ingestije lijekova primljeni u nacionalnom Centru za kontrolu otrovanja u Zagrebu u posljednjih 15 godina. Tri skupine psihoaktivnih lijekova (benzodiazepini, neuroleptici, antidepresivi) bile su od posebnog značenja u ovom radu. Svi slučajevi ingestije lijekova analizirani su u dva vremenska intervala: period I (1985.–1991.) i period II (1992.–1999.) te u dvije skupine s obzirom na dob otrovanih: djeca (<16 godina) i odrasli (316 godina). Svaki telefonski poziv brojen je kao jedan slučaj trovanja, uključujući i višestruke ingestije lijekova (ingestije više od jedne vrste lijeka u isto vrijeme) koje su uključivale barem jedan psihoaktivni lijek. Kod djece, učestalost akutnih otrovanja neurolepticima bila je značajno veća u periodu II nego u periodu I (7.4%:4.4%; P<0.05). Učestalost otrovanja benzodiazepinima, antidepresivima i amitriptilinom kod djece nije se značajno razlikovala u periodu I i II (benzodiazepini – 13.5%:9.9%; antidepresivi – 1.8%:1.8%; amitriptilin – 0.3%:0.6%), kao ni učestalost višestrukih ingestija lijekova (19.4%:20.5%). Kod odraslih, učestalost otrovanja antidepresivima i amitriptilinom bila je značajno veća u periodu II nego u periodu I (antidepresivi – 13.0%:5.9%; P<0.01; amitriptilin – 7.3%:2.9%; P<0.05), kao i učestalost višestrukih ingestija lijekova (45.3%: 29.1%; P<0.01). Učestalost otrovanja benzodiazepinima i neurolepticima kod odraslih nije se značajno razlikovala u periodu I i II (benzodiazepini – 27.5%: 28.4%; neuroleptici – 20.6%: 19.7%). U oba perioda učestalost otrovanja psihoaktivnim lijekovima bila je značajno veća u odraslih nego u djece (period I – 53.9%: 19.4%; P<0.01; period II – 61.3%:19.1%; P<0.01). Od 1992. u Hrvatskoj se bilježi značajan porast broja akutnih otrovanja antidepresivima, osobito tricikličkim, u odraslih osoba, što je vezano vjerojatno uz učestalije propisivanje tih lijekova. Ovaj fenomen nije zabilježen u djece. Povećanje učestalosti akutnih otrovanja psihoaktivnim lijekovima, kao jedna od mnogih posljedica rata i posttraumatskoga stresnog poremećaja, upućuje na potrebu pažljive psihijatrijske procjene oboljelih, osobito pažljiviju uporabu antidepresiva. Rezultati ovog rada govore u prilog potrebe daljnjeg istraživanja učestalosti propisivanja psihoaktivnih lijekova u Hrvatskoj

Razlike u znanju o tuberkulozi među općom urbanom i studentskom populacijom u Zagrebu

Aim of study: The aim of this study is to find out the population knowledge, the most common misconceptions about tuberculosis (TB) and target groups for educational programs. Methods: Through a questionnaire (13 questions about the extent of the disease, symptoms, modes of transmission, risk factors and the curability of tuberculosis) respondents were pre-tested in the Croatian capital city Zagreb. Respondents (N = 328) were divided into groups ranked by two city locations: the Student Centre location, with the expected predominance of the younger student population (N = 157) and the main square area, with the expected predominance of people of different ages and professions (general urban population) (N = 171). Results: The general urban population group showed better knowledge in questions considering droplet transmission, smoking and excessive alcohol use as a risk factor for TB and description of TB as a primary infectious disease and curable disease. Many of the respondents (almost 20%) did not know the symptoms of manifest TB. Some respondents had misconceptions and perhaps the most important is that TB happens to someone else. Conclusion: Misconceptions about TB need to be eliminated through focused health education. Improvement in knowledge about TB can be achieved especially among student (young) population.Cilj: Cilj istraživanja bio je upoznati znanje stanovništva o tuberkulozi i najčešće zablude o njoj i otkriti ciljne skupine za provedbu potencijalnih edukativnih programa. Ispitanici i metode: Upitnik koji se sastoji od 13 pitanja o proširenosti bolesti, simptomima, načinima prijenosa, čimbenicima rizika i izlječivosti tuberkuloze; ispitanici su testirani u Zagrebu. Ispitivanje je provedeno među 328 ispitanika na dvije gradske lokacije: u Studentskom centru (N = 157), kao mjestu na kojem se očekuje da će predominantno prevladavati mlađa studentska populacija, i glavnom zagrebačkom trgu, gdje se očekuje da će biti ljudi različite dobi i zanimanja, tj. uzorak opće urbane populacije (N = 171). Rezultati: Uzorak opće urbane populacije pokazao je bolje znanje o kapljičnom prijenosu bolesti, rizičnim čimbenicima za tuberkulozu kao što su pušenje cigareta i alkohol, te definiranju tuberkuloze kao primarno zarazne i izlječive bolesti. Mnogi od ispitanika (gotovo 20 %) nisu znali što su simptomi tuberkuloze, a kao možda najvažnija zabluda ističe se kako se tuberkuloza događa nekome drugome. Zaključak: Kroz ciljane edukativne programe trebalo bi raditi na uklanjanju zabluda o tuberkulozi i poboljšanju znanja, posebice među studentskom populacijom

EXERCISE-INDUCED ASTHMA IN ATHLETES – A REVIEW

Profesionalni sportaši često su podvrgnuti treninzima izdržljivosti u okolišu u kojem su kronično izloženi inhalacijskim onečišćivačima/iritansima, alergenima ili hladnom zraku. Ti čimbenici dovode do povećanog rizika od razvoja disfunkcije gornjih i donjih dišnih putova. Upravo je u toj specifičnoj populaciji dijagnoza astme krucijalna zbog potencijalnog učinka ne samo na njihovo opće stanje nego i na natjecateljske sposobnosti. Simptomi astme u vrhunskih sportaša nisu nužno povezani s klasičnim obilježjima astme u općoj populaciji. I drugi klinički entiteti mogu stvarati simptome slične onima u astmi i zbog toga mogu voditi netočnoj dijagnozi i neuspješnu liječenju. Zbog toga je za postavljanje konačne dijagnoze potrebna kombinacija simptoma i pozitivnih laboratorijskih testova. Trenutačno ne postoji dokaz da se postupanje s astmom u sportaša treba razlikovati od postupanja s astmom u nesportaša. Međutim, neka specifična pitanja treba uzeti u obzir u vrhunskih sportaša, poput usklađenosti s pravilima Svjetske antidopinške agencije i Međunarodnog olimpijskog odbora.Elite athletes are often subjected to endurance training in the environment in which they are chronically exposed to pollutants/irritants, allergens or cold air. These factors lead to an increased risk of upper and lower respiratory tract dysfunction. The diagnosis of asthma is crucial in elite athletes because of potential implications on athlete’s general well–being as well as their competitive ability. Symptoms of asthma in elite athletes are not necessarily associated with the classic features of asthma seen in general population. Other clinical entities can create symptoms similar to those of asthma and therefore can lead to an incorrect diagnosis and ineffective treatment. The diagnosis requires a combination of symptoms and positive laboratory tests. Currently, there is no evidence that the treatment of asthma in athletes should be different from the treatment of asthma in non-athletes. However, some specific issues need to be considered in the elite athletes, such as compliance with the rules of World Anti-Doping Agency and International Olympic Committee

Lung function Diagnostics of Asthma

Od astme u svijetu danas boluje oko 235 milijuna ljudi uz i dalje znatan porast pojavnosti te značajne međuregionalne razlike u učestalosti (2-35%). Osnovni patofiziološki mehanizam jest upala dišnih putova, a povremena i varijabilna opstrukcija dišnih putova te bronhalna hiperreaktivnost njezine su izravne i mjerljive manifestacije. Dijagnoza se postavlja klinički, ali se temeljem podležećih patofizioloških procesa dopunjuje funkcionalnom dijagnostikom. Dijagnostiku treba započeti spirometrijskim mjerenjem uz nuždan bronhodilatacijski test salbutamolom i/ili ipratropijem, a u slučaju negativnog nalaza provesti četverotjedni pokus reverzibilnosti inhalacijskim kortikosteroidom. Taj pokus treba popratiti mjerenjem vršnog ekspiratornog protoka (ujutro i navečer prije uzimanja inhalacijske terapije) uz vođenje dnevnika simptoma. U slučaju negativnih nalaza tako provedene dijagnostike treba izvesti bronhoprovokacijski test metakolinom, a ako se simptomi javljaju u naporu, valja provesti testiranje u naporu uz mjerenje spirometrije. Specifična bronhoprovokacija rabi se u izuzetnim slučajevima kada drugačije nije moguće doći do dijagnoze ili pri dijagnostici profesionalne astme.Today asthma affects 235 million people globally, with a significant rise in incidence and significant interregional differences in prevalence (2-35%). The basic pathophysiological mechanism in asthma is airway inflammation, and intermittent obstruction of the airways and bronchial hyperresponsiveness are its direct and measurable consequences. Diagnosis is still made clinically but, based on the underlying pathophysiology, it is supplemented with lung function diagnostics. Lung function diagnostic workup should start with spirometry, followed by a reversibility test using bronchodilators (salbutamol and/or ipratropium). Negative reversibility test could be followed by a 4-week reversibility corticosteroid challenge monitored by peak flow measurements (morning and evening measurements before therapy) and symptom diary. If previous tests show negative results, methacholine challenge could be performed. Exercise challenge with spirometry measurements could be performed if the symptoms appear during exercise. Allergen challenge can be used in specific cases when other tests fail or during occupational asthma diagnostic workup